The knowns and unknowns of smokeless tobacco in WHO EMRO countries

Tobacco heavily contributes to preventable disease worldwide. Although cigarette smoking is on the decline, smokeless tobacco, is becoming more prevalent in the World Health Organization (WHO) Eastern Mediterranean Region (EMRO) countries. There has been a lack of adequate research and policy response to smokeless tobacco. Tobacco control efforts in the region are hindered by a lack of evidence on key issues, including long-term health outcomes, risks associated with different products, patterns among users, particularly among young individuals and women, and effective strategies for cessation. This article combines evidence on smoked and smokeless tobacco in the WHO EMRO which comes from epidemiological, clinical, and policy-related sources. It reviews patterns of prevalence, the known oral and systemic health risks, and biomarkers of harm. It also highlights significant gaps in tobacco use surveillance, labeling, and cessation trials. To develop evidence-based regulations, it is crucial to enhance surveillance, product testing, and research that is culturally appropriate. Pending the advent of more compelling evidence, the prevailing public health policy approach of categorizing all tobacco products as harmful remains a rational course of action. • Smokeless tobacco use is common in the WHO EMRO region, yet it remains understudied. It is particularly prevalent among adults, adolescents, and migrant populations, underscoring the pressing need for enhanced surveillance and regulation. • Even though smokeless tobacco products are marketed in a way that makes them seem less harmful, products such as imported Snus, and traditional ones such as Shammah (in Yemen and Saudi Arabia), and Toombak (in Sudan), hold a documented health risk, meanwhile, the evidence gaps surrounding long-term outcomes, youth uptake, and effective cessation strategies remain significant. • Tobacco products must be treated as harmful under public health policies, with warning labels, regulation, youth protection, and regional research informing strategies to control and end use of tobacco.