Abstract
Abstract Smokeless tobacco use remains a significant public health concern in Pakistan, particularly in rural settings where prevention and cessation efforts remain limited. Existing literature has largely emphasized social normalization, dependence, and barriers to quitting, but does not fully capture the structural drivers of use. This commentary examines the roles of food insecurity and livelihood stress in sustaining smokeless tobacco use in rural Sindh. Evidence suggests that products such as gutka may have appetite-suppressing effects that interact with dietary compromise in food-insecure settings, alongside wider structural pressures including chronic poverty, weak rural health outreach, and climate-related livelihood instability. Prevention strategies focused solely on awareness or regulation are unlikely to be sufficient. More effective responses will require integrating smokeless tobacco screening and brief counselling into primary healthcare and aligning tobacco control with nutrition and social protection interventions.