For much of the world, tobacco is more popular than ever. Now what?

Tobacco use is the leading cause of preventable death, responsible for seven million people dying around the world each year. In Western countries like the US, concerns are growing about smoking’s resurgence in pop culture and whether it could reverse decades of progress in reducing usage. 

Yet 80 percent of the world’s 1.3 billion tobacco users live in low- and middle-income countries, where rates of use are on the rise—and few countries offer research-backed programs and support that could help people to quit, according to a new article led by Donna Shelley, professor of public health policy and management at NYU School of Global Public Health.

The paper, “Evidence-Based Tobacco-Cessation Strategies for Low- and Middle-Income Countries,” published in the New England Journal of Medicine, examines case studies from India and Vietnam to illustrate how local social norms, unique tobacco use patterns, regulatory environments, and health care financing vary by region, and as a result, dictate access to and success of treatment. 

“In light of the wide variation in global tobacco-control contexts and the range of effective treatment options available, a one-size-fits-all approach is neither necessary nor desirable,” the authors write.

When tailoring these solutions to local contexts, Shelley and her colleagues advocate for scalable strategies—such as widespread screening for tobacco use, digital interventions, and access to medications—to establish a global standard for tobacco care.  

“Expanding equitable access to proven tobacco cessation treatments is critical and a vital policy solution to curbing the global rise in tobacco-related disease and preventing millions of deaths worldwide,” says Shelley. “We just have to implement what we know works.” 

NYU News spoke with Shelley—who led the analysis with colleagues at Harvard Medical School and Mass General Hospital, the National Institute of Mental Health and Neurosciences in India, Hanoi University of Public Health in Vietnam, and the University of York in the UK—about the enduring global tobacco crisis and what can be done to address it. 

What solutions work best to help people quit tobacco? 

The World Health Organization defines best practice for helping people quit using tobacco as providing—and covering the cost of—both behavioral interventions and medications. For example, behavioral counseling delivered by clinicians, telephone quitlines and digital platforms, and using medications—including nicotine replacement therapy and non-nicotine medications—can significantly increase the likelihood of quitting. Combining behavioral support and medication is more effective than either used alone.

It is important to note that offering help to quit is only one component of an effective tobacco control program. The WHO defines six proven strategies to reduce tobacco use. This includes implementing smoke-free air laws, increasing the price of tobacco products, and using counter-marketing campaigns and warnings to raise awareness of the dangers of tobacco use. These policies exert a synergistic effect to create an environment that discourages tobacco use and supports quitting. In countries that have implemented these strategies, smoking has significantly declined.

To what extent are  these best practices being implemented in low- and middle-income countries? 

In 2024, only 31 of 195 countries surveyed by the WHO were providing WHO-recommended cessation support. Of those, only 11 percent were middle-income, and 4 percent were low-income countries. The disparities are stark. Curbing the rising global burden of tobacco related deaths requires establishing cessation support as a universal standard of care that ensures equitable access for those most affected.

How does tobacco use vary across countries and cultures—and how does this influence how we think about cessation?

The wide range of tobacco products can complicate our approach to helping people quit. For example, smokeless tobacco use is common in India, particularly among women. In contrast, in Southeast Asia and the Middle East, waterpipe use is common, particularly among men. While the common denominator is nicotine addiction, tobacco use is also a social behavior that can be influenced by local norms that can support or hinder attempts to quit.

Weak policies, such as low cigarette taxes and poor enforcement of smoke-free air laws, can also undermine efforts to quit. Countries that have invested in effective tobacco control policies have seen prevalence decline, but globally—including in the US—the impact is not consistent across populations. Smoking is more prevalent among those with lower education and income levels and those with mental health and substance use disorders. 

Variation across countries in industry influence, norms, tobacco-use patterns, health care system financing, and the wide range of effective treatment options available requires a tailored approach. ‘One size fits all’ will not work. There is a need to align interventions with available resources to ensure that all smokers receive support to quit. For example, a lack of affordable medication does not preclude health care systems from integrating routine screening, brief advice, and referrals to behavioral counseling. In the article, we offer a stepped approach that outlines the full range of strategies for countries to adopt. Equitable access to proven, scalable tobacco cessation treatment is an achievable goal.

What role do local health care systems and providers play? 

Health care systems have a central role to play in helping people quit. All countries can develop guidelines for tobacco use treatment, require training of all health care workers, and implement routine screening and treatment across their systems as a standard of care. Even brief counseling from a clinician can increase quit rates.

Models like “Ask-Advise-Connect” are particularly promising and offer a feasible, low-burden pathway for integrating cessation care into routine practice, expanding access to treatment, and increasing treatment uptake. This approach includes asking about tobacco use, offering brief advice to quit, and connecting patients to treatment. It allows health care providers to delegate counseling to population-level cessation programs—for example, free quitlines where people can call or text to get support. 

These approaches are highly cost effective, including in low- and middle-income countries. As we describe in the article, India and Vietnam have implemented population-level treatment programs that facilitate access to care.  

You’ve studied tobacco use and cessation in Vietnam and the US. Is there something universal you’ve found across countries where you’ve conducted research?

My research in the US and Vietnam has demonstrated the feasibility and effectiveness of implementing the Ask-Advise-Connect model in both primary care and HIV health care settings. In primary care settings, we integrated a system to screen all patients for tobacco use and trained health care providers to offer brief advice to quit. We leveraged the village health worker infrastructure to provide clinicians with an option to “connect” patients to trained local health workers to receive more intensive counseling, and compared the Ask-Advise-Connect model to one that included health worker counseling. 

In HIV clinics we implemented a similar model. The only difference was the availability of a national quitline that provided a new option for connecting patients to treatment. Both studies showed that even brief clinician counseling can increase rates, but connecting patients to more intensive multisession programs can enhance the impact. More importantly, the studies reinforce that even in places like Vietnam where cost-covered medication is not offered, countries can institute an Ask-Advise-Connect model.