Still Burning: Why the Developing World Can't Quit Cigarettes
While smoking rates plummet in the West, the tobacco epidemic is shifting south and east. In low-income countries, cigarettes are cheaper, regulation is weaker, and the industry is fighting harder than ever to keep the fire burning.
Walk through the commercial district of any major Indonesian city and you'll see something that has largely vanished from London, Sydney, or New York: cigarette advertising everywhere. Billboards featuring rugged men on motorcycles, point-of-sale displays at eye level with children, sponsored concerts with free cigarette sampling, and single cigarettes sold for pennies at roadside kiosks—a practice known as 'stick sales' that makes the product accessible even to the very poor. Indonesia has one of the highest smoking rates in the world: over 60% of adult men smoke, and the youth smoking rate is climbing. It's the face of a global shift that receives a fraction of the attention given to vaping in Western high schools: the tobacco epidemic is moving south.
The WHO estimates that over 80% of the world's 1.3 billion tobacco users now live in low- and middle-income countries (LMICs). As smoking prevalence has fallen in high-income nations—thanks to taxation, advertising bans, smoke-free laws, and decades of public education—the tobacco industry has redirected its marketing machine toward markets with younger populations, weaker regulatory infrastructure, and governments that are reluctant to challenge an industry that provides significant tax revenue and agricultural employment. The result is a textbook case of epidemiological injustice: the countries least equipped to handle the healthcare burden of tobacco-related disease are the ones being targeted most aggressively.
The economic dynamics are as brutal as they are simple. In high-income countries, tobacco taxes have driven cigarette prices to $10–$15 per pack, a level at which consumption measurably decreases—the WHO estimates a 10% price increase reduces consumption by about 4% in wealthy nations. In many LMICs, a pack of cigarettes costs less than $2, and in some cases as little as $0.50. Indonesia is one of the few countries that hasn't ratified the WHO Framework Convention on Tobacco Control (FCTC), and its cigarette taxes remain among the lowest in the world. The industry has aggressively opposed tax increases, deploying arguments about tobacco farmer livelihoods and illicit trade that echo the playbook used in the West decades earlier.
The marketing tactics in LMICs are a throwback to the mid-20th century West—except updated for the social media age. In Africa, tobacco companies sponsor music festivals, sports events, and fashion shows, associating their brands with aspiration and modernity. In Bangladesh and Pakistan, point-of-sale advertising targets children with colorful displays at candy-counter height. In the Philippines, 'sari-sari' convenience stores—ubiquitous neighborhood kiosks—ensure cigarettes are never more than a two-minute walk away. WhatsApp and Facebook have become vectors for tobacco promotion, reaching populations that traditional anti-smoking campaigns never touch. A 2024 investigation by The Bureau of Investigative Journalism documented tobacco influencers in Nigeria paid to feature cigarettes in lifestyle content viewed by millions.
The health consequences are already catastrophic and projected to worsen dramatically. Tobacco-related diseases currently kill approximately 7 million people annually, and that number is expected to rise to 8 million by 2030 as the LMIC epidemic matures—despite continued declines in high-income countries. Cancer, cardiovascular disease, chronic obstructive pulmonary disease, and tuberculosis (smoking doubles the risk of TB infection progressing to active disease) are all rising in regions with the least capacity to treat them. The economic toll is equally devastating: the WHO estimates that tobacco use costs the global economy over $1.4 trillion annually in healthcare expenditures and lost productivity, with the heaviest relative burden falling on the poorest countries.
Meanwhile, the same companies that are pivoting to 'smoke-free' products in wealthy markets continue to expand combustible cigarette sales in LMICs. Philip Morris International's 'Unsmoke Your World' campaign does not run in Indonesia. British American Tobacco's sustainability reports highlight reduced-risk products while the company continues to grow cigarette volumes across Africa and South Asia. This bifurcation—cessation for the rich, combustion for the poor—is not a contradiction in the industry's strategy; it IS the strategy. As long as combustible cigarettes remain profitable and regulatory environments remain permissive, the 'smoke-free future' will remain selectively applied.
The policy solutions are known and cost-effective—MPOWER measures work everywhere they're implemented—but they require political will that's often undermined by industry lobbying. Tax increases are the single most effective intervention, particularly in LMICs where price sensitivity is highest. Comprehensive advertising bans, graphic warning labels, smoke-free public places, and cessation support are all proven strategies. What's missing is global solidarity: the funding to support tobacco control in LMICs is a tiny fraction of what's spent on other global health priorities, and the industry's ability to outspend and outlast public health campaigns remains formidable. The international community faces a choice: invest now in preventing an epidemic, or pay far more later in treating one. As a WHO tobacco control officer put it: 'We're not asking for charity. We're asking high-income countries to stop exporting an epidemic they've already solved at home.'
