The Developing World's Cigarette Boom: Why the Global South Is Still Lighting Up

The narrative of tobacco's decline is true—if you live in a high-income country. In the United States, smoking prevalence has fallen from 42% in 1965 to 11.5% in 2023. In Australia, it's below 11%. In the UK, 12.7%. In Sweden, below 5%. The public health community has, understandably, celebrated these declines as evidence that tobacco control works. But the global picture tells a different story. The absolute number of smokers worldwide—approximately 1.1 billion—has barely changed in two decades. The decline in prevalence has been offset by population growth, and the decline in rich countries has been offset by increases or plateaus in poor ones. The cigarette epidemic is not ending. It's moving—from the Global North to the Global South, from the rich to the poor, from populations with access to cessation support to populations without it.

The numbers are stark. In Indonesia, 65% of adult men smoke—one of the highest rates in the world—and the prevalence has been essentially flat for decades. In China, despite some recent declines, over 300 million people still smoke, consuming roughly 40% of the world's cigarettes. In several African countries—Lesotho, Sierra Leone, Madagascar—smoking prevalence among men exceeds 30% and is rising. The WHO's African region is projected to have the largest relative increase in tobacco-attributable mortality in the coming decades, as the latency period between smoking uptake and disease manifestation runs its course through populations that took up smoking later than their Western counterparts. The tobacco industry, facing declining markets in the West, has shifted its marketing and political efforts to the regions where growth is still possible.

The forces sustaining smoking in low- and middle-income countries (LMICs) are the same forces that sustained it in high-income countries fifty years ago—intensified by structural factors that make them harder to overcome. Industry opposition to tobacco control is more aggressive and less constrained in LMICs, where regulatory capacity is weaker and political accountability is more limited. The economic dependence on tobacco—both as a source of government revenue and as a livelihood for farmers—is higher in countries that can least afford to forgo the income. Public awareness of the health risks of smoking is lower; in several African countries, surveys find that a majority of smokers do not believe that smoking causes lung cancer. Cessation support is almost nonexistent—fewer than 30% of LMICs have a national quitline, and NRT is unavailable or unaffordable in most.

The regulatory environment in LMICs is a product of both domestic constraints and international influence. The FCTC has been widely ratified—over 180 countries—but ratification does not equal implementation. Most LMICs have adopted tobacco control legislation on paper, but enforcement is minimal, funding is inadequate, and the political will to confront the industry is undermined by the economic realities of tobacco dependence. The international dimension adds another layer: the WHO's hostility to harm reduction, formalized in COP decisions that urge LMICs to restrict or ban e-cigarettes, has the effect of denying the Global South access to the products that are accelerating smoking cessation in the Global North. The countries that could benefit most from safer nicotine products—because they have the highest smoking rates and the least cessation infrastructure—are being advised to prohibit them. The recommendation is framed as a precautionary measure against 'a new epidemic.' It functions as a barrier to the most effective available harm reduction strategy.

The equity dimensions is acute and uncomfortable. The global tobacco control movement was built by and for high-income countries. Its evidence base, its policy tools, its funding structures, and its advocacy priorities all reflect the contexts in which it developed. The movement's success in reducing smoking in rich countries is real, but the methods that achieved that success—comprehensive cessation services, mass media campaigns, pharmacotherapy, harm reduction products—are precisely the interventions that are least available in LMICs. The result is a global tobacco control regime that is extraordinarily effective at reducing smoking among the rich and not very effective at reducing smoking among the poor. The equity gap is not a side effect of tobacco control. It is, increasingly, its defining feature.

What would an equity-centered global tobacco control strategy look like? It would prioritize making cessation support—including NRT, counseling, and safer nicotine products—affordable and accessible in LMICs. It would fund farmer transition programs at the scale that the FCTC's aspirational language promises but has never delivered. It would empower LMIC governments to make their own risk-benefit determinations about harm reduction products, rather than importing the precautionary approach favored by the WHO. And it would involve genuine partnership with LMIC researchers, advocates, and policymakers—not the donor-recipient dynamic that characterizes much of global health. The cigarette epidemic is globalizing. The response needs to globalize on the same terms—or the one billion tobacco deaths projected for this century will be concentrated in the countries least equipped to bear them.

Shareable insight: The cigarette epidemic is not ending. It's migrating—from rich countries to poor ones, from populations with resources to populations without them. A global response that works only for the rich is not a global response.