Only 13 low- and middle-income countries provide smokers with the full package of care recommended to help them quit, according to a new review published in the New England Journal of Medicine. The finding exposes a major gap between the scale of the global tobacco epidemic and the healthcare systems available to address it. Around 1.3 billion people are believed to be left without reliable access to effective cessation support, even though tobacco use remains the world’s leading preventable cause of death and is responsible for more than seven million deaths each year.
The researchers, from the University of York, New York University, and Harvard University, examined how smoking-cessation services are delivered across countries where healthcare resources are often limited and the burden of tobacco-related illness is high. More than 80 percent of tobacco users live in low- and middle-income countries, yet these populations are frequently the least likely to receive structured medical assistance when they decide to stop smoking. The review suggests that quitting is still treated in many places as an individual matter rather than as a core responsibility of health services, despite the well-established links between tobacco addiction, cancer, cardiovascular disease, chronic respiratory illness, and premature death.
The standard recommended by the World Health Organization is not simply a brief instruction to stop smoking. Comprehensive cessation care combines behavioral support with pharmacological treatment, creating a two-part intervention designed to address both the psychological and biological dimensions of nicotine dependence. Counseling can help people identify triggers, manage cravings, change routines, and prepare for relapse risks. Medication, meanwhile, reduces withdrawal symptoms and the intense physiological drive to consume nicotine. The researchers found that only 13 lower-income countries currently offer this combination at the level required for care to be considered comprehensive, with medication available free of charge or at a subsidized cost.
The disparity is particularly striking because tobacco-cessation interventions are among the most practical measures available to healthcare systems seeking to reduce long-term disease. Nicotine dependence alters reward pathways in the brain, reinforcing repeated tobacco use even when a person understands the health risks. When nicotine intake stops, the resulting withdrawal can include irritability, anxiety, difficulty concentrating, sleep disturbance, and powerful cravings. Behavioral counseling helps patients develop strategies to cope with these effects, while medicines such as nicotine replacement therapy, cytisine, and varenicline can reduce withdrawal and improve the likelihood of sustained abstinence. Without access to both forms of support, many smokers are left to confront a chronic addictive disorder with little more than general advice.
The review also indicates that the availability of services on paper often differs sharply from the care patients can actually obtain. Researchers examining healthcare delivery in countries including India and Vietnam found that cessation support is shaped by a complex combination of cultural expectations, government policy, financing arrangements, clinical training, and the influence of the tobacco industry. In some regions, smoking may be deeply embedded in social or occupational settings, making cessation more difficult to sustain without community-level support. In others, doctors may lack the time, resources, or incentives to offer counseling, while essential medicines remain unavailable through public clinics or too expensive for patients to purchase privately.
These local differences mean that a single global model is unlikely to work everywhere. A cessation programme designed for an urban hospital may be poorly suited to rural communities where patients must travel long distances for care, or where physicians are scarce and community health workers provide most routine medical services. Researchers therefore argue that countries should adapt proven interventions to their own healthcare structures and social environments while maintaining the central components known to improve quitting success. The goal is not to create entirely new methods for every setting, but to deliver effective support through channels that people already use and trust.
Among the lower-cost strategies highlighted in the review are national telephone quitlines and mobile health services. Quitlines can connect smokers with trained counselors without requiring them to attend a clinic, making them especially useful for people living far from hospitals or facing mobility and financial barriers. Mobile applications and text-based programmes can provide reminders, personalized advice, craving-management techniques, and encouragement during the early stages of quitting. Although digital tools cannot replace clinical care for everyone, they can extend the reach of limited health workforces and provide repeated support at moments when a person is most vulnerable to relapse.
Community health workers represent another potentially powerful link between national policy and local access. In rural and underserved areas, these workers may already be involved in vaccination, maternal health, infectious-disease prevention, or chronic-disease management. With suitable training, they can identify tobacco users, provide basic behavioral counseling, explain treatment options, and refer patients who need more specialized care. Integrating cessation into existing programmes could help prevent tobacco treatment from becoming an isolated service that patients must actively seek out. It would also allow health systems to reach people who rarely interact with physicians but regularly encounter community-based providers.
The researchers further point to routine screening systems such as “Ask-Advise-Connect,” in which healthcare professionals ask patients about tobacco use, advise them to quit, and connect them directly with treatment. This approach turns ordinary medical visits into opportunities for prevention. Screening can identify people who might not describe themselves as dependent or who have never sought help, while direct referral reduces the chance that motivation will disappear after a patient leaves the clinic. Professor Kamran Siddiqi of the Hull York Medical School said healthcare services have a fundamental responsibility to treat tobacco addiction, adding that cessation interventions are cost-effective, relatively easy to integrate, and capable of producing substantial health and economic gains.
The review also calls for broader access to proven cessation medicines, including nicotine patches, cytisine, and varenicline. The authors argue that these treatments should be licensed worldwide and that full courses should be covered by governments or insurers. Partial coverage, short-term supplies, or high out-of-pocket costs can undermine treatment before patients have completed the period needed to establish a stable change in behavior. Removing those financial barriers could make cessation support more equitable, particularly in countries where household income determines whether a person can obtain medicine. Professor Donna Shelley of New York University said that ensuring comprehensive tobacco-cessation support as standard care would be a vital step toward preventing millions of tobacco-related deaths globally. The findings place responsibility not only on individual smokers, but also on governments, insurers, healthcare providers, and regulators to make effective treatment available wherever tobacco addiction is found.
Subject of Research: Tobacco cessation services and access to treatment in low- and middle-income countries
References: New England Journal of Medicine
Keywords: Tobacco addiction, smoking cessation, health equity, nicotine dependence, public health, low- and middle-income countries, quitlines, varenicline, cytisine, nicotine replacement therapy
