Highly unequal access to smoking cessation services worldwide

A review published on August 13, 2026 in the New England Journal of Medicine[1] This article provides an overview of smoking cessation strategies in low- and middle-income countries, home to more than 80% of the 1.3 billion tobacco users worldwide. The authors, coordinated by Donna Shelley (New York University), note that tobacco remains the leading cause of preventable death, responsible for more than 7 million deaths each year. They observe that by 2024, only 31 out of 195 countries were implementing the best practices defined by the World Health Organization, namely access to validated drug treatments and their financial coverage, which can be combined with behavioral support. The article details interventions whose effectiveness has been established and then illustrates, through two national examples (Vietnam and India), how the social, economic, and health context influences actual access to care.

This publication falls under the format of a review article (review articleThis approach involves compiling and contextualizing previously published scientific work, rather than presenting the results of a new clinical study. The analysis draws on recommendations and surveillance data from the World Health Organization, as well as the scientific literature on the effectiveness of smoking cessation treatments. It is supplemented by two clinical vignettes, one concerning a man residing in Vietnam and the other a woman residing in India. These situations are composites developed from several research studies and the authors' clinical experience, and do not correspond to documented individual cases. Their purpose is to illustrate the impact of public policies and the organization of healthcare systems on effective access to smoking cessation resources.

A healthcare burden concentrated in the most vulnerable countries

Since 2008, the World Health Organization has recommended six measures grouped under the acronym MPOWER, which incorporates some of the key provisions of the Framework Convention on Tobacco Control (FCTC). Among these measures is the provision of smoking cessation services. By 2024, 28 % countries in high-income countries, 11 % countries in middle-income countries, and only 4 % countries in low-income countries had reached the level of good practice defined by the WHO.

Effective solutions, but still too rarely implemented.

The authors reiterate that validated treatments combined with behavioral support are effective individually, but even more so when combined. Behavioral support refers to brief counseling during consultations, smoking cessation helplines, text message or mobile app programs, and specialist consultations. Treatments include nicotine replacement therapies, varenicline, bupropion, and cytisine, the latter of which will be added to the World Health Organization's list of essential medicines in 2025. A simple organizational model, called Ask Advise Connect, is presented as a low-cost way to integrate this systematic screening into the routine practice of healthcare professionals.

To illustrate how these principles are translated, or not, into the reality of national health systems, the authors devote the second part of the article to two countries with high tobacco prevalence, Vietnam and India, whose public policies, consumption habits and methods of financing care differ significantly.

Vietnam, when the cost of treatment hinders cessation

Vietnam ratified the FCTC treaty in 2004 and has implemented several MPOWER measures, including smoke-free zones, health warnings on cigarette packs, media campaigns, and tobacco taxation. The country has approximately 16 million tobacco users, including 41 million men and 1 million women. The majority smoke cigarettes; 13 million men and fewer than 1 million women use the traditional bamboo water pipe (thuốc lào). More than 93% of Vietnamese adults believe that tobacco causes serious illnesses, reflecting a high level of awareness without a corresponding decrease in consumption: between 2010 and 2020, male prevalence fell by only six points, from 47% to 41%, with the decline benefiting mainly urban and affluent populations.

The country established a free smoking cessation helpline in 2015, supported by national media campaigns and patient referrals from clinicians. A train-the-trainer program was also developed for provincial health officials, but training for professionals working in community health centers, which are the main point of access to primary care in rural areas, remains limited. A provincial survey conducted in 2020 shows that education level, awareness of health risks, and having received medical advice to quit smoking during a consultation in the twelve months preceding the survey are strongly correlated with attempts to quit.

Financially, smoking cessation treatments are not covered by national health insurance; only nicotine patches, gum, and lozenges are available for purchase in pharmacies. A box of gum costs approximately $50 per month, representing 20% of the estimated average monthly income of $247, while a pack of cigarettes remains affordable at around $0.40. The level of taxation is significantly lower than the recommendations of the World Health Organization, in a country where tobacco tax policy is influenced by the state-owned Vietnam National Tobacco Corporation. This imbalance between the cost of tobacco and the cost of treatment constitutes, according to the authors, a structural obstacle to smoking cessation.

India, an existing but still largely untapped supply

India also became a party to the FCTC treaty in early 2004 and implemented the full MPOWER program: media campaigns, regulations governing tobacco advertising and promotion, smoke-free areas, health warnings covering more than 85% of the main surface of tobacco packaging, including smokeless tobacco, a national helpline and SMS program, and free access to nicotine replacement therapy. The country has 251 million adult tobacco users, 53 million of whom are women.

Smokeless tobacco is the predominant traditional form of tobacco consumption in India, used daily by 21% of adults (30% of men and 13% of women). It comes in various forms, including betel quid mixed with tobacco, khaini, gutka, mawa, mishri, pan masala, and zarda. These products are highly addictive and associated with a proven risk of oral cancer. Their use most often begins in adolescence among women and continues into adulthood. It enjoys a more favorable social perception than smoked tobacco and is subject to significantly lower taxes, which reduces the deterrent effect of the price.

The country has 500 national smoking cessation centers, which face insufficient staffing and limited funding. Furthermore, the country faces uneven enforcement of smoking bans. The national helpline, established in May 2016 with four national centers, remains underutilized by women who smoke, with fewer than 2% of them using it. Results from the national SMS-based smoking cessation program show a self-reported quit rate of one in five users at four weeks, despite limited public awareness. Community health workers (Accredited Social Health Activists), particularly those involved in monitoring pregnant women, play a documented role in initiating quit attempts: according to an analysis combining two national surveys, advice provided by a healthcare professional is a strong predictor of quitting among smoke-free tobacco users.

Towards universal access to smoking cessation

The authors conclude that reducing the global burden of tobacco-related diseases requires establishing smoking cessation as a universal healthcare standard. This implies systematically identifying tobacco users during consultations, providing routine medical advice, facilitating referrals to appropriate support, and ensuring financial access to treatments recognized as essential. The Vietnamese and Indian examples demonstrate that the mere availability of a device is insufficient to guarantee its use, and that financial support policies play a crucial role in transitioning from the intention to quit to actual cessation.

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[1] Shelley D, Rigotti NA, Murthy P, Van Minh H, Siddiqi K. Evidence Based Tobacco Cessation Strategies for Low and Middle Income Countries. New England Journal of Medicine, 2026;395:684 to 693. DOI: 10.1056/NEJMra2507061.

National Committee Against Smoking |