Understanding research gaps and priorities for tobacco harm reduction in low-income and middle-income countries

Introduction

Tobacco use is among the leading preventable causes of premature death worldwide, with disproportionate effects in low-income and middle-income countries (LMICs). Global tobacco control efforts have shown inconsistent results, highlighting the need for innovative approaches, such as tobacco harm reduction (THR), to complement existing strategies. We aimed to identify gaps in THR research in the global and LMIC contexts.

Methods

We conducted a bibliometric review, using Scopus, to identify articles addressing THR published from January 2014 to August 2024. Research output was categorized by product type, geographical focus, volume of research output, and funding sources. A narrative synthesis was performed to outline research gaps and propose a strategic research agenda.

Results

THR research was dominated by e-cigarettes, primarily from high-income countries. Citations per 1 million smokers were highest in New Zealand (1,128.0), United Kingdom (634.3), United States (466.4), Australia (432.1), Switzerland (177.1), and South Korea (132.9). By contrast, rates were very low across Asia, Africa, and South America (range 1.8–53.5). Over the study period, research output increased only for e-cigarettes and heated tobacco products. Publicly funded research tended to focus on public health concerns, while private-sector research focused on product safety and efficacy.

Conclusions

THR research remains disproportionately concentrated in high-income countries and reflects a clear divergence between public and private research agendas. More research is needed to evaluate the long-term impacts, affordability, and real-world effectiveness of THR products using rigorous and standardized methodologies in diverse settings. Strengthening the evidence base in LMICs will be essential for developing affordable, accessible, and acceptable THR strategies tailored to local needs.