A report by Columbia University’s Earth Institute blamed cigarettes, cheap food, and city living for contributing to millions of premature deaths from heart disease in the developing world.

“The tobacco scourge, now at epidemic levels in less-developed countries, exacts its toll in many ways, but cardiovascular deaths are its principal mode of mortality,” the report said.

The report further found that unlike the United States, few developing countries are helping people to quit smoking.

The study examined the death rates in Brazil, South Africa, China, Tatarstan, and India.