Smoking causes one-tenth of deaths worldwide, according to a new study sponsored by the Bill & Melinda Gates Foundation. Half of the deaths occur in the United States, China, India and Russia.

“Despite more than 50 years of anti-tobacco efforts, smoking remains a leading global risk factor,” researchers wrote in The Lancet. “Its toll will remain substantial without more concerted policy initiatives, policy compliance and enforcement, and sustained political will to offset commercial interests.”

The study found almost one in seven people smoked worldwide in 2015—one in four men and one in 20 women, CNBC reports. The study analyzed smoking habits in 195 countries between 1990 and 2015.