United States: Report Finds Significant Geographic Disparities in Smoking in Midwest and Southern States

A new one report published by the Truth Initiative organization[1] shows significant geographic disparities in smoking prevalence particularly in the 12-state contiguous Midwest and South region, dubbed the "Tobacco Nation."

The organization's 2023 report highlights that in the 12 states of the "tobacco nation" - Alabama, Arkansas, Indiana, Kentucky, Louisiana, Michigan, Mississippi, Missouri, Ohio, Oklahoma, Tennessee and West Virginia, smoking prevalence and consumption levels are higher than the average recorded in the other states of the country, regardless of the age group considered. Thus, adults aged 18 and over have a prevalence of 19.2 % compared to 13 %. Within the category of young adults (18-24 years old) there are 11.2 % to smoke compared to 7.6 % on average and among adolescents (12-17 years old) this prevalence is 6.3% compared to 4%. Overall, the prevalence is therefore 50% higher than that of the 30% and the quantity of cigarettes smoked per inhabitant each year is also significantly higher: 53 compared to 29 packs for residents of other states.

Other distinctive criteria characterize this population of the "Tobacco nation": the inhabitants are generally less educated, and are in a more precarious economic situation and less likely to have a managerial job.

A delay in implementing effective anti-smoking policies in these states

Smoking has declined significantly in the United States, with smoking prevalence among high school students (ages 15–18) falling from 28% in 2000 to 2% in 2022. This significant decline in consumption is attributed to the effects of tobacco control policies, including price increases, the establishment of smoke-free spaces, and the Tobacco 21 law.[2]), the ban on flavourings for tobacco and nicotine products as well as prevention campaigns in the media.

However, these measures have not been implemented evenly across the country, and overall, these more conservative southern and midwestern states have less restrictive tobacco control policies than most of the country. Packs of cigarettes are on average $19 % cheaper in these states (average $5.69 $) than in the rest of the United States (average $7.05 $). Cigarette tax data indicate that these states have increased cigarette excise taxes by only $0.59 $ on average since 2015, compared to an average tax increase of $1.04 $ in the other states.

Regarding tobacco sales to minors under 21, with the exception of Arkansas, which adopted a statewide “Tobacco 21” policy in 2019, and some localities in Ohio, Missouri, Michigan, and Mississippi, no state in the “Tobacco Nation” has implemented this measure to reduce youth smoking. As for restrictions on flavored tobacco products, only three municipalities in these states have adopted policies banning the sale of flavored tobacco products, compared to nearly 400 in the rest of the country.

Additionally, although none of the 50 states meet the spending level recommended by the Centers for Diseases Control and Prevention (CDC),[3] For tobacco prevention and cessation programs, Tobacco Nation states spend less than $15 billion of their recommended spending on tobacco prevention and cessation programs. By comparison, the proportion of such spending in other states is $30 billion, or double that. Some states, such as Tennessee, have even redirected $100 billion of their tobacco prevention and cessation funds to COVID-19 efforts in 2022, resulting in no funding for tobacco control programs.

These states also have fewer comprehensive smoke-free policies, which protect 47,000 of the nation's residents from tobacco, compared to 64,000 in the rest of the United States.

Tobacco industry interference in the implementation of anti-smoking policies

According to the Truth Initiative, the anti-smoking policies of these 12 states have failed to take hold, in particular because of the tobacco lobby and its interference in public policies.

For example, in 2022, Altria (Philip Morris) spent $198,685 lobbying against bills in Kentucky that would increase cigarette taxes, establish new smoke-free spaces, and allow local governments to impose stricter laws on the advertising, sale, and distribution of tobacco products and e-cigarettes. In Missouri, which has the lowest per-pack cigarette excise tax in the country (17 cents per pack), the rate has not changed in over 25 years due to indirect pressure from tobacco companies. A 2020 report by Tom Kruckemeyer[4], a former economist with the Missouri State Budget Office, showed that 33 of the state's 34 senators had accepted campaign donations to tobacco.

The difficulty for municipalities to implement effective measures against smoking

In the United States, some states prevent local governments from adopting local laws that are stricter or different from state tobacco control policies. The state can "preempt"[5] local tobacco control laws across the board or for specific policies (taxation, smoke-free areas, sales restrictions). The tobacco industry has consistently supported these state preemption laws to overturn existing, more restrictive local tobacco control laws and prevent future adoption of such laws. Thus, many states in the "Tobacco Nation" prohibit local governments from adopting more restrictive policies in the areas of taxation, smoking bans, flavor bans, etc. under this principle.

On this basis, Arkansas passed a law in 2019 preventing local jurisdictions from enacting laws on taxes and youth access to tobacco products that are more restrictive than those in effect within the state.

In 2021, Tennessee passed a law that subjects vaping products to the same restrictions as tobacco products but also preempts future vaping product laws, including flavor restrictions and tax laws.

In 2022, after Columbus, Ohio, passed a law banning the sale of flavored tobacco products, state legislation attempted to prevent local governments from enacting stricter tobacco laws than the state's. However, the governor ultimately vetoed it.

Smoking, a significant health burden

This high and persistent prevalence of cigarette smoking has serious consequences. Smoking remains the leading cause of preventable death and premature illness in the country, particularly given the burden of these high-burden states. This impact is all the more noticeable given that American life expectancy has declined due to a variety of factors, including COVID-19 and opioid overdoses. As a result, residents of the “tobacco nation” are living shorter lives and are at greater risk of dying prematurely than other citizens, with an average life expectancy of 76 years, compared to 79 years in the rest of the country.

Residents of these states are more likely to die from cancer, heart disease and chronic lower respiratory disease than those living in the rest of the United States. They also have much higher rates of chronic diseases, particularly chronic obstructive pulmonary disease and diabetes, compared to the general adult population, according to Truth's report.

A separate analysis by the Truth Initiative and HealthPartners Institute[6] showed that increased spending on tobacco prevention and cessation programs, combined with higher cigarette taxes, could reduce adult smoking disparities in the region to levels comparable to those observed in the rest of the country. The analysis also projects that implementing these key policies in these 12 states could lead to the prevention of approximately 100,000 cancer cases, 730,000 hospitalizations, and 170,000 premature deaths over the next two decades as a result of these public policies. Savings of more than $24 billion in medical costs attributable to smoking would be realized, while productivity gains at the workplace would be increased by more than $100 billion as a result of these tobacco and cost reduction measures.

Keywords: United States, smoking, Midwest, health inequality, interference, tobacco industry

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[1] Press release, New Report Finds Major Geographic Smoking Disparities Across Midwest and Southern States, Truth Initiative, published June 28, 2023, accessed June 29, 2023

[2] Generation without tobacco, United States: Tobacco 21 laws are effective and convince other countries, published on January 13, 2021, consulted on June 29, 2023

[3] Centers for Disease Control and Prevention. Best Practices for Comprehensive Tobacco Control Programs: 2014

[4] Tom Kruckemeyer: Big Tobacco and Missouri political leaders — a love story, Jopling Globe, January 2020, accessed June 29, 2023

[5] Fact Sheet, Centers for Diseases Control and Prevention, STATE System Preemption Fact Sheet

[6] Report, Eliminating smoking disparities in Tobacco Nation, Truth Initiative, published January 13, 2023, accessed June 29, 2023