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Wyoming State Highlights Select a different state

Tobacco use remains the leading cause of preventable death and disease in the United States and in Wyoming. To address this enormous toll, the American Lung Association calls for the following actions to be taken by Wyoming's elected officials:
1. Raise tobacco taxes by $1.00 or more per pack;
2. Increase funding for tobacco prevention and cessation programs; and
3. Pass additional local or state legislation creating smokefree public places and workplaces.

The American Lung Association in Wyoming supports raising tobacco taxes as evidence shows making tobacco products more expensive is one of the best ways to delay initiation of tobacco use as well as encouraging current users to quit using tobacco.

During the 2019 legislative session, Representative Dan Zwonitzer sponsored House Bill 218 which would have raised the cigarette tax by $1.00 per pack and increased the tax on other tobacco products. Unfortunately, the bill died in the House Revenue committee with a 5-4 vote. While the Lung Association is deeply disappointed with this outcome, raising the tax will continue to be a policy priority.

With an 8 to 1 vote in August 2019, the Cheyenne City Council added electronic smoking devices to an ordinance passed in 2006 that restricts cigars, cigarettes, pipes, hookahs and waterpipes in certain public places. The amended ordinance creates smokefree environments in restaurants, bars, private clubs and other public places.

Wyoming's cigarette tax remains one of the lowest in the nation at $0.60 per pack. The American Lung Association in Wyoming will continue working with partners to support increases in tobacco taxes and additional appropriations for tobacco prevention and cessation programs. The Lung Association will continue support for local or statewide smokefree workplace laws in Wyoming.

Wyoming Facts

Economic Cost Due to Smoking: $257,674,019
Adult Smoking Rate: 18.80%
Adult Tobacco Use Rate: 29.90%
High School Smoking Rate: 10.80%
High School Tobacco Use Rate: 38.40%
Middle School Smoking Rate: 2.40%
Smoking Attributable Deaths: 800

Adult smoking and tobacco use data come from CDC's 2018 Behavioral Risk Factor Surveillance System. High school and middle school smoking rates are taken from the 2018 Wyoming Prevention Needs Assessment Survey. High school tobacco use rate is taken from the 2015 Youth Risk Behavior Surveillance System.

Health impact information is taken from the Smoking Attributable Mortality, Morbidity and Economic Costs (SAMMEC) software. Smoking attributable deaths reflect average annual estimates for the period 2005-2009 and are calculated for persons aged 35 years and older. Smoking-attributable health care expenditures are based on 2004 smoking-attributable fractions and 2009 personal health care expenditure data. Deaths and expenditures should not be compared by state.


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Wisconsin State Highlights Select a different state

Tobacco use remains the leading cause of preventable death and disease in the United States and in Wisconsin. To address this enormous toll, the American Lung Association calls for the following actions to be taken by Wisconsin's elected officials:
1. Ensure enforcement of the federal law that raises the legal age of sale for tobacco products to 21;
2. Add e-cigarettes to the smokefree air law; and
3. Require all tobacco products to be placed behind the counter or in a locked cabinet.

Despite a Democratic governor assuming office at the beginning of 2019, both houses of Wisconsin's legislature continue to be controlled by Republicans ushering in an era of divided government. Several bills have been introduced that would have a dramatic impact on reducing youth consumption of e-cigarettes, but despite their positive benefits in the face of a clear public health crisis, all faced stiff opposition in the legislature.

In his first budget, the new Governor included an increase in funding for the Tobacco Prevention and Control Program and an e-cigarette tax that would have been equal to the tax on regular cigarettes. Unfortunately, the program increase was stricken from the final version of the budget and the tax reduced to a measly $.05/mL of "juice" or about 3.5 cents per pod of JUUL. Wisconsin's cigarette tax, in contrast, is $2.52/pack.

The American Lung Association in Wisconsin is proud to be associated with Children's Hospital of Wisconsin, the health organization that first uncovered the link between severe lung damage and vaping. Their discovery opened the floodgates to thousands of other, previously undocumented cases and national attention by the Centers for Disease Control and Prevention and state health departments to the dangers of vaping. This has led to swift action on the part of the federal government and numerous states and municipalities to restrict or prohibit the sale of e-cigarettes and flavorings. Despite nationwide recognition of the dangers of vaping, Wisconsin's legislature has yet to take any strong action to control vaping within the state.

The good news is, that where the state refuses to take action, local municipalities have stepped up efforts to strengthen their smoke free air laws by including e-cigarettes. Over 40 municipalities, comprising nearly one-third of the state's population now protect residents from secondhand aerosol from e-cigarettes. Unfortunately, state law preempts those same municipalities from passing Tobacco 21 laws, restricting flavors, or requiring tobacco products to be removed from the store aisles and placed behind the counter or locked up, as cigarettes are required to be.

For the immediate future, it appears that Wisconsinites will have to rely on their local municipal governments and the federal government to respond to the ever-evolving tobacco and vaping crisis. The American Lung Association in Wisconsin and other public health advocates will continue to work with state officials at every opportunity to educate elected officials on the benefits of strong tobacco control laws and convince them that such laws are critical to the present and future health and well-being of our citizens.

Wisconsin Facts

Economic Cost Due to Smoking: $2,663,227,988
Adult Smoking Rate: 16.40%
Adult Tobacco Use Rate: 23.30%
High School Smoking Rate: 4.70%
High School Tobacco Use Rate: 17.30%
Middle School Smoking Rate: 1.40%
Smoking Attributable Deaths: 7,850

Adult smoking and tobacco use data come from CDC's 2018 Behavioral Risk Factor Surveillance System. High school and middle school smoking rates are taken from the 2018 Wisconsin Youth Tobacco Survey. High school tobacco use rate is taken from the 2017 Youth Risk Behavior Surveillance System.

Health impact information is taken from the Smoking Attributable Mortality, Morbidity and Economic Costs (SAMMEC) software. Smoking attributable deaths reflect average annual estimates for the period 2005-2009 and are calculated for persons aged 35 years and older. Smoking-attributable health care expenditures are based on 2004 smoking-attributable fractions and 2009 personal health care expenditure data. Deaths and expenditures should not be compared by state.


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West Virginia State Highlights Select a different state

Tobacco use remains the leading cause of preventable death and disease in the United States and in West Virginia. To address this enormous toll, the American Lung Association calls for the following actions to be taken by West Virginia's elected officials:
1. Fund tobacco prevention and cessation programs at the Centers for Disease Control and Prevention (CDC)-recommended level; and
2. Protect local control of smokefree air laws throughout the state.

The 2019 legislative session saw multiple bills to increase the sales age for all tobacco products from 18 to 21 introduced in both the state Senate and the House of Delegates. A bill introduced by Senate Majority Leader Takubo was strongly supported by the American Lung Association in West Virginia and other public health partners, including youth organizations and the Coalition for a Tobacco-Free West Virginia. Building on this momentum, the bill passed the Senate. However, the bill was severely weakened in the Senate Judiciary committee to include poison pill amendments, including adding smoking sections in restaurants, exemption and preemption of local smokefree laws to apply to veterans' organizations, and harsh penalties on youth purchase of tobacco. The Lung Association and partners were forced to oppose the bill, which ultimately died in the House.

For the first time in two years, funding was restored from $0 to $500,000 for tobacco prevention and control programs in West Virginia. This success was severely minimized by the zeroing of state funds for the Coalition for a Tobacco-Free West Virginia.

Clean Indoor Air had several setbacks in 2019. The Hancock County Board of Health amended its clean indoor air regulation to allow smoking in casinos and gaming sections of local video lottery cafes. Similarly, the Brooke County Board of Health voted to amend its regulation to allow smoking in establishments with limited video lottery rooms.

The Lung Association and West Virginia's tobacco prevention youth group, Raze, has worked tirelessly to address the high rates of tobacco use in the state along with the skyrocketing e-cigarette use rates amongst young people. Through ongoing education, local and statewide events, youth continue to fight the disproportionately high burden of tobacco across West Virginia.

The American Lung Association in West Virginia will continue to work with our partners to educate lawmakers and the public on the ongoing fight against tobacco through proven policies such as increasing funding for tobacco prevention and control programs and protecting local control of smokefree air laws.

West Virginia Facts

Economic Cost Due to Smoking: $1,008,474,499
Adult Smoking Rate: 25.20%
Adult Tobacco Use Rate: 35.00%
High School Smoking Rate: 10.30%
High School Tobacco Use Rate: 26.60%
Middle School Smoking Rate: 4.50%
Smoking Attributable Deaths: 4,280

Adult smoking and tobacco use data come from CDC's 2018 and 2017 Behavioral Risk Factor Surveillance System, respectively. High school and middle school smoking rates are taken from the 2017 Youth Tobacco Survey. High school tobacco use rate is taken from the 2017 Youth Risk Behavior Surveillance System.

Health impact information is taken from the Smoking Attributable Mortality, Morbidity and Economic Costs (SAMMEC) software. Smoking attributable deaths reflect average annual estimates for the period 2005-2009 and are calculated for persons aged 35 years and older. Smoking-attributable health care expenditures are based on 2004 smoking-attributable fractions and 2009 personal health care expenditure data. Deaths and expenditures should not be compared by state.


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Washington State Highlights Select a different state

Tobacco use remains the leading cause of preventable death and disease in the United States and in Washington. To address this enormous toll, the American Lung Association calls for the following actions to be taken by Washington's elected officials:
1. Increase state funding for tobacco prevention and cessation programs;
2. Prohibit the sale of all flavored tobacco products, including electronic cigarettes; and
3. Defend smokefree workplace laws.

After several years of consideration, Tobacco 21 passed the Washington Legislature and was signed into law by Governor Inslee in 2019. The American Lung Association in Washington applauds the strong persistent leadership of Representative Paul Harris who led the effort in the legislature. The policy was strongly supported by Attorney General Bob Ferguson, Secretary of Health John Weisman, and Governor Inslee.

House Bill 1074 raised the minimum legal sale age for tobacco products, including electronic cigarettes to 21 years of age. The bill also authorizes the governor to seek out government to government consultations with Indian tribes regarding raising the minimum legal age of sale in certain tribal compacts. One-time funding of $1 million was appropriated to the Department of Health to support local health jurisdictions to provide youth tobacco and vapor prevention programs, including the necessary outreach and education for the provisions of HB 1074.

In the last hours of the 2019 legislation session, House Bill 1873 passed. This legislation imposes a tax of 9 cents per milliliter of solution on products in an "accessible container", and a tax on all other vapor products of 27 cents per milliliter of solution. The bill directs revenues to be divided between the Foundational Public Health Services Account and the Andy Hill Cancer Research Endowment Fund. A reduction in tax is provided for products issued with a modified risk tobacco order.

The Lung Association was disappointed to see the volumetric tax structure used to tax these harmful products, as well as the low rate. The Lung Association will work towards a tax structure that creates tax parity with electronic cigarettes and other tobacco products.

In September 2019, Governor Jay Inslee signed an executive order asking the Department of Health to restrict the sale of all flavored vapor products in the state. On October 9, 2019, Washington's Board of Health approved a 120-day emergency prohibition on flavored vape products. The sales restriction has been challenged in court, but as of early November remains in effect. The case is being considered in Thurston County and a hearing has been scheduled for November 8 to consider the breadth of the statutory authority of the Board of Health.

The American Lung Association in Washington will continue to work with stakeholders and engaged grassroot supporters to advocate for policies to reduce tobacco use and its health impacts on Washington residents. Building on the successful implementation of the state's Tobacco 21 law, the Lung Association will continue to build the foundation of support to increase appropriations for tobacco prevention programs in the state.

Washington Facts

Economic Cost Due to Smoking: $2,811,911,987
Adult Smoking Rate: 12.00%
Adult Tobacco Use Rate: 17.90%
High School Smoking Rate: 5.00%
High School Tobacco Use Rate: N/A
Middle School Smoking Rate: 2.70%
Smoking Attributable Deaths: 8,290

Adult smoking and tobacco use data come from CDC's 2018 and 2017 Behavioral Risk Factor Surveillance System, respectively. High school (10th grade only) and middle school (8th grade only) smoking rates are taken from the 2018 Washington State Healthy Youth Survey. A current high school tobacco use rate is not available for this state.

Health impact information is taken from the Smoking Attributable Mortality, Morbidity and Economic Costs (SAMMEC) software. Smoking attributable deaths reflect average annual estimates for the period 2005-2009 and are calculated for persons aged 35 years and older. Smoking-attributable health care expenditures are based on 2004 smoking-attributable fractions and 2009 personal health care expenditure data. Deaths and expenditures should not be compared by state.


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Virginia State Highlights Select a different state

Tobacco use remains the leading cause of preventable death and disease in the United States and in Virginia. To address this enormous toll, the American Lung Association calls for the following actions to be taken by Virginia's elected officials:
1. Strengthen the existing Tobacco 21 law by removing the active military exemption and the purchase, use and possession penalties;
2. Increase the cigarette tax by at least $1.00 per pack; and
3. Fund tobacco prevention and cessation programs at the level recommended by the Centers for Disease Control and Prevention (CDC).

In the 2019 legislative session a bill to raise the age of sale for tobacco products to 21 was introduced and ultimately passed the Virginia General Assembly. Unfortunately, this bill contained many provisions that the American Lung Association in Virginia along with public health partner organizations opposed. Those provisions included an exemption for active duty military and purchase, use and possession penalties that wrongly put the blame for violations on those under age 21 instead of on tobacco product retailers.

Virginia is long overdue for a comprehensive evidence-based approach to address tobacco use among both youth and adults. This approach should include increasing the cigarette tax and creating parity between the tax on cigarettes and other tobacco products including e-cigarettes, licensing tobacco product retailers including e-cigarette retailers which should include annual renewal, graduated penalties for violations with suspension and revocation provisions and required retailer education. These evidence-based approaches could provide a sustainable funding source for enforcement.

Additionally, Virginia should also update its statewide law on smoking to eliminate smoking in all public places and workplaces, including all restaurants and bars.

The American Lung Association in Virginia will continue to educate lawmakers on the ongoing fight against tobacco. Our goal is to build champions within the legislature and a grassroots advocacy network to advance our goals of increasing the cigarette tax by at least $1.00 and creating parity between the tax on cigarettes and other tobacco products, as well as a comprehensive retail licensing program.

Virginia Facts

Economic Cost Due to Smoking: $3,113,009,298
Adult Smoking Rate: 14.90%
Adult Tobacco Use Rate: 22.10%
High School Smoking Rate: 6.50%
High School Tobacco Use Rate: 16.30%
Middle School Smoking Rate: 2.40%
Smoking Attributable Deaths: 10,310

Adult smoking and tobacco use data come from CDC's 2018 Behavioral Risk Factor Surveillance System. High school smoking and tobacco use data come from the 2017 Youth Risk Behavior Surveillance System. Middle school smoking rate is taken from the Virginia 2017 Youth Risk Behavior Surveillance System.

Health impact information is taken from the Smoking Attributable Mortality, Morbidity and Economic Costs (SAMMEC) software. Smoking attributable deaths reflect average annual estimates for the period 2005-2009 and are calculated for persons aged 35 years and older. Smoking-attributable health care expenditures are based on 2004 smoking-attributable fractions and 2009 personal health care expenditure data. Deaths and expenditures should not be compared by state.


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Vermont State Highlights Select a different state

Tobacco use remains the leading cause of preventable death and disease in the United States and in Vermont. To address this enormous toll, the American Lung Association calls for the following actions to be taken by Vermont's elected officials:
1. Prohibit the sale of all flavored tobacco products;
2. Increase funding to Vermont's tobacco control program; and
3. Minimize barriers to quit smoking treatment coverage.

The 2019 legislative session was an unprecedented year for Vermont's fight against tobacco. The renewed effort by the American Lung Association in Vermont and its partners to increase the minimum legal age of sale for tobacco products to 21 was rewarded by the bill being signed into law and Vermont becoming the 14th state to pass Tobacco 21. Vermont also extended its existing law prohibiting online sales of tobacco products to electronic cigarettes and became the first state to prohibit Internet sales of tobacco paraphernalia.

Vermont's legislature also agreed upon and passed into law a brand-new excise tax on electronic cigarettes, including associated liquids, and the delivery devices sold separately. Taxed at the rate of 92 percent of their wholesale price, all tobacco products in Vermont are now taxed at the same rate.

Unfortunately, Vermont's tobacco control program saw around a $500,000 decrease in funding for its tobacco control program in fiscal year 2020 from the previous year. This may be the result of one-time funding from last year expiring, but puts Vermont that much farther away from attaining the CDC-recommended level of funding for the state.

Youth use of electronic cigarettes has become a true epidemic. Enticed by kid friendly flavors that also mask the harshness that comes with inhalation, Vermont's youth are being set up for a lifetime of nicotine addiction. The American Lung Association in Vermont will continue to work with our coalition partners to educate policy makers, business leaders and the media of the importance of having a law prohibiting flavored tobacco products. Having strong tobacco control and prevention laws in Vermont, the American Lung Association in Vermont will be working with the Department of Health and lawmakers to find ways to minimize existing barriers to tobacco cessation-related coverages and continue to advocate for tobacco control program funding to be brought up to the CDC-recommended levels.

Vermont Facts

Economic Cost Due to Smoking: $348,112,248
Adult Smoking Rate: 13.70%
Adult Tobacco Use Rate: 19.50%
High School Smoking Rate: 9.30%
High School Tobacco Use Rate: 18.90%
Middle School Smoking Rate: 2.00%
Smoking Attributable Deaths: 960

Adult smoking and tobacco use data come from CDC's 2018 and 2017 Behavioral Risk Factor Surveillance System, respectively. High school smoking and tobacco use data come from the 2017 Youth Risk Behavior Surveillance System. Middle school smoking rate is taken from the 2015 Youth Tobacco Survey. High school smoking and tobacco use rates are taken from the 2017 Youth Risk Behavior Surveillance System. Middle school smoking rate is taken from the Vermont 2017 Youth Risk Behavior Surveillance System; results are rounded to the nearest whole number.

Health impact information is taken from the Smoking Attributable Mortality, Morbidity and Economic Costs (SAMMEC) software. Smoking attributable deaths reflect average annual estimates for the period 2005-2009 and are calculated for persons aged 35 years and older. Smoking-attributable health care expenditures are based on 2004 smoking-attributable fractions and 2009 personal health care expenditure data. Deaths and expenditures should not be compared by state.


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Utah State Highlights Select a different state

Tobacco use remains the leading cause of preventable death and disease in the United States and in Utah. To address this enormous toll, the American Lung Association in Utah calls for the following actions to be taken by our elected officials:
1.Maintain or increase funding for state's tobacco prevention and control program;
2.Increase excise taxes on tobacco products by $1.00 per pack or more; and
3.Strengthen state laws related to tobacco retailer licensing

In 2019, the American Lung Association in Utah advocated forted lawmakers to raise the minimum age of sale for tobacco products to 21. A law was passed and signed by Governor Herbert that raises the age of sale to 21 over several years, however the law leaves in place the purchase and possession penalties on minors and extends those penalties to those who are 19 and 20. The legislation also includes preemption on increasing the age of sale above age 21, and a provision that waives penalties for purchase and possession of tobacco products for active duty military members and their spouses under 21.

Funding for the Utah Tobacco Prevention and Control Program at the state Department of Health was again maintained at about the same level as previous years in fiscal year 2020. The program is funded by a combination of tobacco Master Settlement Agreement dollars and tobacco tax revenue.

Moving forward in 2020, the American Lung Association in Utah will once again make it a priority to educate our legislature and communities about the dangers of tobacco use and the importance of a well-funded tobacco prevention and cessation program. Additionally, the Lung Association will be working on raising the excise tax on tobacco products, and seeking to strengthen tobacco retail licensing laws in the state.

Utah Facts

Economic Cost Due to Smoking: $542,335,526
Adult Smoking Rate: 9.00%
Adult Tobacco Use Rate: 15.00%
High School Smoking Rate: 3.80%
High School Tobacco Use Rate: 9.70%
Middle School Smoking Rate: N/A
Smoking Attributable Deaths: 1,340

Adult smoking and tobacco use data come from CDC's 2018 Behavioral Risk Factor Surveillance System. High school smoking and tobacco use rates are taken from the 2017 Youth Risk Behavior Surveillance System. A current middle school smoking rate is not available for this state.

Health impact information is taken from the Smoking Attributable Mortality, Morbidity and Economic Costs (SAMMEC) software. Smoking attributable deaths reflect average annual estimates for the period 2005-2009 and are calculated for persons aged 35 years and older. Smoking-attributable health care expenditures are based on 2004 smoking-attributable fractions and 2009 personal health care expenditure data. Deaths and expenditures should not be compared by state.


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Texas State Highlights Select a different state

Tobacco use remains the leading cause of preventable death and disease in the United States and in Texas. To address this enormous toll, the American Lung Association calls for the following actions to be taken by Texas' elected officials:
1. Restore funding for tobacco prevention and cessation programs that was significantly cut in 2017;
2. Continue to pass comprehensive local smokefree ordinances to build towards a statewide smokefree law; and
3. Strengthen state laws related to tobacco retailer licensing.

The American Lung Association in Texas along with our partners at Smoke-Free Texas provides leadership and guidance for public policy efforts to continue the state's success in reducing the impact of tobacco among Texans. Together with our partners, the Lung Association in Texas works to ensure tobacco control and prevention remains a priority for state legislators and local decision makers.

During the 2019 legislative session, the Lung Association along with our partners worked to support raising the minimum legal sales age for tobacco products to 21. The final bill which was signed by Governor Abbott did include a provision preempting local governments from raising the age above 21 as well as an exemption for federal or state military members. The Lung Association withdrew its support for the bill in the end due to these provisions, and the fact that there were limited resources for enforcement of the law. The Lung Association did support a measure to send to the ballot a bond to fund the Cancer Prevention and Research Institute of Texas (CPRIT) for another 10 years. The bond was approved by voters in November 2019.

Funding for tobacco prevention and cessation programs in Texas increased slightly in the two-year state budget approved by the legislature in 2019; for fiscal year 2020 it is $4.67 million vs. $4.25 million in fiscal year 2019. However, this remains well short of the over $10 million funding level prior to 2017 limiting the program's ability to address the youth e-cigarette epidemic.

The Lung Association in Texas and its partners in the Smokefree Texas coalition worked in communities around the state to pass local smokefree ordinances. Fort Worth implemented its local smokefree law in March 2019 becoming the last major city in Texas to prohibit smoking in virtually all public places and workplaces. Texas currently has 104 cities with comprehensive smokefree ordinances protecting more than 12.5 million citizens from the harmful effects of secondhand smoke.

The Texas Legislature only meets in off numbered years, so moving forward in 2020 the American Lung Association in Texas and its partners in the Smokefree Texas Coalition will continue to work in communities around the state to pass local smokefree ordinances.

Texas Facts

Economic Cost Due to Smoking: $8,855,602,443
Adult Smoking Rate: 14.40%
Adult Tobacco Use Rate: 25.10%
High School Smoking Rate: 5.50%
High School Tobacco Use Rate: 22.40%
Middle School Smoking Rate: 1.80%
Smoking Attributable Deaths: 28,030

Adult smoking and tobacco use data come from CDC's 2018 Behavioral Risk Factor Surveillance System. High school smoking and tobacco use (11th grade only) and middle school smoking (8th grade only) rates are taken from the 2018 Texas School Survey.

Health impact information is taken from the Smoking Attributable Mortality, Morbidity and Economic Costs (SAMMEC) software. Smoking attributable deaths reflect average annual estimates for the period 2005-2009 and are calculated for persons aged 35 years and older. Smoking-attributable health care expenditures are based on 2004 smoking-attributable fractions and 2009 personal health care expenditure data. Deaths and expenditures should not be compared by state.


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Tennessee State Highlights Select a different state

Tobacco use remains the leading cause of preventable death and disease in the United States and in Tennessee. To address this enormous toll, the American Lung Association calls for the following actions to be taken by Tennessee's elected officials:
1. Increase funding for the Tennessee Tobacco Program to $4 million and designate funding as a recurring line item in the annual budget;
2. Close loopholes in the statewide law restricting smoking; and
3. Repeal preemption of local tobacco control authority.

During the 2019 session of the Tennessee General Assembly, funding was restored at $2 million for the Tennessee Department of Health's tobacco prevention and cessation program after being zeroed out the previous year. A push is expected in 2020 to increase the funding level to $4 million and to establish it as a recurring line item in the state's annual budget.

Also in the 2019 session, a strong bill was introduced to raise the state sales age for tobacco to 21, including e-cigarettes. The bill included meaningful enforcement provisions and was supported by the American Lung Association in Tennessee and our partner health organizations. Marking a first and significant shift in process, the legislation was referred to the Senate Health and Welfare Committee, instead of the committee on Agriculture where opposition is formidable. Plans are presently underway for another Tobacco 21 push when the 2020 session convenes.

While efforts to remove preemption of local smokefree ordinances in Tennessee have not advanced in recent years, the Lung Association and our health advocate partners will continue the effort to educate the many newly elected legislators and Administration on this important issue.

Finally, the Administration has released its first-in-the-nation draft waiver to block grant the state's Medicaid program, TennCare. Block grants, instead of matching dollars, mean federal government contributions to fund the state program are limited. This could, among other things, limit prescription drug coverage and access to tobacco cessation medications, undermining smokers' quit attempts.

A 2019 Tennessee Tobacco and Vape Poll found support for Tobacco 21 is broad and deep in the state, crossing party, ideological and demographic lines. Voters strongly support smokefree workplaces, and Tennesseans overwhelmingly back dedicated tobacco prevention funding. This, in conjunction with the many concerns that have surfaced over the health implications of e-cigarette use, will likely help create a climate more amenable to tobacco policy advances.

The American Lung Association in Tennessee will continue working with our many health coalition partners and others to grow and activate our grassroots network statewide, and to advance tobacco control and prevention initiatives at the state and local levels. As the legislature begins its work in 2020, the Lung Association will continue our efforts to educate policymakers, business leaders and media on the importance of the American Lung Association's goals to reduce all tobacco use, including e-cigarettes, and to protect public health.

Tennessee Facts

Economic Cost Due to Smoking: $2,672,824,085
Adult Smoking Rate: 20.70%
Adult Tobacco Use Rate: 31.20%
High School Smoking Rate: 9.40%
High School Tobacco Use Rate: 20.30%
Middle School Smoking Rate: N/A
Smoking Attributable Deaths: 11,380

Adult smoking and tobacco use data come from CDC's 2018 Behavioral Risk Factor Surveillance System. High school smoking and tobacco use rates are taken from the 2017 Youth Risk Behavior Surveillance System. A current middle school smoking rate is not available for this state.

Health impact information is taken from the Smoking Attributable Mortality, Morbidity and Economic Costs (SAMMEC) software. Smoking attributable deaths reflect average annual estimates for the period 2005-2009 and are calculated for persons aged 35 years and older. Smoking-attributable health care expenditures are based on 2004 smoking-attributable fractions and 2009 personal health care expenditure data. Deaths and expenditures should not be compared by state.


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South Dakota State Highlights Select a different state

Tobacco use remains the leading cause of preventable death and disease in the United States and in South Dakota. To address this enormous toll, the American Lung Association calls for the following actions to be taken by South Dakota's elected officials:
1. Increase the tax on cigarettes and other tobacco products by a $1.00 per pack or more;
2. Ensure compliance and enforcement of Tobacco 21; and
3. Fully fund South Dakota's tobacco control program at Centers for Disease Control and Prevention recommended levels.

The South Dakota Department of Health along with national, state and local partners continue to work together on the implementation of the five-year tobacco strategic plan. The four goal areas of the plan include: preventing initiation of tobacco use, promoting quitting among adults and youth, eliminating exposure to secondhand smoke and identifying and eliminating tobacco-related disparities among population groups. Priority populations include: American Indians, Medicaid clients, pregnant women, people with mental illness and substance use disorders, spit tobacco users, youth and young adults.

During the 2019 legislative session, the legislature approved a law that prohibits the use of e-cigarettes in public places where smoking is prohibited. This law strengthens the current law and protects the rights of those who live or work in South Dakota to breathe clean air, free from secondhand exposure to nicotine or other potentially harmful chemicals found in these products. It also helps ensure the enforcement of existing smoke-free laws and that the benefits to public health are not undermined.

Medicaid coverage of quit smoking treatments in South Dakota are far from comprehensive, and one of the main reasons is a state law that prevents the state Medicaid program from covering non-prescription medications. The American Lung Association in South Dakota encourages legislators to address this issue in 2020 by either repealing this antiquated state law or making an exception, so Medicaid enrollees who smoke at higher rates can gain access to a fuller range of quit smoking treatment options.

The coalition in South Dakota has strong roots across the state and is working together to support tobacco control best practices and continues to work together to implement the strategic plan to reduce the harm from tobacco in South Dakota.

South Dakota Facts

Economic Cost Due to Smoking: $373,112,273
Adult Smoking Rate: 19.00%
Adult Tobacco Use Rate: 28.30%
High School Smoking Rate: 10.10%
High School Tobacco Use Rate: 30.30%
Middle School Smoking Rate: 2.00%
Smoking Attributable Deaths: 1,250

Adult smoking and tobacco use data come from CDC's 2018 Behavioral Risk Factor Surveillance System. High school smoking and tobacco use data come from the 2015 Youth Risk Behavior Surveillance System. Middle school smoking rate is taken from the 2017 Youth Tobacco Survey.

Health impact information is taken from the Smoking Attributable Mortality, Morbidity and Economic Costs (SAMMEC) software. Smoking attributable deaths reflect average annual estimates for the period 2005-2009 and are calculated for persons aged 35 years and older. Smoking-attributable health care expenditures are based on 2004 smoking-attributable fractions and 2009 personal health care expenditure data. Deaths and expenditures should not be compared by state.


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South Carolina State Highlights Select a different state

Tobacco use remains the leading cause of preventable death and disease in the United States and in South Carolina. To address this enormous toll, the American Lung Association calls for the following actions to be taken by South Carolina's elected officials:
1. Increase the price of tobacco products to reduce tobacco use among youth and adults and equalize tax for all tobacco products including e-cigarettes;
2. Oppose all forms of preemption of state and local tobacco control authority; and
3. Maintain funding for the state's tobacco prevention program and ensure funding is spent according to Centers for Disease Control and Prevention (CDC) Best Practices.

2019 was a busy year in the South Carolina Legislature. Bills were introduced on youth access to tobacco and electronic cigarettes, increasing the age of sale, Internet sales, increasing tobacco taxes, and prohibiting local governments from enacting laws to protect kids from vaping products.

Tobacco industry supporters launched Senate Bill 492 and House Bill 3274 to prohibit local governments from passing ordinances to protect kids from tobacco and electronic cigarettes. This preemption of local authority pertained to ingredients, flavors, or licensing of cigarettes, electronic cigarettes, tobacco products, or alternative nicotine products. House Bill 3274 moved to the Senate but was denied a vote on the Senate floor by a vote of 21 to 18 in the final two days of the session. Senator Marlon Kimpson, from Charleston, led the charge to keep the bill from passing. The Lung Association and partners fought the influence of many tobacco and JUUL lobbyists. As this is a carryover session both bills are eligible for consideration again next year.

To reduce youth access to all tobacco products including e-cigarettes, legislation passed into law by Rep. Beth Bernstein sought to strengthen age verification requirements for Internet sales, prohibit persons under age 18 from entering retail establishments that primarily sell such products, require local school districts to prohibit the use of tobacco and alternative nicotine products on school campuses and at school events; and require child-resistant e-liquid containers with warning labels.

Legislative discussions highlighted the need to strengthen tobacco use policies to reduce smoking-caused disease and keep kids from beginning to smoke and vape. South Carolina is among the minority of states that does not require a license for sales of tobacco products including electronic cigarettes. It is a law that is sorely needed. The cigarette tax is $0.57 per pack (45th among all states and DC). The average state tax on a pack of cigarettes is $1.81. Electronic cigarettes should be included and taxed at the same rate as other tobacco products. The state tobacco prevention program needs additional funds to arm kids, parents and communities with information, resources and tools to fight the youth vaping epidemic.

In 2020, the American Lung Association in South Carolina will continue to advocate for policies that reduce smoking rates and prevent the loss of future generations to tobacco-caused disease.

South Carolina Facts

Economic Cost Due to Smoking: $1,906,984,487
Adult Smoking Rate: 18.00%
Adult Tobacco Use Rate: 24.00%
High School Smoking Rate: 10.00%
High School Tobacco Use Rate: 21.60%
Middle School Smoking Rate: 3.20%
Smoking Attributable Deaths: 7,230

Adult smoking and tobacco use data come from CDC's 2018 and 2017 Behavioral Risk Factor Surveillance System, respectively. High school smoking and tobacco use data come from the 2017 Youth Risk Behavior Surveillance System. Middle school smoking rate is taken from the 2015 Youth Tobacco Survey. High school smoking and tobacco use data come from the 2017 Youth Risk Behavior Surveillance System. Middle school smoking rate is taken from the 2017 Youth Tobacco Survey.

Health impact information is taken from the Smoking Attributable Mortality, Morbidity and Economic Costs (SAMMEC) software. Smoking attributable deaths reflect average annual estimates for the period 2005-2009 and are calculated for persons aged 35 years and older. Smoking-attributable health care expenditures are based on 2004 smoking-attributable fractions and 2009 personal health care expenditure data. Deaths and expenditures should not be compared by state.


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Rhode Island State Highlights Select a different state

Tobacco use remains the leading cause of preventable death and disease in the United States and in Rhode Island. To address this enormous toll, the American Lung Association calls for the following actions to be taken by Rhode Island's elected officials:
1. Prohibit the sale of all flavored tobacco products; and
2. Fund tobacco prevention and cessation programs at the Centers for Disease Control and Prevention (CDC) recommended level; and
3. Ensure enforcement of the minimum age of sale of 21 for tobacco products.

Tobacco prevention and control legislation was not a priority for the Rhode Island State Legislature in 2019. Despite strong hearings with an outpouring of support from advocates statewide, and success in both of Rhode Island's neighboring states Massachusetts and Connecticut, state legislation to raise the minimum tobacco sales age from 18 to 21, died in committee. With all other states in New England passing or already having higher minimum ages after 2019, Rhode Island at 18 is now the lowest. Equalizing tax rates across all tobacco products including establishing a state excise tax on e-cigarettes, was eliminated from the state budget, along with hopes of increasing funding to Rhode Island's severely underfunded tobacco control program to the CDC-recommended level of $12.8 million.

Given several lawsuits against Rhode Island cities and towns in the past few years, and a noticeable halt in public policies enacted at the local level for fear of being sued, new state legislation which would give back the power to local authorities to implement and enforce strong tobacco control strategies, was necessary, timely and introduced. Strong support from local advocates and localities was garnered and capacity was built in preparation for next year.

Tobacco Free Rhode Island (TFRI), a grant funded through the Rhode Island Department of Health and administered through the American Lung Association in Rhode Island, made huge gains this year. More than 12,000 students, parents, educators, medical and public health professionals, were educated about the harms of e-cigarette use, marketing strategies, and current tobacco trends. Furthermore, through a strong partnership and funding from CVS Health, TFRI also created and implemented a smoke-free schools model policy, inclusive of e-cigarettes, that detailed enforcement best practices.

In light of the alarming youth e-cigarette epidemic, in September 2019, Governor Raimondo took strong executive action to temporarily prohibit the sale of all flavored e-cigarettes and directed state departments to explore other comprehensive policy solutions that are proven to reduce youth tobacco use rates. A vaping advisory committee was established to weigh-in on permanent regulations.

Looking ahead to 2020, the American Lung Association in Rhode Island calls on Rhode Island state legislators and policy makers now more than ever, to enact permanent regulations that prohibit the sales of all flavored tobacco products with strong enforcement and penalties to hold violators accountable and to pass a comprehensive set of tobacco control policies aimed at protecting all Rhode Islanders from a lifetime of tobacco addiction and disease.

Rhode Island Facts

Economic Cost Due to Smoking: $639,604,224
Adult Smoking Rate: 14.60%
Adult Tobacco Use Rate: 18.60%
High School Smoking Rate: 4.20%
High School Tobacco Use Rate: 25.90%
Middle School Smoking Rate: 1.60%
Smoking Attributable Deaths: 1,780

Adult smoking and tobacco use data come from CDC's 2018 Behavioral Risk Factor Surveillance System. High school and middle school smoking rates are taken from the 2019 Rhode Island Youth Risk Behavior Surveillance System. High school tobacco use rate is taken from the 2017 Youth Risk Behavior Surveillance System.

Health impact information is taken from the Smoking Attributable Mortality, Morbidity and Economic Costs (SAMMEC) software. Smoking attributable deaths reflect average annual estimates for the period 2005-2009 and are calculated for persons aged 35 years and older. Smoking-attributable health care expenditures are based on 2004 smoking-attributable fractions and 2009 personal health care expenditure data. Deaths and expenditures should not be compared by state.


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Pennsylvania State Highlights Select a different state

Tobacco use remains the leading cause of preventable death and disease in the United States and in Pennsylvania. To address this enormous toll, the American Lung Association calls for the following actions to be taken by Pennsylvania's elected officials:
1. Fund tobacco prevention and cessation programs at the Centers for Disease Control and Prevention (CDC)-recommended level;
2. Close loopholes in Pennsylvania's Clean Indoor Air Act and make all public places and workplaces smokefree; and
3. Create tax parity between cigarettes and other tobacco products.

The 2019 legislative session was the first year of the Pennsylvania General Assembly's two-year session. In March 2019, Senator Mario Scavello introduced Tobacco 21 legislation, which proposed increasing the age of sale for tobacco products to 21. The bill was amended and passed out of the Senate Judiciary committee, adding e-cigarettes to the definition of tobacco products, making them enforceable under Act 112 retail compliance checks. The American Lung Association in Pennsylvania supported the amended legislation and took bold action to mobilize regional and statewide advocates including youth to launch the #UpTheAge campaign. In September 2019, the Pennsylvania Senate passed this legislation 43-6. The bill then moved to the House for consideration. On November 21, 2019, the Pennsylvania House passed an amended version of Senate Bill 473. Unfortunately, during the legislative process, an amendment was added to the bill that provides an exemption for active duty military and veterans, which the Lung Association strongly opposed. The bill was also amended to include language allowing school districts to designate areas on school property where tobacco products can be used by non-students. Because of these provisions, the Lung Association withdrew support of the bill. Governor Wolf signed the bill into law on November 27, 2019. The legislation will go into effect July 1, 2020.

The 2019 legislative session brought the threat of devastating funding cuts to tobacco prevention and control programs. The Lung Association and partners initiated a comprehensive statewide effort to educate legislators and the public on the programs and their necessity in the fight to further reduce tobacco use. The Pennsylvania state budget passed and was signed by the Governor, which allocated intact funding for tobacco prevention and control programs, in the amount of $15.146 million, or 4.5 percent of distributions from the Tobacco Settlement Fund. This fund is where annual tobacco Master Settlement Agreement payments in Pennsylvania are directed to.

Other notable legislative activities include Representative Dan Frankel and Senator Mario Scavello's introduction of a co-sponsorship memorandum to close the loopholes in Pennsylvania's Clean Indoor Air Act. Representative Eddie Day Pashinki similarly introduced legislation to restrict the sales of flavored e-cigarettes in the Commonwealth.

In 2020, the American Lung Association in Pennsylvania will continue to work with our partners to educate lawmakers and the public on the ongoing fight against tobacco through proven policies such as increasing funding for tobacco prevention and control programs and removing exemptions from the state Clean Indoor Air Act.

Pennsylvania Facts

Economic Cost Due to Smoking: $6,383,194,368
Adult Smoking Rate: 17.00%
Adult Tobacco Use Rate: 23.00%
High School Smoking Rate: 8.70%
High School Tobacco Use Rate: 18.70%
Middle School Smoking Rate: 1.30%
Smoking Attributable Deaths: 22,010

Adult smoking and tobacco use data come from CDC's 2018 and 2017 Behavioral Risk Factor Surveillance System, respectively. High school smoking and tobacco use data come from the 2017 Youth Risk Behavior Surveillance System. Middle school smoking rate is taken from the 2015 Youth Tobacco Survey.

Health impact information is taken from the Smoking Attributable Mortality, Morbidity and Economic Costs (SAMMEC) software. Smoking attributable deaths reflect average annual estimates for the period 2005-2009 and are calculated for persons aged 35 years and older. Smoking-attributable health care expenditures are based on 2004 smoking-attributable fractions and 2009 personal health care expenditure data. Deaths and expenditures should not be compared by state.


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Oregon State Highlights Select a different state

Tobacco use remains the leading cause of preventable death and disease in the United States and in Oregon. To address this enormous toll, the American Lung Association calls for the following actions to be taken by Oregon's elected officials:
1. Prohibit the sale of all flavored tobacco products, including electronic cigarettes;
2. Increase state funding for tobacco prevention and cessation programs; and
3. Defend Oregon's Clean Indoor Air Act.

During the 2019 legislative session, the American Lung Association in Oregon joined together with other tobacco prevention advocates to support increasing the cigarette tax by $2.00 per pack. Oregon's current tax is $1.33 per pack and ranks 32nd among all states. House Bill 2270 passed both the House and Senate, referring the $2.00 tobacco tax to the voters. The measure will also impose a tax on inhalant delivery systems at a rate of 65% of the wholesale price and increase the cap on cigar taxes from $0.50 to $1.00.

The $2.00 per pack cigarette tax increase is projected to raise $160 million of new revenue for Oregon. Oregon voters will cast their ballots for this measure on November 3, 2020.

Legislation to exempt cannabis lounges from Oregon's Clean Indoor Air Act did not pass.

In response to the deaths and illness from vaping, Governor Kate Brown issued a 180 day restriction on the sale of all flavored vaping products. The executive order was challenged in court and the ban on non-THC tobacco products was stayed by the court. The American Lung Association in Oregon will work to pursue a legislative solution to prohibit the sale of all flavored tobacco products.

Counties around Oregon are working proactively on policies to reduce the toll of tobacco in local communities. Multnomah County has hosted listening sessions on restricting the sale of tobacco products. Clackamas, Lane and Hood River counties are discussing tobacco retail licensing.

The American Lung Association in Oregon will continue its work with stakeholders and engaged volunteers to advocate for policies to reduce tobacco use and its health impacts on all Oregonians in 2020.

Oregon Facts

Economic Cost Due to Smoking: $1,547,762,592
Adult Smoking Rate: 15.60%
Adult Tobacco Use Rate: 23.50%
High School Smoking Rate: 7.70%
High School Tobacco Use Rate: 18.90%
Middle School Smoking Rate: 3.00%
Smoking Attributable Deaths: 5,470

Adult smoking and tobacco use data come from CDC's 2018 Behavioral Risk Factor Surveillance System. High school (11th grade only) smoking and tobacco use and middle school (8th grade only) smoking rates are taken from the 2017 Oregon Healthy Teens Survey. High school tobacco use includes cigarettes, cigars, smokeless tobacco, and electronic vapor products, as well as hookah, making it incomparable to other states.

Health impact information is taken from the Smoking Attributable Mortality, Morbidity and Economic Costs (SAMMEC) software. Smoking attributable deaths reflect average annual estimates for the period 2005-2009 and are calculated for persons aged 35 years and older. Smoking-attributable health care expenditures are based on 2004 smoking-attributable fractions and 2009 personal health care expenditure data. Deaths and expenditures should not be compared by state.


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Oklahoma State Highlights Select a different state

Tobacco use remains the leading cause of preventable death and disease in the United States and in Oklahoma. To address this enormous toll, the American Lung Association calls for the following actions to be taken by Oklahoma's elected officials:
1. Maintain dedicated funding for tobacco prevention and cessation programs; and
2. Pass a comprehensive statewide smokefree law that protects all workers and patrons from secondhand smoke.

During the 2019 legislative session, the American Lung Association in Oklahoma along with our partners worked on House Bill 2288, The Oklahoma Workplace Clean Air Act. Oklahoma remains one of 22 states that still does not have a comprehensive statewide smokefree law. The bill was able to make it to the House Floor but did not receive a floor vote. However, the legislation is eligible for consideration again in 2020.

Dedicated funding from the tobacco Master Settlement Agreement (MSA) for the Oklahoma Tobacco Settlement Endowment Trust (TSET) remained intact for fiscal year 2020, despite several attempts during the 2019 legislative session to divert funding. Oklahoma voters made a wise decision by putting 75 percent of MSA payments each year into TSET, and the Lung Association will oppose any attempts to raid these funds by the legislature.

Program initiatives of TSET and the Oklahoma Department of Health to prevent and reduce tobacco use include the Oklahoma Tobacco Helpline at 1-800-QUIT-NOW, cessation systems grants, community grants covering over 85 percent of the state's population, funding for tribal nations and other priority populations and statewide media campaigns intended to change the social norms related to tobacco use.

In 2020, the American Lung Association in Oklahoma, along with public health partners, will continue to raise public awareness regarding the need for a comprehensive statewide smokefree law. The Lung Association will also continue to protect funding for TSET and the Oklahoma Department of Health.

Oklahoma Facts

Economic Cost Due to Smoking: $1,622,429,589
Adult Smoking Rate: 19.70%
Adult Tobacco Use Rate: 28.60%
High School Smoking Rate: 12.50%
High School Tobacco Use Rate: 25.60%
Middle School Smoking Rate: 4.10%
Smoking Attributable Deaths: 7,490

Adult smoking and tobacco use data come from CDC's 2018 and 2017 Behavioral Risk Factor Surveillance System, respectively. High school and middle school smoking rates are taken from the 2019 Youth Risk Behavior Surveillance System. High school tobacco use rate is taken from the 2017 Youth Risk Behavior Surveillance System.

Health impact information is taken from the Smoking Attributable Mortality, Morbidity and Economic Costs (SAMMEC) software. Smoking attributable deaths reflect average annual estimates for the period 2005-2009 and are calculated for persons aged 35 years and older. Smoking-attributable health care expenditures are based on 2004 smoking-attributable fractions and 2009 personal health care expenditure data. Deaths and expenditures should not be compared by state.


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Ohio State Highlights Select a different state

Tobacco use remains the leading cause of preventable death and disease in the United States and in Ohio. To address this enormous toll, the American Lung Association calls for the following actions to be taken by Ohio's elected officials:
1. Match the tax on non-cigarette forms of tobacco like spit tobacco, cigars and hookah to the cigarette tax;
2. Prohibit flavorings for all tobacco products, including e-cigarettes; and
3. Increase funding for tobacco prevention and cessation programs to bring it closer to the Centers for Disease Control and Prevention's recommendation for Ohio.

In 2019, Ohio became the 18th state to enact a statewide Tobacco 21 law. This new law was proposed by Governor Mike DeWine in his 2019 budget recommendation and adopted as part of final state budget by the legislature. The Lung Association had been successful at working with coalitions that adopted local Tobacco 21 laws in a number of Ohio communities. By the time that Ohio adopted the state law in July 2019, 19 cities and counties in Ohio had already adopted local Tobacco 21 ordinances.

The state budget also established a new, separate tax on e-cigarettes. While the establishment of a tax on these products is a good thing, the tax is a low weight-based tax that may have limited impact on the use of the products.

While increasing the taxes on tobacco products was not proposed by Governor DeWine, the Lung Association will continue to work with our partners to increase the cigarette tax and to call for parity for taxes on non-cigarette forms of tobacco like spit tobacco, cigars, and e-cigarettes. These tobacco products attract younger, more price sensitive consumers and raising taxes on these products to achieve parity with cigarette taxes can prevent some kids from becoming addicted in the first place.

The Lung Association will also advocate for an increase in funding for tobacco control and prevention programs. While funding increased to a higher baseline under the Kasich Administration, which has continued under Governor DeWine, Ohio is currently spending just 11 percent of what is recommended by the Centers for Disease Control for a state of our size.

As we look to 2020, the American Lung Association in Ohio will continue to work with a broad coalition of stakeholders to increase funding for evidence-based tobacco prevention and cessation programs and put restrictions on the sale of flavored tobacco products.

Ohio Facts

Economic Cost Due to Smoking: $5,647,310,236
Adult Smoking Rate: 20.50%
Adult Tobacco Use Rate: 28.00%
High School Smoking Rate: 7.00%
High School Tobacco Use Rate: N/A
Middle School Smoking Rate: 2.60%
Smoking Attributable Deaths: 20,180

Adult smoking and tobacco use data come from CDC's 2018 Behavioral Risk Factor Surveillance System. High school and middle school smoking rates are taken from the 2018-2019 Ohio Youth Tobacco Survey. A current high school tobacco use rate is not available for this state.

Health impact information is taken from the Smoking Attributable Mortality, Morbidity and Economic Costs (SAMMEC) software. Smoking attributable deaths reflect average annual estimates for the period 2005-2009 and are calculated for persons aged 35 years and older. Smoking-attributable health care expenditures are based on 2004 smoking-attributable fractions and 2009 personal health care expenditure data. Deaths and expenditures should not be compared by state.


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North Dakota State Highlights Select a different state

Tobacco use remains the leading cause of preventable death and disease in the United States and in North Dakota. To address this enormous toll, the American Lung Association calls for the following three actions to be taken by our elected officials:
1. Raise the state tobacco tax currently at 44 cents per pack by a significant amount;
2. Ensure the compliance and enforcement of Tobacco 21; and
3. Restrict access to all flavored tobacco products.

North Dakota has the fourth lowest cigarette tax in the country at 44 cents per pack. The tax has not been raised since 1993. The Tobacco Free North Dakota coalition worked to pass a tobacco tax increase along with taxing liquid nicotine and electronic smoking devices in 2019.

One proposal on the table during the 2019 legislative session was to change the tax on cigarettes to an ad valorem percentage of wholesale price tax. One downside to this approach was it would have created bigger price gaps between premium and discount brands of cigarettes potentially leading smokers to use cheaper brands rather than quit. However, the legislature ended up passing an act to provide for a legislative management study of the issue. The study is to include the current method of taxation applied to these products, the methods of taxation applied in other states, and the fiscal impact of applying an alternative or additional method of taxation.

In 2019, coalition efforts successfully defended the strong North Dakota smokefree workplace law by defeating a bill that would allow for the indoor smoking of cigars and any premium tobacco product under certain conditions. State funding for the state's tobacco control program in the new two-year state budget passed in 2019 remained about the same as the previous two years at $5.28 million per year. This is still a substantial reduction from when the the voter-approved Tobacco Prevention and Control Trust Fund still existed prior to 2017.

North Dakota does not have a legislative session in 2020. However, the American Lung Association in North Dakota will continue its work to educate both state and local
decision makers about the benefits of a higher tobacco tax, ensuring the compliance and enforcement with the nationwide tobacco sales age of 21 and restricting access to flavored tobacco products.

North Dakota Facts

Economic Cost Due to Smoking: $325,798,988
Adult Smoking Rate: 19.10%
Adult Tobacco Use Rate: 27.50%
High School Smoking Rate: 9.00%
High School Tobacco Use Rate: 28.80%
Middle School Smoking Rate: 2.40%
Smoking Attributable Deaths: 980

Adult smoking and tobacco use data come from CDC's 2018 Behavioral Risk Factor Surveillance System. High school and middle school smoking rates are taken from the 2017 Youth Tobacco Survey. High school tobacco use rate is taken from the 2017 Youth Risk Behavior Surveillance System.

Health impact information is taken from the Smoking Attributable Mortality, Morbidity and Economic Costs (SAMMEC) software. Smoking attributable deaths reflect average annual estimates for the period 2005-2009 and are calculated for persons aged 35 years and older. Smoking-attributable health care expenditures are based on 2004 smoking-attributable fractions and 2009 personal health care expenditure data. Deaths and expenditures should not be compared by state.


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North Carolina State Highlights Select a different state

Tobacco use remains the leading cause of preventable death and disease in the United States and in North Carolina. To address this enormous toll, the American Lung Association calls for the following actions to be taken by North Carolina's elected officials:
1. Restore funding for tobacco use prevention and cessation programs, including QuitlineNC;
2. Raise the state cigarette tax to the national average of $1.81 per pack; and
3. Resist attempts to weaken the smokefree restaurants and bars law and expand the law to include all public places and private worksites.

North Carolina experienced an epidemic rise in high school e-cigarette use according to the 2017 North Carolina Youth Tobacco Survey. The report noted a staggering increase in use of 894 percent from 2011 to 2017. Stepping forward to address this alarming trend, the North Carolina Division of Public Health introduced an evidence-based social marketing campaign directed at teens and young adults. The campaign targeted a "country" peer crowd, who are at risk for using e-cigarettes as well as cigarettes and smokeless tobacco. Results showed those who identified with the Country Teen Peer Crowd messages were more likely to be aware of the campaign than non-country teens, they liked the campaign ads (74%), and found them believable (78-79%) and impactful (79-81%). Country Teens aware of the campaign were more likely to report attempting to quit tobacco compared with Country Teens unaware of the campaign. Also, in May of 2019, State Attorney General Josh Stein filed a lawsuit against JUUL for designing, marketing, and selling its e-cigarettes to attract young people and for misrepresenting the potency and danger of nicotine in its products. North Carolina was the first state to take legal action against JUUL. These actions demonstrate what can be done when leadership and resources are at hand.

As part of the North Carolina Alliance for Health, the American Lung Association in North Carolina and tobacco control partners have advocated for increases in funding for the Tobacco Prevention and Control Branch of the North Carolina Division of Public Health. Funding levels are far less than the $17.3 million the tobacco use prevention and cessation programs received in 2011 and before, and even further from the levels recommended by the Centers for Disease Control and Prevention.

Without passage of the fiscal year 2020 North Carolina budget, the state tobacco program has only $2,150,000 in state funds to meet the challenges ahead. The Lung Association warns we risk losing future generations to tobacco-caused diseases as the result of e-cigarettes and other vaping products. More funding is critical to meet this emerging public health crisis.

The American Lung Association in North Carolina will continue to partner with the North Carolina Alliance for Health to increase state tobacco prevention program funding, defend against any attempts to weaken the smokefree restaurants and bars law and increase the excise tax on all tobacco products including electronic cigarettes in 2020.

North Carolina Facts

Economic Cost Due to Smoking: $3,809,676,476
Adult Smoking Rate: 17.40%
Adult Tobacco Use Rate: 27.10%
High School Smoking Rate: 8.90%
High School Tobacco Use Rate: 28.80%
Middle School Smoking Rate: 2.50%
Smoking Attributable Deaths: 14,220

Adult smoking and tobacco use data come from CDC's 2018 Behavioral Risk Factor Surveillance System. High school smoking and tobacco use and middle school smoking rates are taken from the 2017 Youth Tobacco Survey. High school tobacco use includes cigarettes, cigars, smokeless tobacco, and electronic vapor products, as well as pipes, bidis, roll-your-own cigarettes, hookah, snus, dissolvable tobacco products, and clove cigars, making it incomparable to other states.

Health impact information is taken from the Smoking Attributable Mortality, Morbidity and Economic Costs (SAMMEC) software. Smoking attributable deaths reflect average annual estimates for the period 2005-2009 and are calculated for persons aged 35 years and older. Smoking-attributable health care expenditures are based on 2004 smoking-attributable fractions and 2009 personal health care expenditure data. Deaths and expenditures should not be compared by state.


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New York State Highlights Select a different state

Tobacco use remains the leading cause of preventable death and disease in the United States and in New York. To address this enormous toll, the American Lung Association calls for the following actions to be taken by New York's elected officials:
1. Prohibit the sale of all flavored tobacco products;
2. Increase funding to New York's Tobacco Control Program; and
3. Increase tobacco taxes by significant amounts.

In 2019, New York made some significant progress on the tobacco use prevention front. The year began with promise and frustration. In January, Governor Cuomo's proposed executive budget included Tobacco 21, language that would prohibit the sale of tobacco products in pharmacies; flavored tobacco restrictions; prohibiting the use of coupons, vouchers or rebates which would discount the price of any tobacco product, including e-cigarettes; a tobacco display prohibition; the licensing of e-cigarette retailers; and a tax on e-cigarettes. Ultimately, the enacted fiscal year 2020 budget passed into law the tax on e-cigarettes and the licensing of e-cigarette retailers.

By 2019, after significant progress at the local level, more than 75 percent of New Yorkers were covered by local laws increasing the tobacco sales age to 21. While Tobacco 21 was not included in the enacted budget, Tobacco 21 legislation ultimately passed both houses and was signed into law. New York now prohibits the sale of tobacco products to those under age 21.

The American Lung Association in New York is making progress with prohibiting the sale of all flavored tobacco products. On the local level, New York City, Albany County, Westchester County and Nassau County have all introduced legislation that prohibits some or all flavored tobacco products. The town of Manheim in Herkimer County passed a local ordinance that restricts all flavored tobacco products and the City of Yonkers restricts the sale of all flavored e-cigarettes.

The Lung Association is highly concerned that New York is seeing the first increase in openness to smoking observed in this decade. The openness to using e-cigarettes is not only higher than openness to smoking conventional cigarettes among high school youth, but it has increased from 23.7 percent in 2014 to 31 percent in 2018, a statistically significant increase.

It is imperative that in 2020 New York begin to counter the stagnation of funding that has plagued the tobacco control program for a number of years. Lack of funding has had a direct impact on two critical areas: decreasing the disparities in tobacco use that continue to exist across the state, and protecting youth from e-cigarette use and a lifetime of nicotine addiction. Ending the sale of flavored tobacco products is critical for prevention and addressing the youth e-cigarette epidemic. In 2020, the American Lung Association in New York hopes to see more counties take the initiative to pass laws to remove flavored tobacco products on the local level while we work with our partners to advance statewide legislation.

New York Facts

Economic Cost Due to Smoking: $10,389,849,268
Adult Smoking Rate: 12.80%
Adult Tobacco Use Rate: 17.50%
High School Smoking Rate: 5.50%
High School Tobacco Use Rate: 19.30%
Middle School Smoking Rate: 1.20%
Smoking Attributable Deaths: 28,170

Adult smoking and tobacco use data come from CDC's 2018 Behavioral Risk Factor Surveillance System. High school smoking and tobacco use rates are taken from the 2017 Youth Risk Behavior Surveillance System. Middle school smoking rate is taken from the New York 2014 Youth Tobacco Survey.

Health impact information is taken from the Smoking Attributable Mortality, Morbidity and Economic Costs (SAMMEC) software. Smoking attributable deaths reflect average annual estimates for the period 2005-2009 and are calculated for persons aged 35 years and older. Smoking-attributable health care expenditures are based on 2004 smoking-attributable fractions and 2009 personal health care expenditure data. Deaths and expenditures should not be compared by state.


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New Mexico State Highlights Select a different state

Tobacco use remains the leading cause of preventable death and disease in the United States and in New Mexico. To address this enormous toll, the American Lung Association calls for the following actions to be taken by New Mexico's elected officials:
1. Maintain or increase funding for state's tobacco prevention and control program;
2. Pass statewide licensing of tobacco product, including e-cigarette retailers; and
3. Remove statewide preemption for tobacco product sales laws.

The American Lung Association in New Mexico provides leadership in convening partners and guiding public policy efforts to continue the state's success in reducing the impact of tobacco among New Mexicans. Together with our partners, the Lung Association works to ensure tobacco control and prevention remains a priority for state legislators and local decision makers.

In 2019, the Lung Association's focus was to continue to educate legislators, legislative staff, and the general public about smoking and the importance of providing tobacco cessation programs for adults and youth, and the dangers of secondhand smoke. During the legislative session the Lung Association along with our partners were unsuccessful in an effort to raise the state's cigarette tax by $1.50 per pack and impose an equivalent tax on other tobacco products including cigars, smokeless tobacco and electronic cigarettes. The legislation would have generated $43 million in new revenue for the state of New Mexico. Instead, the cigarette tax was increased by only 34 cents per pack, too small an amount to impact public health, and two different e-cigarette taxes were established on e-liquid and closed system cartridges.

The American Lung Association also supported Senate Bill 339 which would require the Health and Human Services Department to create rules covering all tobacco cessation medications approved by FDA under the state Medicaid program. The bill passed the Senate, but, unfortunately, ran out of time before being heard on the House Floor.

On a more positive note, the Lung Association was successful in adding electronic smoking devices into the Dee Johnson Clean Indoor Air Act and removing several existing exemptions. Additionally, funding for the New Mexico Tobacco Use Prevention and Control program was maintained at $5.68 million in fiscal year 2020, about the same level as last year.

Moving forward in 2020, the American Lung Association in New Mexico will once again make it a priority to educate our legislature and communities about the dangers of tobacco use and the importance of a well-funded tobacco prevention and cessation program. Additionally, since the federal age of sale for tobacco products is now age 21, the Lung Association will be working to ensure compliance and enforcement of the new federal law by working on tobacco retailer licensure.

New Mexico Facts

Economic Cost Due to Smoking: $843,869,235
Adult Smoking Rate: 15.20%
Adult Tobacco Use Rate: 22.50%
High School Smoking Rate: 10.60%
High School Tobacco Use Rate: 31.90%
Middle School Smoking Rate: 4.30%
Smoking Attributable Deaths: 2,630

Adult smoking and tobacco use data come from CDC's 2018 Behavioral Risk Factor Surveillance System. High school smoking and tobacco use data come from the 2017 Youth Risk Behavior Surveillance System. Middle school smoking rate is taken from the 2017 New Mexico Youth Risk and Resiliency Survey.

Health impact information is taken from the Smoking Attributable Mortality, Morbidity and Economic Costs (SAMMEC) software. Smoking attributable deaths reflect average annual estimates for the period 2005-2009 and are calculated for persons aged 35 years and older. Smoking-attributable health care expenditures are based on 2004 smoking-attributable fractions and 2009 personal health care expenditure data. Deaths and expenditures should not be compared by state.


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