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State of Tobacco Control 2019

Top 10 Populations Disproportionately Affected by Cigarette Smoking and Tobacco Use

It's no secret that quitting smoking significantly reduces the risk for a wide range of diseases and early death. Yet, tobacco use remains the leading cause of preventable death and disease in the U.S. The good news is smoking rates have decreased over the past decade and are at historically low levels. In 2017, 14 percent of adults smoked cigarettes.1 However, not all Americans are benefiting equally from this decline. Certain parts of the country and populations continue to smoke at high rates, highlighting the uneven progress where we need to do a better job of preventing and reducing tobacco use. Here are the top 10 populations disproportionately affected by cigarette smoking and tobacco use:

  1. Adults that Live in Rural Areas
    Adults that live in rural areas smoke at a rate of 18.2 percent compared to 12.5 percent among adults that live in urban areas. They are also more likely to be heavier smokers, smoking 15 or more cigarettes per day, compared to smokers in urban areas.2 Kids in rural areas are also more likely to start smoking at a much younger age and smoke daily, making addiction more severe and smoking harder to quit.3

  2. Adults Living in Traditional Tobacco-Growing States Tobacco Field
    The average smoking rate in traditional tobacco-growing states (Georgia, Kentucky, North Carolina, South Carolina, Tennessee and Virginia) is 18.8 percent, but this hides significantly higher smoking rates in several of the states.4 For decades, tobacco industry influence has blocked tobacco control policies in these states. However, there has been some progress on tobacco-control policies and smokefree laws at the state or local level in many of them in recent years.

  3. Military Veterans
    Military veterans smoke at a rate of 21.6 percent. That number jumps significantly in certain age groups—the highest being a shocking 50.2 percent among male veterans aged 18-25.5 Sadly, the military has a long history with tobacco use, including cigarettes previously being included with rations. Many veterans report beginning tobacco use in the military or reinforcing their tobacco use during their service.

  4. Lesbian/Gay/Bisexual Adults (LGB)
    LGB* individuals have a smoking rate of 24.9 percent, meaning one in four LGB adults smoke cigarettes compared with about one in six straight adults.6 While we don't have good national data on smoking among transgender individuals, LGBT individuals often face risk factors such as daily stress related to prejudice and stigma. The tobacco industry has aggressively targeted and marketed to the LGBT community, advertising in publications aimed at LGBT audiences and depicting tobacco use as an “accepted” part of LGBT life.7, 8
    *The statistic around this smoking rate does not include transgender individuals.

  5. Adults that Did Not Graduate High School
    Adults with lower levels of educational attainment smoke at higher rates than the general population, and smoking rates decrease significantly with increased education. Adults who did not graduate high school smoke at a rate of 27.0 percent, adults who did graduate high school smoke at a rate of 21.1 percent, and adults who graduated from a technical school or college smoke at a rate of 6.4 percent.8

  6. Americans Making Less Than $20,000 a YearSOTC Stat
    Americans making less than $20,000 a year have a smoking rate of 26.6 percent, close to double the rate of 14.5 percent among those making $20,000 a year or more.9 People living in poverty smoke cigarettes more heavily and smoke for nearly twice as many years as people with a family income three times the poverty rate.10 Lower income cigarette smokers suffer more from smoking-caused diseases than smokers with higher incomes.11 Tobacco companies often target advertising campaigns toward low-income communities12 and a higher density of tobacco retailers can often be found in low-income neighborhoods.13

  7. Uninsured Americans
    Uninsured Americans under the age of 65 smoke at a rate of 24.8 percent, more than double the rate of adults with private insurance, whose smoking rate is 11.0 percent.14 Research shows that gaining insurance coverage increases the odds of quitting smoking, due to more primary care visits, follow-up smoking assessments and smoking cessation medication ordered.15

  8. American Indians/Alaskan Natives
    American Indians/Alaska Natives smoke at a rate of 24.0 percent and have the highest prevalence of cigarette smoking among all racial/ethnic groups in the U.S.16 For the Native American community, it is important to distinguish between commercial tobacco use and tobacco use in traditional ceremonies as some Native Americans use tobacco for ceremonial, religious or medicinal purposes.

  9. Americans with Seven or More Days per Month of Poor Mental HealthSOTC Stat
    Individuals with behavioral health conditions smoke at a rate of 28.0 percent,17 and smoking rates can be even higher depending on the condition. Even more alarming is that people with mental health conditions and substance abuse make up 22 percent of the population, but account for 38 percent of all cigarettes smoked.18 Nicotine's mood-altering effects can also mask the negative symptoms of mental illness, putting people with mental health conditions at higher risk for nicotine addiction and cigarette use.19

  10. Adults in Public Housing
    Adults living in public housing smoke at a rate of 33.6 percent,20 more than twice the national rate. Secondhand smoke is also a pressing issue in public housing since the movement of secondhand smoke between units cannot be controlled in multifamily buildings. In July 2018, the Department of Housing and Urban Development (HUD) implemented a rule requiring all public housing authorities (PHA) to have smokefree policies in place to protect residents, staff and guests from secondhand smoke, which may also prompt some smokers to quit.

How Do We Keep Those at Greatest Risk from Being Left Behind?
All Americans deserve the chance to live a full and healthy life. Yet smoking rates are now higher in certain parts of the country and among certain populations in America. Complicating this crisis are that the factors listed above tend to combine and compound the risk. For example, low-income adults are more likely to be uninsured and live in public housing. Racial and ethnic minorities and people with mental health or behavioral health conditions live in public housing at higher rates than the general population. How do we help? We must insist our federal and state decision makers put policies in place that are focused on reducing tobacco use among all Americans. The disparity in smoking rates must be eliminated to put an end to the tobacco epidemic. To make this happen, tobacco prevention and cessation efforts must focus on the policies called for in our “State of Tobacco Control” report, and on reaching our most vulnerable communities.

  • Sources
    1. Centers for Disease Control and Prevention. National Center for Health Statistics. National Health Interview Survey, 2017. Analysis performed by the American Lung Association Epidemiology and Statistics Unit using SPSS software.
    2. Centers for Disease Control and Prevention. Behavioral Risk Factor Surveillance Survey, 2017. Analysis by the American Lung Association Epidemiology and Statistics Unit using SPSS software.
    3. American Lung Association. Cutting Tobacco’s Rural Roots: Tobacco Use in Rural Communities. Chicago: American Lung Association, 2015.
    4. Centers for Disease Control and Prevention. Behavioral Risk Factor Surveillance Survey, 2017. Analysis by the American Lung Association Epidemiology and Statistics Unit using SPSS software.
    5. Odani S, Agaku I, Graffunder CM, Tynan M, Armour B. Tobacco Product Use Among Military Veterans – United States, 2010-2015. MMWR Morb Mortal Wkly Rep 2018;67:7-12.
    6. Centers for Disease Control and Prevention. Behavioral Risk Factor Surveillance Survey, 2017. Analysis by the American Lung Association Epidemiology and Statistics Unit using SPSS software.
    7. American Lung Association. The LGBT Community: A Priority Population for Tobacco Control. Available at: https://www.lung.org/assets/documents/tobacco/lgbt-issue-brief-update.pdf.
    8. Centers for Disease Control and Prevention. Behavioral Risk Factor Surveillance Survey, 2017. Analysis by the American Lung Association Epidemiology and Statistics Unit using SPSS software.
    9. Ibid.
    10. Siahpush M, Singh GH, Jones PR, Timsina LR. Racial/Ethnic and Socioeconomic Variations in Duration of Smoking: Results from 2003, 2006 and 2007 Tobacco Use Supplement of the Current Population Survey. Journal of Public Health 2009;32(2):210-8.
    11. Campaign for Tobacco-Free Kids. Tobacco and Socioeconomic Status. Washington, D.C., last updated Nov. 9. 2018.
    12. U.S. Department of Health and Human Services. The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General. Atlanta, GA, 2014.
    13. Yu D, Peterson NA, Sheffer MA, Reid RJ, Schneider JE. Tobacco Outlet Density and Demographics: Analyzing the Relationships with a Spatial Regression Approach. Public Health, 2010;124(7):412–6.
    14. Centers for Disease Control and Prevention. National Center for Health Statistics. National Health Interview Survey, 2017. Analysis performed by the American Lung Association Epidemiology and Statistics Unit using SPSS software.
    15. Bailey SR, Hoopes MJ, Marino M, et al. Effect of Gaining Insurance Coverage on Smoking Cessation in Community Health Centers: A Cohort Study. Journal of General Internal Medicine. 2016;31(10):1198-1205.
    16. Centers for Disease Control and Prevention. National Center for Health Statistics. National Health Interview Survey, 2017. Analysis performed by the American Lung Association Epidemiology and Statistics Unit using SPSS software.
    17. Centers for Disease Control and Prevention. Behavioral Risk Factor Surveillance Survey, 2017. Analysis by the American Lung Association Epidemiology and Statistics Unit using SPSS software.
    18. Ibid.
    19. Centers for Disease Control and Prevention. Vital Signs: Adult Smoking Focusing on People With Mental Illness, February 2013.
    20. Helms V, King B, Ashley P. Cigarette smoking and adverse health outcomes among adults receiving federal housing assistance. Preventative Medicine 2017; 99:171-7.

    Page Last Updated: January 29, 2019


    Did You Know?

    1. More than 27 percent of high school students in the U.S. use at least one tobacco product, including e-cigarettes, according to the 2018 National Youth Tobacco Survey.
    2. 7.2 percent of middle school students use at least one tobacco product, including e-cigarettes, according to the 2018 National Youth Tobacco Survey.
    3. From 2017 to 2018, high school e-cigarette use increased by 78 percent and middle school e-cigarette use increased by close to 50 percent in the 2018 National Youth Tobacco Survey.
    4. Smoking is the number one preventable cause of death in the U.S., killing over 480,000 people per year.
    5. Secondhand smoke kills more than 41,000 people in the U.S. each year.
    6. 28 states and Washington D.C. have passed laws making virtually all public places and workplaces, including restaurants and bars smokefree.
    7. The District of Columbia has the highest cigarette tax in the country at $4.50 per pack.
    8. Missouri has the lowest cigarette tax in the country at 17 cents per pack.
    9. The average of all states plus the District of Columbia's cigarette taxes are $1.78 per pack.
    10. Three states – Connecticut, Tennessee and West Virginia – spend no state dollars at all tobacco prevention programs.
    11. No state is funding its tobacco control programs at or above the CDC-recommended level (in Fiscal Year 2019).
    12. Kentucky, Oklahoma and the District of Columbia increased their cigarette taxes in 2018.
    13. No state approved a comprehensive smokefree workplace law in 2018.
    14. 12 states – California, Colorado, Connecticut, Indiana, Kansas, Kentucky, Maine, Massachusetts, Missouri, Ohio, Oregon and South Carolina– offer a comprehensive cessation benefit to tobacco users on Medicaid.
    15. Each of the 50 states and the District of Columbia provide tobacco quitlines, a phone number for quit smoking phone counseling. The median amount states invest in quitlines is $2.21 per smoker in the state.
    16. Massachusetts passed legislation increasing its minimum sales age for tobacco products to 21 in 2018.
    17. Six states, the District of Columbia and over 350 communities have passed Tobacco 21 laws.
    18. Nationwide, the Medicaid program spends more than $39.6 billion in healthcare costs for smoking-related diseases each year – more than 15.2 percent of total Medicaid spending.
    19. In 2009, the American Lung Association played a key role in the passage of the Family Smoking Prevention and Tobacco Control Act, which gives the U.S. Food and Drug Administration authority over tobacco products.
    20. The American Lung Association played a key role in airplanes becoming smokefree in the 1990s.
    21. 43 states and the District of Columbia spend less than half of what the CDC recommends on their state tobacco prevention programs.
    22. States spend less than three cents of every dollar of the $27.3 billion they get from tobacco settlement payments and tobacco taxes to fight tobacco use.
    23. Each day, more than 2,000 kids under 18 try their first cigarette and more than 300 kids become new, regular smokers.
    24. Each day, more than 1,900 kids try their first cigar. On average, more than 80 kids try their first cigar every hour in the United States – equaling about 712,000 every year.
    25. Smoking costs the U.S. economy over $332 billion in direct health care costs and lost productivity every year.
    26. The five largest cigarette companies spent over $23 million dollars per day marketing their products in 2016.
    27. Secondhand smoke causes $5.6 billion in lost productivity in the U.S. each year.
    28. Smoking rates are over twice as high for Medicaid recipients compared to those with private insurance.
    29. A 2013 study of California's tobacco prevention program shows that the state saved $55 in healthcare costs for every $1 invested from 1989 to 2008.
    30. A 2017 study found that states which expanded Medicaid had a 36 percent increase in the number of tobacco cessation medication prescriptions relative to the states that did not expand Medicaid. This means more quit attempts with proven cessation treatments are being made. 
    31. In 2018, three states, Idaho, Nebraska and Utah, voted to expand their Medicaid coverage, providing more smokers with access to tobacco cessation treatments.
    32. Uninsured Americans smoke at a rate more than two times higher than people with private insurance.
    33. An estimated one-third of Americans living in public housing smoke.
    34. Persons with mental illness consume close to 40 percent of all cigarettes in the U.S.
    35. Native Americans and Alaska Natives have the highest smoking rates among any racial/ethnic group.
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