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State of Tobacco Control 2019

Federal Highlights

The American Lung Association has identified four key actions that federal policymakers must take in 2019 that will ultimately eliminate the death and disease caused by tobacco use:

  1. FDA must release both a proposed and final rule, eliminating all flavored tobacco products from the marketplace, including menthol cigarettes, flavored cigars and e-cigarettes;
  2. Clarify and ensure that all tobacco users have access to a comprehensive tobacco cessation benefit without barriers and cost-sharing;
  3. Ensure the Centers for Disease Control and Prevention's (CDC) Tips from Former Smokers Campaign and the Food and Drug Administration's (FDA) Real Cost Campaign continue; and
  4. Pass legislation raising the minimum of age of sale for all tobacco products to 21.

E-cigarette use among youth continued to lead national headlines in 2018. In January 2018, the National Academies of Science, Engineering and Medicine released a major report at the behest of Congress that found using e-cigarettes causes health risks, increases the chance that youth will start to use combustible tobacco products and exposes others to dangerous secondhand e-cigarette emissions.

Throughout 2018, the Lung Association urged FDA to take more meaningful and aggressive action to reduce youth e-cigarette use in response but to no avail. These efforts by the Lung Association and its public health partners included: suing the FDA to compel it to follow the Tobacco Control Act and complete a pre-market review of all e-cigarettes, cigars and other newly regulated tobacco products currently on the market; requesting the agency enforce the law and stop e-cigarettes that look like Juul from coming onto the market without the agency's prior review and authorization; and the Lung Association's National President and CEO and his counterparts sending a letter to FDA Commissioner Scott Gottlieb outlining key principles and provisions the agency needs to take in order to reduce youth e-cigarette use.

Results released from the 2018 National Youth Tobacco Survey in November found that high school student use of e-cigarettes had increased by a staggering 78 percent from 2017 to 2018. FDA Commissioner Scott Gottlieb released a statement saying that the agency would move forward with releasing a proposed rule removing all menthol cigarettes and flavored cigars from the marketplace. He also announced additional sales and youth access restrictions around flavored e-cigarette use but failed to heed the advice of these organizations which urged FDA to remove all flavored tobacco products from the market. FDA had yet to take any of these steps formally when this report went to print.

In December, U.S. Surgeon General Jerome Adams declared e-cigarette use among youth to have reached epidemic levels. And Altria announced it purchased a significant stake in Juul, the most popular e-cigarette brand and the biggest driver of youth use. 

The strong tobacco mass media campaigns from the federal government continued in 2018. CDC's highly effective and extremely cost-effective "Tips from Former Smokers" campaign began its seventh year of highlighting the diseases caused by tobacco use. In September, the Lung Association applauded FDA for adding e-cigarettes to its highly successful youth prevention campaign, "The Real Cost."

Other notable 2018 highlights include:

  • A federal court found in favor of the Lung Association and against the FDA for its delay in implementing graphic warning labels on cigarette packs. The judge ruled that "FDA has unlawfully withheld and unreasonably delayed action."
  • A rule making all public housing smokefree took effect on July 31, 2018. This protected close to two million residents, including hundreds of thousands of children, from secondhand smoke in their homes.
  • The House of Representatives again attached a provision to FDA's funding bill that would undermine the Tobacco Control Act and create special protections for candy-flavored cigars. The rider remains unresolved as part of the Fiscal Year 2019 budget, that was unresolved as of the time this report went to print.
  • In May 2018, the federal court judge overseeing the decades-old racketeering lawsuit against major tobacco companies ruled that the companies must publish corrective statements on both their websites and on cigarette packs starting in 2018. These statements are aimed at holding these tobacco companies accountable for decades of fraud and deception, and follow earlier statements published in major newspapers and aired on television.

United States Facts

Economic Costs Due to Smoking:


Adult Smoking Rate:


Adult Tobacco Use Rate:


High School Smoking Rate:


High School Tobacco Use Rate:


Middle School Smoking Rate:


Middle School Tobacco Use Rate:


Smoking Attributable Deaths per Year:


Smoking Attributable Lung Cancer Deaths per Year:


Smoking Attributable Respiratory Disease Deaths per Year:


Adult smoking and tobacco use rates are taken from the 2017 National Health Interview Survey. High school and middle school smoking rates are taken from the 2017 National Youth Tobacco Survey. High school and middle school tobacco use rates are taken from the 2018 National 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.

    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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