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State of Tobacco Control 2019

Key Findings

Adult and youth cigarette smoking rates are near historically low levels in the U.S., but there was a staggering 78 percent increase in youth e-cigarette use from 2017 to 2018 that caused both the FDA Commissioner and U.S. Surgeon General to declare youth e-cigarette use an epidemic. This year's "State of Tobacco Control" report shines a spotlight on the failure of states and the federal government to act to reduce tobacco use, including e-cigarette use, and how this places the lives and lung health of Americans at risk and emboldens the tobacco industry.

Report Overview

"State of Tobacco Control" 2019: The Failure by Government Officials to Act Jeopardizes Lives and Lung Health

The 17th annual American Lung Association "State of Tobacco Control" report evaluates states and the federal government on actions taken to halt the nation's leading cause of preventable death—tobacco-caused disease—and save lives with proven-effective and urgently needed tobacco control laws and policies.

As a result of implementing the policies called for in "State of Tobacco Control," adult and youth cigarette smoking rates are at an all-time low, with 7.6 percent of high school students1 and 14.0 percent of adults smoking cigarettes.2 In particularly positive news, there was a significant drop in adult smoking rates from 15.5 percent in 2016 to 14.0 percent in 2017.3 However, this positive news was tempered by a dramatic and extremely troubling 78 percent rise in youth e-cigarette use from 2017 to 2018.4

Continued progress on reducing both cigarette smoking, and other tobacco product use requires more aggressive action on the part of our federal, state and local governments. On that front, the American Lung Association's 2019 "State of Tobacco Control" report showed a disturbing failure of our policymakers to put in place meaningful policies to prevent and reduce tobacco use in 2018 at both the state and federal level. This failure places the lung health and lives of Americans at risk.

The failure to act to apply proven-effective policies to other tobacco products including cigars and e-cigarettes is directly responsible for the dramatic rise in youth e-cigarette use, and 27 percent of youth now use at least one tobacco product.6 This could set the stage for not only another generation of Americans addicted to tobacco products but ultimately more tobacco-caused death and disease. Nicotine is not only addictive but also harms adolescent brain development and places youth at risk for a host of other lung diseases related to this relatively new tobacco product.

The rise of JUUL, an e-cigarette product that looks like a USB flash drive, and its popularity with youth is one consequence of inaction by federal and state governments. As noted in last year's "State of Tobacco Control" 2018 report, tobacco use places a greater burden on certain populations and those living in certain parts of the country, and these areas and populations consequently pay a higher price when elected officials fail to act to prevent and reduce tobacco use.

The Failure to Act Emboldens the Tobacco Industry

For decades, the tobacco industry has urged federal, state and local officials to delay meaningful action or not take any action at all to prevent and reduce tobacco use, especially among youth. This has resulted in a vicious circle, with tobacco companies becoming even more emboldened to devise new and egregious ways to addict youth and sustain addiction among current users. This delay, allows tobacco companies to resist meaningful action to protect public health as it would potentially cut into company profits.

This has been especially true of the policies called for in "State of Tobacco Control" 2019. The tobacco industry and its allies routinely oppose efforts at the state level to increase tobacco taxes, pass comprehensive smokefree laws, and in recent years, oppose efforts to increase the tobacco sales age to 21 and restrict access to flavored tobacco products to protect youth. In 2018, they spent over $18 million opposing a ballot measure in Montana that would have both increased the cigarette tax by $2.00 per pack and provided continued funding to the state's expansion of Medicaid. At the federal level, the tobacco industry has made repeated efforts in Congress to weaken the U.S. Food and Drug Administration's (FDA) authority over tobacco products, including trying to exclude "premium" cigars from basic FDA oversight and exempt all cigars, including cigarillos and flavored cigars popular among youth, from FDA review.

FDA's Failure to Act in Time

FDA has full authority over the manufacture, marketing and sale of tobacco products in the U.S. under a law passed by Congress in 2009 and through the 2016 "deeming" rule. However, in many cases over the past two Administrations, the agency has failed to implement the law and use this comprehensive authority to put meaningful restrictions on tobacco products in place. This lack of action continued to earn the federal government an "F" grade for FDA Regulation of Tobacco Products in the 2019 "State of Tobacco Control" report.

One clear consequence of FDA's inaction has been a steep rise in e-cigarette use among youth to "epidemic" levels, with 20.8 percent of high school students using e-cigarettes in 2018—a stunning increase from 11.7 percent in 2017.7 It has also led to the rise of JUUL, an e-cigarette that looks like a USB flash drive, which contains high amounts of nicotine, comes in several kid-friendly flavors and is particularly popular with youth. JUUL has claimed the largest share of the overall e-cigarette market in a very short time period and has inspired a number of other companies to create similar types of e-cigarettes.

In early November, American Lung Association National President and CEO Harold P. Wimmer and his counterparts at several other major national organizations committed to ending tobacco-caused disease sent a letter to FDA Commissioner Scott Gottlieb. The letter included three core principles essential to reducing tobacco use, including:

  1. Voluntary action by the industry—including the e-cigarette industry—is insufficient. Industry-wide regulatory action is essential.
  2. FDA's approach must be comprehensive and not limited to sales restrictions to prevent illegal sales to youth.
  3. It is essential to address the problem of youth use of other tobacco products as well as e-cigarettes.

Since 2009, the American Lung Association has urged aggressive action by FDA to curb these types of products. On November 15, 2018—the same day the study showing a 78 percent spike in high school e-cigarette use in one year was released 8—the FDA announced several actions it intends to take that it says would help address youth e-cigarette use. Unfortunately, FDA's plans around e-cigarettes rely primarily on sales restrictions of some flavored products in stores that allow customers under the age of 18 to enter, as well as voluntary actions announced by both Altria (the tobacco company formerly known as Philip Morris) and JUUL regarding their sales of flavored e-cigarettes.

However, these sales restrictions will not apply to mint and menthol flavors of e-cigarettes. An article released by the Centers for Disease and Control and Prevention (CDC) at the same time as FDA's announcement showed that over 50 percent of high school students that use e-cigarettes use mint or menthol flavors of e-cigarettes.9 This finding severely undercuts any potential impact these sales restrictions might have. In addition, FDA contributed to this problem with its July 2017 decision to delay the review of all e-cigarettes until 2022—the subject of a lawsuit brought against the agency by the American Lung Association and its partners. Given the "epidemic" levels of e-cigarette use revealed by the 2018 National Youth Tobacco Survey, the partial measures announced by FDA are insufficient, as are the voluntary measures from these two major tobacco companies. Ultimately, FDA must take meaningful action and prohibit all flavored tobacco products, including all e-cigarettes. 

In its November 2018 announcement, FDA did announce its intention to issue a proposed rule that would prohibit the sale of menthol cigarettes and all flavored cigars. The American Lung Association strongly supports this FDA action, which would be a historic achievement if it comes to pass. Menthol in cigarettes plays a significant role in youth becoming addicted to cigarettes, masking the harsh taste of tobacco smoke and making the poison go down easier. Menthol cigarettes are also disproportionately used by African-Americans and make it more difficult to quit smoking. Earlier in 2018, FDA also launched a new nationwide media campaign focused on reducing e-cigarette use among youth ages 12-17 as part of its "Real Cost" campaign, which is also to be commended.

MSA 20th Anniversary and the Failure of States to Act

November 23, 2018, marked the 20th anniversary of the 1998 tobacco Master Settlement Agreement (MSA), where 46 states 1, the District of Columbia and several U.S. territories reached a legal settlement with the tobacco industry requiring the industry to make annual payments to the states in perpetuity to reimburse states for tobacco-caused healthcare costs. The settlement also imposed some advertising and marketing restrictions on tobacco companies, including ending the use of cartoon characters in advertisements, such as Joe Camel.

Around the time the MSA was announced, many state Attorneys General and other state leaders made public promises about the annual payments from the MSA being used to fund programs to prevent and reduce tobacco use. However, there was no provision in the actual MSA that required states to spend money on tobacco prevention and quit smoking programs, and in the 20 years since, virtually all the states have used most or all of the annual MSA payments for different and in some cases questionable purposes.

This broken promise in relation to the MSA represents a tremendous failure on the part of states to fund comprehensive programs proven to drive down smoking rates even faster and prevent more of the previous generation of youth from ever starting. In states where comprehensive tobacco control programs have been in place, states have seen accelerated declines in smoking rates especially among youth, and later saw declines in tobacco-caused diseases. In California, which has routinely invested in its prevention and cessation programs since 1989, deaths from lung cancer have declined rapidly and as of 2013, were 28 percent lower than the rest of the U.S. 10 Overall, states are spending only three cents of every dollar from tobacco settlement payments and tobacco taxes on tobacco control programs in fiscal year 2019 11. In addition, 43 states and the District of Columbia received "F" grades in "State of Tobacco Control" for failing to spend even 50 percent of CDC-recommended levels on tobacco prevention and quit smoking programs.

Some Positive News

The news in 2018 was not all bad. The year saw several important actions taken by states and the federal government to curb tobacco use and exposure to secondhand smoke:

  • Massachusetts became the sixth state to pass a law increasing the tobacco sales age to 21, and the District of Columbia implemented its Tobacco 21 law, originally approved in 2016.
  • Oklahoma and the District of Columbia approved significant increases in state tobacco taxes of a $1.00 per pack or more.
  • San Francisco and a number of other communities in California and in Minnesota passed laws that prohibit the sale of all flavored tobacco products, including menthol, despite intense and well-funded tobacco industry opposition.
  • Kansas and New Jersey expanded coverage for quit smoking treatments under their state Medicaid programs, and several states expanded Medicaid under the Affordable Care Act giving more of the state's lower-income population access to low-cost quit smoking treatments.
  • The U.S. Department of Housing and Urban Development successfully implemented its rule prohibiting smoking in federally-owned public housing, protecting close to 2 million children and adults living in public housing from exposure to secondhand smoke.

2018 State and Federal Trends

Success and Challenges in 2018

States

Overall, states continued their unfortunate record of failing to put in place the proven policies called for in “State of Tobacco Control” that would help significantly reduce the 480,000 lives lost to tobacco each year. A few states did make notable progress:  

  • The District of Columbia increased its cigarette tax by $2.00 per pack, and Oklahoma increased its cigarette taxes by $1.00 per pack. Montana and South Dakota had ballot measures to increase cigarette taxes by $2.00 and $1.00 per pack respectively, ultimately not approved by voters, with the tobacco industry spending enormous amounts of money to defeat these measures. Kentucky also increased its cigarette tax in 2018, but only by 50 cents per pack, missing a golden opportunity to take meaningful action to address its nearly highest in the country smoking rates for adults and youth. The average state cigarette tax is now $1.78 per pack – with the District of Columbia now having the highest cigarette tax ($4.50 per pack) and Missouri having the lowest (17 cents per pack).
  • Only one state—Massachusetts—passed a law raising the minimum age of sale for all tobacco products to 21 in 2018. Due to revenue from the increase in the District of Columbia's cigarette tax, the Tobacco 21 law previously approved in 2016 was also finally implemented, as the inclusion in the city's budget was required for the law to take effect. Sadly, Illinois was blocked just short of becoming the seventh state to pass a Tobacco 21 law, when then-Governor Bruce Rauner vetoed a bill passed by the legislature and the legislature failed to override the veto. This brings the national total to six states and the District of Columbia that have acted to reduce youth tobacco initiation and save lives. Many cities and counties in New York have also passed Tobacco 21 laws bringing the population covered by such laws in New York to close to 76 percent.
  • Kansas led the way in improving access to cessation treatments for low-income residents in 2018. The state passed a bill providing a comprehensive quit smoking benefit for all Medicaid enrollees. Currently, 12 states have a comprehensive tobacco cessation benefit for all standard Medicaid enrollees, covering all seven tobacco cessation medications and all three forms of counseling to help smokers quit. However, 49 states still have barriers for Medicaid enrollees to access this treatment.  
  • New Jersey saw a $6.7 million increase in funding for its state tobacco prevention program in fiscal year 2019 as the result of a law approved in 2017 allocating one percent of tobacco tax revenues to tobacco prevention programs. In addition, Florida, Kentucky and the District of Columbia all saw a $1 million or more increase in funding to tobacco prevention programs in fiscal year 2019. However, several states also had setbacks on funding for their tobacco prevention and quit smoking programs, including Idaho, Minnesota and Wyoming. Three states—Connecticut, Tennessee and West Virginia—provided no state funding at all for tobacco prevention and quit smoking programs, severely hampering their ability to respond to large increases in youth tobacco use. The total amount spent by states on tobacco prevention and cessation is over $652 million, less than three cents of every dollar of the close to $27.3 billion states collect from tobacco settlement payments and tobacco taxes.
  • Alaska approved a statewide law that prohibits smoking in public places and workplaces in 2018 but included a provision in the law that allows local communities to opt out of the law by ballot measure. Unfortunately, this means the law cannot be considered comprehensive because protections from exposure to secondhand smoke can be taken away by communities at any time. Indeed, in the fall, some Sitka residents attempted to opt out of the law, but the effort was rejected by voters in October 2018. Massachusetts and Rhode Island also added e-cigarettes to their comprehensive smokefree laws, and Florida added e-cigarettes to its current secondhand smoke protections by constitutional amendment in November 2018.
  • In June 2018, voters in San Francisco overwhelmingly upheld the city's ordinance to prohibit the sale of flavored tobacco products, including menthol tobacco products, in retail stores. The tobacco industry had referred the law to the ballot and spent over $12 million trying to get it overturned. Additional communities in California and Minnesota also passed similar flavored tobacco product ordinances, in some cases with exemptions for over age 18 or 21 retail tobacco stores. Massachusetts also became the first state to completely prohibit tobacco sales in pharmacies.

Federal Government:

FDA announced that it intends, in the future, to propose a rule to remove all menthol cigarettes and flavored cigars from the marketplace. However, FDA continued to avoid meaningful action to protect the public’s health from the newest tobacco product: e-cigarettes. Other federal government agencies, including the Department of Housing and Urban Development (HUD), made progress on reducing tobacco use and exposure to secondhand smoke.

  • In December, Surgeon General Jerome Adams issued a rare public health advisory, warning the public about the e-cigarette epidemic among youth. The advisory was issued the day after 2018 Monitoring the Future data was released that showed a 90 percent increase of e-cigarette use among high school students.12
  • Despite the skyrocketing of youth e-cigarette use and the declared epidemic, the FDA did not reverse its 2017 delay for newly regulated tobacco products to be reviewed by the FDA before being placed on the market. This action weakened FDA's "deeming" rule that granted FDA's Center for Tobacco Products authority over e-cigarettes, cigars, hookah and other previously unregulated tobacco products in 2016. FDA’s delay by more than four years of the deadline looks even more shortsighted with the dramatic increase in rates of youth e-cigarette use from 2017 to 2018, with 1 million more kids using e-cigarettes over the course of one year alone. In response to FDA's failure to implement the law, the American Lung Association and other public health groups filed a lawsuit in 2018 seeking to reverse these damaging changes to FDA's "deeming" rule.  
  • FDA signaled its intent to propose a rule in the future to remove menthol cigarettes and flavored cigars from the market. However, FDA's plan to restrict the display of flavored e-cigarettes—with the notable exceptions of menthol and mint flavors—in retail stores amounts to a half measure that fails to adequately respond to the youth e-cigarette use crisis. In response to requests for comment by the FDA, the American Lung Association submitted three sets of comments with FDA in 2018 on nicotine reduction, "premium cigars" and flavored tobacco products, where the Lung Association called on FDA to remove flavored tobacco products from the market.
  • The tobacco industry—Altria and the cigar industry—combined forces with its Fiscal Year 2019 rider in an attempt to weaken FDA authority over tobacco products. After two years of strong pushback against opening loopholes to allow candy-flavored e-cigarettes to remain on the marketplace indefinitely, the FY19 rider included in the House funding bill for FDA would exclude so-called "premium" cigars and grandfather in flavored and little cigars. The Senate did not include this rider. 
  • The U.S. Department of Housing and Urban Development's rule requiring all federally-owned public housing to implement smokefree policies took effect on July 30, 2018. The rule will protect close to 2 million people, including 690,000 children living in public housing, from secondhand smoke exposure13, as well as prompt many smokers living in public housing to make a quit attempt. The American Lung Association marked the implementation of this historic rule with a celebration at a public housing complex in Milwaukee, Wisconsin, and has a number of state-based projects still in progress to help adult residents of public housing quit smoking.
  • Despite a federal court judge declaring the entire Affordable Care Act unconstitutional in December, key quit smoking policies required in the Affordable Care Act remain in effect.  However, the Administration put forward new rules that expand plans that are not required to cover quit smoking treatments. The U.S. Department of Health and Human Services has also approved a tobacco surcharge for Medicaid enrollees who smoke in Indiana and Wisconsin. The American Lung Association opposes tobacco surcharges as there is no evidence that they help smokers quit.
  • Both the House of Representatives and Senate supported maintaining funding in their fiscal year 2019 spending bill for CDC's Office on Smoking and Health and its "Tips from Former Smokers" campaign, a highly effective media campaign that features stories of people living with smoking-related diseases. In previous years, the House had attempted to make cuts to this invaluable program.
  • In September 2018, FDA launched an extension of its "The Real Cost" media campaign to address the risks of youth use of e-cigarettes, targeting youth ages 12-17 who have used e-cigarettes or are open to trying them. The American Lung Association applauded FDA for this decision. Given e-cigarettes are now at "epidemic" levels among high school youth at 20.8 percent in 2018 and the rise of JUUL, this media campaign came at a critical time.15
  • During 2018, major tobacco companies were finally required to issue "corrective statements" about the dangers of smoking and secondhand smoke through print newspaper and TV ads, on company websites and on cigarette packs. These corrective statements were one of the remedies from a lawsuit won by the Department of Justice against the tobacco companies in 2006 where the major tobacco companies were found guilty of civil racketeering. However, the industry delay of these "corrective statements" through numerous legal challenges since 2006 potentially keeps them from being viewed by a wider audience due to the inability to be placed in more modern media channels online.
  • In August 2018, a U.S. District Court judge ruled FDA unreasonably delayed finalizing a new rule requiring graphic warning labels on cigarettes. In her order, the judge required FDA to submit a plan and timeline to the court. FDA previously met a Tobacco Control Act-mandated timeline of finalizing graphic warning labels on 50 percent of the front and back of cigarette packs. However, after the cigarette companies sued FDA and a judge sided with the industry and tossed out the specific warnings, FDA failed to move forward with proposing new graphic warning labels, despite it being required by law. The lawsuit compelling FDA to act was filed by the American Lung Association and other public health groups, aimed at forcing action by FDA on this important public policy, which could have a substantial impact on smoking rates.

2019 State and Federal Opportunities

2019: Policies that States and the Federal Government Can Put in Place to End their Failure to Act and See Lasting Reductions in Tobacco Use and Exposure to Secondhand Smoke

States:

  • States Must Increase Funding for Tobacco Control Programs and Focus These Programs on At-Risk Populations: States must fund programs that prevent youth from starting to use tobacco and help smokers quit at levels recommended by the Centers for Disease Control and Prevention (CDC). State tobacco control programs must also prioritize reaching and serving the needs of populations that continue to use tobacco at higher rates, and adequate funding for tobacco prevention and quit smoking programs can be particularly important in accomplishing that. Comprehensive tobacco control prevention programs must also include efforts aimed at reducing youth e-cigarette use.
  • The Remaining 22 States Must Pass Comprehensive Smokefree Laws: While many workplaces in these 22 states are smokefree, people working in the hospitality (i.e., restaurants, bars and gaming establishments) and manufacturing sectors may be and often are exposed to secondhand smoke at work on a daily basis. Certain racial/ethnic groups are disproportionately represented in the hospitality sector and are therefore more likely to be exposed to secondhand smoke16. They will benefit the most if the remaining 22 states pass comprehensive smokefree laws that include all workplaces, including restaurants, bars and gaming establishments. In 2006, the U.S. Surgeon General concluded that there is no safe level of exposure to secondhand smoke.
  • States Must Expand Comprehensive Cessation Coverage in All Medicaid Programs: It is well-established that helping smokers quit saves lives and money. Smoking is a serious addiction, and while nearly seven out of 10 smokers want to quit, only 10 percent quit successfully.17 Medicaid covers some of the most vulnerable groups in society including poor families, low-income pregnant women and people with disabilities, as well as a high percentage of smokers (24.5 percent of Medicaid recipients smoke18). Additionally, Medicaid is the largest single payer for behavioral health services in the United States.19 Despite the overwhelming evidence that the number of people quitting smoking increases when coverage provides access to all seven FDA-approved tobacco cessation treatments and all three forms of counseling without barriers, such as copays and prior authorization, only two states require such coverage.

    States must ensure that both standard and expansion Medicaid offer comprehensive quit smoking coverage without barriers such as copays, prior authorization or stepped therapy (where a patient must try and fail with one product before using others). As of December 31, 2018, 43 states limit the duration of cessation treatment and 36 states require prior authorization for at least some plans.
  • States Must Increase Tobacco Taxes and Equalize Taxes Across All Tobacco Products:  Significantly increasing tobacco taxes is one of the most effective ways to reduce tobacco use, especially among youth. Georgia, Missouri, North Carolina, North Dakota and Virginia have the five lowest state cigarette tax rates in the country and are long overdue for significant increases. These states also all have adult cigarette smoking rates higher than the national smoking rate of 14 percent. Bringing parity to (equalizing) tobacco taxes across all products, including cigars, little cigars and roll-your-own, eliminates any financial incentive for people to switch to a different product, thereby encouraging people to quit tobacco entirely.
  • States Must Increase the Minimum Age of Sale to 21. The National Academy of Medicine (formerly the Institute of Medicine) found increasing the minimum age of sale for all tobacco products to 21 could prevent 223,000 deaths among people born between 2000 and 2019, including 50,000 fewer dying from lung cancer, the nation's leading cancer killer.20 Six states, the District of Columbia and hundreds of localities have already passed such laws.

Federal Government:

  • FDA Must End Its Delay of the Deeming Rule. FDA Commissioner Scott Gottlieb, M.D., threatened—on a case-by-case basis—to revisit the July 2017 decision to delay pre-market review of all newly deemed tobacco products. However, FDA has taken no action to implement this critical provision of the Tobacco Control Act. Litigation brought by the American Lung Association and our public health partners in response to FDA's 2017 announcement remains ongoing.
  • FDA Must Move Forward with Graphic Warning Labels on Cigarettes. A federal court judge sided with the American Lung Association and other public health litigants in August and ruled that FDA is still responsible for implementation of graphic warning labels on all cigarette packs.  The judge's timeline for FDA to comply with the ruling is still pending.
  • FDA Must Issue a Product Standard Eliminating All Flavored Tobacco Products, Including Menthol. In July, the American Lung Association submitted comments to FDA, urging them to remove all flavored tobacco products including e-cigarettes, smokeless, cigars, hookah and menthol cigarettes from the marketplace. The evidence is overwhelming that flavored tobacco products are more appealing to youth and are one of the primary reasons that kids use tobacco products. In addition, menthol tobacco products make it both easier for kids to start smoking and harder for adults to quit, in particular, African-Americans who have long been targeted by the tobacco industry.21 A 2011 report from FDA's own Tobacco Products Scientific Advisory Committee concluded that "removal of menthol cigarettes from the marketplace would benefit public health in the United States."22
  • Federal Government Must Do More to Help Smokers Quit. Current law requires that Medicaid expansion and most private insurance plans cover a comprehensive quit smoking benefit with no cost sharing. However, a December 2016 study co-authored by the American Lung Association and the Centers for Disease Control and Prevention found of the 31 states and the District of Columbia that have expanded Medicaid, only nine states require health plans to cover all seven FDA-approved cessation treatments as well as individual and group counseling.23

    Similar studies of private insurance plans have also found that plans are not covering this benefit. The Department of Health and Human Services, the Department of Labor, and the Department of Treasury must be proactive in putting health insurance plans on notice that they must cover these critical preventive services.

    CDC has declared 2019 to be the "Year of Cessation" an important first step that underscores the need for comprehensive coverage for cessation services.
  • CDC and FDA Must Continue Their Successful and Cost-Effective Mass Media Campaigns.FDA's "Real Cost" and CDC's "Tips from Former Smokers" mass media campaigns are succeeding in reducing smoking rates. It is critically important that both campaigns continue and that they retain their emphasis on reaching historically underserved populations including racial/ethnic minorities, LGBTQ people and rural communities.

    In January 2017, CDC published a report that found FDA's "The Real Cost" Campaign prevented almost 350,000 youth from smoking from 2014-2016.24 A 2018 CDC study also found that the "Tips" campaign led to approximately 522,000 people quitting smoking for at least six months from 2012 to 2015.25 The campaigns also feature and focus on tobacco use among priority populations. A 2016 study found that priority populations including African-Americans and Hispanics perceive the “Tips” ads to be effective in reaching them.26
  • Congress Must Increase Taxes on All Tobacco Products. The Federal Government has not increased taxes on cigarettes and other tobacco products since 2009 and is long overdue for a significant increase. The $0.62 increase in 2009 had a significant impact on smoking rates and increasing tobacco taxes is one of the most significant actions Congress could take to prevent and reduce tobacco use. Equalizing taxes between cigarettes and other tobacco products is also important to help tobacco users quit for good.

"State of Tobacco Control" 2019 provides a blueprint that states, and the federal government can follow to put in place proven policies that will have the greatest impact on reducing tobacco use and exposure to secondhand smoke in the U.S. The real question is: Will lawmakers end their failure to act and take this opportunity to achieve lasting reductions in tobacco-related death and disease?


    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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