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State of Tobacco Control 2018State of Tobacco Control 2018State of Tobacco Control 2018

Key Findings

Adult and youth cigarette smoking rates are near historically low levels in the U.S., but not all Americans have seen the health benefits associated with this nationwide decline. This year's "State of Tobacco Control" report shines a spotlight on the parts of the country and populations that are disproportionately impacted by tobacco use or exposure to secondhand smoke. Learn more about who continues to use tobacco at high rates as well as trends and opportunities for both states and the federal government.

Report Overview

2018: Closing the Gaps – Uneven Progress in Implementing Proven Policies Leaves Many Vulnerable Americans Behind

The 16th annual American Lung Association "State of Tobacco Control" report evaluates states and the federal government on proven-effective tobacco control laws and policies that are urgently needed to prevent tobacco-caused disease and save lives.

As a result of the effective policies called for in "State of Tobacco Control," adult and youth cigarette smoking rates are at historically low levels. Overall, 16.4 percent of adults or about 39.0 million people in the United States in 2016 smoked cigarettes1. In 2016, eight percent of high school students smoked cigarettes2.

However, not all Americans have seen the health benefits associated with this nationwide decline in smoking rates. Significant disparities in tobacco use and exposure to secondhand smoke remain, highlighting the uneven progress in states where policies need to be implemented and/or improved. Americans living in public housing, Americans who make less than $20,000 per year and Lesbian, Gay and Bisexual Americans have some of the highest smoking rates, and as a result, are at the greatest risk for tobacco-caused death and disease. The bar graph/chart below shows specific populations that have the highest smoking rates in the country compared to the national average3:

Adult Smoking Rates by Key Demographics chart

Two recently released reports highlight and emphasize how certain populations and parts of America continue to smoke at much higher levels:

  • A 2017 Tobacco Control Monograph from the National Cancer Institute, "A Sociological Approach to Addressing Tobacco-Related Health Disparities," did a thorough review of the research around tobacco-related health disparities for racial/ethnic minorities and low socioeconomic status populations and came to similar conclusions. One of the main conclusions was: "Enormous progress has been made in reducing overall tobacco use. However, some population groups have benefited less or at a slower pace from efforts to reduce tobacco use. As a result, they experience higher tobacco-related morbidity and mortality, including mortality from cancer."4
  • A 2017 report from the organization Truth Initiative, "Tobacco Nation: the Deadly State of Smoking Disparity in the U.S." showed significant geographic disparities in smoking rates still exist in the U.S. In 12 contiguous states stretching from the Upper Midwest to the South the report found that smoking prevalence exceeds not only the national average, but that of many of the most tobacco-dependent countries in the world5. Many of these states have yet to pass comprehensive smokefree laws too leaving millions of Americans exposed to secondhand smoke.

    Three additional populations that are disproportionately impacted by tobacco use, but are often overlooked are Native American and Alaskan Natives, persons with behavioral health or substance abuse disorders and uninsured Americans.
  • Native Americans and Alaskan Natives have long had high rates of commercial tobacco use, with the most recent estimate being 28.6 percent of adults in 20166. State laws generally do not apply to sovereign tribal lands, but many of the proven policies called for in "State of Tobacco Control" can be implemented by tribal governments.
  • Persons with behavioral health and substance abuse problems not only have high rates of tobacco use, but can also be particularly heavy smokers depending on the condition. One study estimates this population consumes about 40 percent of the cigarettes sold in the United States7.
  • Since the implementation of the Affordable Care Act (ACA), the rate of uninsured people has dropped to historic lows, however, there are still approximately 28 million Americans that are uninsured8. This population smokes at a high rate – 26.7 percent, which is 56 percent greater than the rate among those with health insurance9. Unfortunately, this group is also the least likely to have access to resources, such as quit smoking medications, that can help them quit. This is due in part to the fact that the uninsured are more likely to live in a state that did not expand its Medicaid program.

"State of Tobacco Control" 2018 is focused on proven policies that federal and state governments can enact to reduce tobacco use rates, especially in priority populations that continue to have high tobacco use rates, and therefore higher rates of tobacco-related disease and death. These include:

  • Tobacco prevention and quit smoking funding, programs and robust insurance coverage;
  • Comprehensive smokefree laws that eliminate smoking in all public places and workplaces;
  • Increased tobacco taxes;
  • Raising the minimum age of sale for tobacco products to 21; and
  • Aggressive implementation of the U.S. Food and Drug Administration's (FDA) Family Smoking Prevention and Tobacco Control Act.

The report assigns grades based on laws and regulations designed to prevent and reduce tobacco use in effect as of January 2018. The federal government, all 50 state governments and the District of Columbia (D.C.) are graded to determine if their laws and policies are adequately protecting citizens from the enormous toll tobacco use takes on lives, health and the economy.

2017 State and Federal Trends

Spotlight on 2017

States

2017 saw policies enacted in several states and localities that have traditionally lagged behind in efforts to reduce tobacco use – important steps forward in working to reduce these geographic gaps in progress.

  • Kentucky and South Carolina led the way in providing comprehensive access to quit smoking treatments for low-income populations. South Carolina's Medicaid program now covers all seven FDA-approved quit smoking medications without the copays that can discourage smokers from using these medications during their quit attempts. Kentucky's law dramatically expands comprehensive quit smoking coverage to smokers with both private insurance and those who are covered by Medicaid. Nine states now have a comprehensive tobacco cessation benefit for all Medicaid enrollees, covering all seven tobacco cessation medications and all three forms of counseling to help smokers quit. Additionally, three states have removed all barriers to access cessation treatments.
  • Louisiana and Texas also made progress by passing strong smokefree laws at the local level, including two big cities - Baton Rouge, Louisiana, and Fort Worth, Texas. Once again, no state passed comprehensive smokefree laws this past year, leaving 22 states without statewide laws that protect everyone in all public places and workplaces from the dangers of secondhand smoke.
  • Indiana, North Carolina and Tennessee all saw $1 million or more increases in funding for their state prevention programs. California saw a massive $250 million increase in funding due to the $2.00 tobacco tax increase approved by voters in November 2016. However, a number of states also had setbacks on funding for their tobacco prevention and quit smoking programs, including West Virginia, which eliminated all its state funding and Texas, which cut its meager funding investment nearly in half. The total amount spent by states on tobacco prevention and cessation is $729.1 million, less than three percent of the $27.5 billion states collect from tobacco settlement payments and tobacco taxes. Pennsylvania also passed legislation that sells off the right to receive part of its annual tobacco settlement payment for a lump sum upfront payment to close a budget deficit this year, which could affect tobacco control program funding in future years.
  • Oklahoma’s legislature passed a $1.50 fee increase on cigarettes, however that increase was overturned by the courts. Connecticut, Delaware and Rhode Island also increased their cigarette taxes but only by 45 cents per pack in Connecticut and 50 cents per pack in the other two states. New York City raised the minimum price for a pack of cigarettes to $13.00, and established minimum prices for many other tobacco products. The average state cigarette tax is now $1.72 – with Connecticut and New York having the highest cigarette taxes ($4.35) and Missouri having the lowest ($0.17).
  • Three states – New Jersey, Oregon and Maine– and many local communities passed laws raising the minimum age of sale for all tobacco products to 21. This brings the national total to five states that have acted to reduce youth tobacco initiation and save lives.
  • Several cities in California, including San Francisco and Oakland, and Minneapolis and St. Paul in Minnesota have passed ordinances that prohibit the sale of flavored tobacco products, including menthol tobacco products, in all or most retail stores. Most of these laws do have exceptions for stores that do not allow persons under age 18 or 21 to enter.
Current Adult Smokers Whose Usual Brand is Menthol by Ethnicity, 2015
Federal Government:
  • In July 2017, the U.S. Food and Drug Administration (FDA) significantly weakened its "deeming" rule, which gave FDA's Center for Tobacco Products authority over e-cigarettes, cigars, hookah and other previously unregulated tobacco products. FDA delayed by more than four years the deadline for newly-regulated tobacco products to submit tobacco product applications for FDA review as required under FDA's May 2016 deeming rule. The final May 2016 rule still faces a number of legal challenges.
  • FDA will soon seek public comment regarding a possible rule that would require cigarette manufacturers to reduce the nicotine in cigarettes to non-addictive levels. They also indicate they will seek public comment on kid-flavored tobacco products and "premium" cigars – issues that had been previously addressed in FDA's May 2016 deeming rule.
  • The Trump Administration has brought in a number of officials who have previously served as tobacco industry lawyers to key positions in the Department of Justice – including the Solicitor General12 and a senior role in the Civil Division13 – creating the potential for conflicts of interest.
  • After Congress rejected two tobacco riders in its Fiscal Year 2017 funding bill for FDA, the House of Representatives once again succumbed to tobacco industry lobbying and added two appropriations riders to FDA's Fiscal Year 2018 funding bill that would weaken FDA’s authority to protect youth and the public health from newly deemed tobacco products. At the end of 2017, Congress deferred final resolution of these riders until 2018.
  • The U.S. Department of Housing and Urban Development is proceeding with its rule requiring all public housing to implement smokefree policies by July 31, 2018. The rule will protect close to 716,000 children and more than 320,000 senior citizens from secondhand smoke exposure in their own homes14, as well as prompt the hundreds of thousands of smokers living in public housing to make a quit attempt.
  • Key quit smoking policies required in the Affordable Care Act remain in effect. As a result, under the law, Medicaid expansion plans and most private insurance plans are still required to offer a comprehensive quit smoking benefit that covers all seven FDA-approved tobacco cessation medications and all three forms of counseling without cost-sharing.
  • The House of Representatives cut funding in its fiscal year 2017 funding bill for CDC's "Tips from Former Smokers" campaign, a highly effective media campaign that features stories of people living with smoking-related diseases. Congress deferred final resolution until 2018 after the House and Senate negotiate funding levels for the Centers for Disease Control and Prevention and its Office on Smoking and Health.
  • In August 2017, FDA announced its Real Cost Campaign will now include advertisements aimed at preventing youth use of e-cigarettes. E-cigarettes remain the most commonly used tobacco products among high school youth at 11.3 percent16. In December, FDA also announced its adult retail point of sale quit smoking campaign "Every Try Counts," which will launch in January 2018.

2018 State and Federal Opportunities

2018: Policies that Will Help "Close the Gap" so Vulnerable Populations Can Also Benefit from Reductions in Tobacco Use

"State of Tobacco Control" 2018 promotes the policies that will have the greatest impact on reducing tobacco use in the U.S. Below are ways that federal and state governments can enact these proven policies that will also help to reduce the higher smoking rates among priority populations.

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). Reaching the populations that still use tobacco at higher rates can sometimes take additional effort, so adequate funding for tobacco prevention and quit smoking programs is particularly important. State tobacco control programs must also prioritize reaching and serving the needs of these underserved populations, and should directly involve the target communities in planning and implementing programs to ensure they are relevant to them.
  • The Remaining 22 States Must Pass Comprehensive Smokefree Laws: While many white-collar workplaces in these states are smokefree, people working in the hospitality (i.e. restaurants and bars) and manufacturing sectors may be and often are exposed to secondhand smoke on a daily basis. Certain racial/ethnic groups are disproportionately represented in the hospitality sector in particular, and are therefore more likely to be exposed to secondhand smoke17. They will benefit greatly if the remaining 22 states pass comprehensive smokefree laws that include 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 seven out of 10 smokers want to quit. Medicaid covers some of the most vulnerable groups in society including poor families, low-income pregnant women and people with disabilities. Medicaid is also the largest single payer for behavioral health services in the United States18. 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 three 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 has to try and fail with one product before using others). As of June 30, 2017, 42 states limit the duration of cessation treatment and 39 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. Bringing parity to – or 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. Equalizing tobacco taxes will also help reduce tobacco-related disparities because these alternate tobacco products are often favored by certain groups including African-Americans and young adults19.
  • 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 killer20. Five states and hundreds of localities have already passed such laws.
Federal Government:
  • HUD Must Fully Implement its Smokefree Public Housing Rule: By fully implementing the rule requiring all public housing to be smokefree by July 31, 2018, the federal government and the U.S. Department of Housing and Urban Development can significantly reduce the number of low-income Americans, especially children, who are exposed to secondhand smoke in their homes. Racial and ethnic minority groups and persons with serious psychological distress or distress with mental hardship live in HUD-assisted housing at higher rates than the general population21. Public housing residents also smoke at disproportionately higher rates and this new smokefree policy is likely to encourage residents who smoke to make a quit attempt. It is important that these individuals get the help they need to quit smoking for good, which will also significantly reduce an existing health gap and benefit this vulnerable population.
  • Federal Agencies Must Enforce Current Law Regarding Cessation Coverage. 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 counseling22. As mentioned earlier, Medicaid covers some of the most vulnerable groups in society including low-income individuals, pregnant women and people with disabilities, and it is critical they have access to tobacco cessation treatments.

    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 plans on notice that they must cover these critical preventive services.
  • FDA Must Issue a Final Product Standard Reducing Carcinogens in Smokeless Tobacco Products. In 2016, FDA proposed a product standard to reduce tobacco-specific nitrosamines (NNN) in smokeless tobacco products. As FDA's own proposal states, "NNN is a potent carcinogenic agent found in smokeless tobacco products and is a major contributor to the elevated cancer risks associated with smokeless tobacco." The Lung Association and our partners filed two sets of comments (one in January and another in July) strongly in support of FDA's proposal – yet there has been no action from FDA moving the proposal forward. Smokeless tobacco use is highest among rural populations (five percent of adults living in rural locations use smokeless tobacco versus two percent among urban populations), and among men living in rural locations the rate jumps to ten percent23. Reducing NNN in smokeless tobacco will reduce exposure to this carcinogen among the rural populations who are at greatest risk.
  • FDA Must Issue a Product Standard Eliminating Menthol Cigarettes. Each year, more than 72,000 African-Americans are diagnosed with and close to 40,000 die from a tobacco-related cancer24. According to a 2013 FDA report, the majority of African-American smokers and most Americans with a lower socio-economic status who smoke use menthol cigarettes25. Research has also shown that African-Americans who smoke menthol cigarettes have a more difficult time quitting26. 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."27
  • 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, including within priority populations. It is 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 2014-2016.28 A 2016 study found that priority populations including African-Americans and Hispanics perceive the "Tips" ads to be effective in reaching them29. The campaigns feature and focus on tobacco use among priority populations.
  • One "Tips" ad featured a woman with depression to call attention to the issue of smoking among those with anxiety, depression and other mental illnesses. Numerous other advertisements have featured African-Americans and Latinos. 
  • In 2016, FDA's "The Real Cost" focused on preventing youth smokeless tobacco use among male youth living in rural areas.
  • Sources
    1. Centers for Disease Control and Prevention. Behavioral Risk Factor Surveillance Survey, 2016. Analysis by the American Lung Association Epidemiology and Statistics Unit using SPSS software.
    2. Jamal A, Gentzke A, Hu SS, et al. Tobacco Use Among Middle and High School Students — United States, 2011–2016. MMWR Morb Mortal Wkly Rep 2017; 66:597-603.
    3. Source for the bar graph: CDC. BRFSS 2016. (for all percentages except public housing, source for that: U.S. Department of Housing and Urban Development. A Health Picture of HUD-Assisted Adults, 2006-2012. March 2017). Traditional tobacco states include: GA, KY, NC, SC, TN and VA.
    4. U.S. National Cancer Institute. A Socioecological Approach to Addressing Tobacco Related Health Disparities. National Cancer Institute Tobacco Control Monograph 22. NIH Publication No. 17-CA-8035A. Bethesda, MD: U.S. Department of Health and Human Services, National Institutes of Health, National Cancer Institute; 2017.
    5. Truth Initiative. "Tobacco Nation: the Deadly State of Smoking Disparity in the U.S." Available at: https://truthinitiative.org/tobacconation. Accessed Friday Nov. 10, 2017.
    6. Centers for Disease Control and Prevention. Behavioral Risk Factor Surveillance Survey, 2016. Analysis by the American Lung Association Epidemiology and Statistics Unit using SPSS software.
    7. Substance Abuse and Mental Health Services Administration. The NSDUH Report: Adults With Mental Illness or Substance Use Disorder Account for 40 Percent of All Cigarettes. March 20, 2013. https://www.samhsa.gov/data/sites/default/files/spot104-cigarettes-mental-illness-substance-use-disorder/spot104-cigarettes-mental-illness-substance-use-disorder.pdf.
    8. Henry J. Kaiser Family Foundation. Key Facts about the Uninsured Population. Updated November 29, 2017.
    9. Centers for Disease Control and Prevention. Behavioral Risk Factor Surveillance Survey, 2016. Analysis by the American Lung Association Epidemiology and Statistics Unit using SPSS software.
    10. U.S. Food and Drug Administration. Preliminary Scientific Evaluation of the Possible Public Health Effects of Menthol Versus Nonmenthol Cigarettes. 2013. – Website Production Note: Restart footnotes at #1 for 2nd section here
    11. Centers for Disease Control and Prevention. National Center for Health Statistics. National Health Interview Survey, 2015. Analysis performed by the American Lung Association Epidemiology and Statistics Unit using SPSS software.
    12. Tim Ryan. Senate Oks Federalist Society Nominee for U.S. Solicitor General. CourthouseNews.com, September 19, 2017.
    13. Juliet Eilperin. FDA Delays Enforcement of Stricter Standards for E-Cigarette, Cigar Industry. Washington Post, May 2, 2017.
    14. U.S. Department of Housing and Urban Development. Resident characteristic report as of August 31, 2017. https://pic.hud.gov/pic/RCRPublic/rcrmain.asp.
    15. Maclean, J, M Pesko, S Hill. The Effect of Insurance Expansion on Smoking Cessation Medication Use: Evidence from Recent Medicaid Expansions. National Bureau of Economic Research. May 2017, Revised September 2017. Accessed at: http://www.nber.org/papers/w23450
    16. Centers for Disease Control and Prevention. Tobacco Use Among Middle and High School Students — United States, 2011–2016. Morbidity and Mortality Weekly Report. June 16, 2017; 66(23):597-603.
    17. U.S. Bureau of Labor Statistics. BLS Reports. Labor force characteristics by race and ethnicity, 2015. September 2016; Report 1062. https://www.bls.gov/opub/reports/race-and-ethnicity/2015/home.htm - Website Production Note: Restart footnotes at #1 for 3rd section here
    18. Medicaid and CHIP Payment and Access Commission. Behavioral Health in the Medicaid Program – People, Use and Expenditures. June 2015.
    19. U.S. National Cancer Institute. A Socioecological Approach to Addressing Tobacco Related Health Disparities. National Cancer Institute Tobacco Control Monograph 22. NIH Publication No. 17-CA-8035A. Bethesda, MD: U.S. Department of Health and Human Services, National Institutes of Health, National Cancer Institute; 2017.
    20. Institute of Medicine, Public Health Implications of Raising the Minimum Age of Legal Access to Tobacco Products, Washington, DC: The National Academies Press, 2015.
    21. U.S. Department of Housing and Urban Development. A Health Picture of HUD-Assisted Adults, 2006-2012. March 2017. Available at: https://www.huduser.gov/portal/sites/default/files/pdf/Health-Picture-of-HUD.pdf 
    22. DiGiulio A, Haddix M, Jump Z, et al. State Medicaid Expansion Tobacco Cessation Coverage and Number of Adult Smokers Enrolled in Expansion Coverage — United States, 2016. MMWR Morb Mortal Wkly Rep 2016;65:1364–1369. DOI: http://dx.doi.org/10.15585/mmwr.mm6548a2
    23. Centers for Disease Control and Prevention. Behavioral Risk Factor Surveillance Survey, 2015. Analysis by the American Lung Association Epidemiology and Statistics Unit using SPSS software.
    24. Henley SJ, Thomas CC, Sharapova SR, et al. Vital Signs: Disparities in Tobacco-Related Cancer Incidence and Mortality — United States, 2004–2013. MMWR Morb Mortal Wkly Rep 2016; 65:1212-1218.
    25. U.S. Food and Drug Administration. Preliminary Scientific Evaluation of the Possible Public Health Effects of Menthol Versus Non-Menthol Cigarettes. https://www.fda.gov/downloads/ucm361598.pdf,page 5
    26. Ibid, page 6.
    27. Ibid.
    28. Farrelly MC, Duke JC, Nonnemaker J, et al. Association Between The Real Cost Media Campaign and Smoking Initiation Among Youths — United States, 2014–2016. MMWR Morb Mortal Wkly Rep 2017; 66:47-50. DOI: http://dx.doi.org/10.15585/mmwr.mm6602a2.
    29. Davis K, Duke J, Shafer P, Patel D, Rodes R and Beistle D. Perceived Effectiveness of Antismoking Ads and Association with Quit Attempts Among Smokers: Evidence from the Tips from Former Smokers Campaign. Health Communication, Vol. 32 – Issue 8. July 19, 2016; 931-938. Available at: http://www.tandfonline.com/doi/full/10.1080/10410236.2016.1196413.

    Did You Know?

    1. More than 1 in 5 high school students in the U.S. use at least one tobacco product, including e-cigarettes, according to the 2016 National Youth Tobacco Survey.
    2. 7.2 percent of middle school students use at least one tobacco product, including e-cigarettes, according to the 2016 National Youth Tobacco Survey.
    3. A 2014 article in the Journal of the American Medical Association found that about 8 million lives have been saved through tobacco control efforts since 1964, including 800,000 lung cancer deaths between 1975 and 2000.
    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. Connecticut and New York have the highest cigarette taxes in the country at $4.35 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 $1.72 per pack.
    10. Ten states have taxes on other tobacco products equivalent to their state's cigarette taxes.
    11. Alaska is the only state that is funding their tobacco control programs at or above the CDC-recommended level (in Fiscal Year 2018).
    12. Three states increased their cigarette taxes in 2017.
    13. No state approved a comprehensive smokefree workplace law in 2017.
    14. 9 states – California, Connecticut, Indiana, Kentucky, Maine, Massachusetts, Missouri, Ohio 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 $2.10 per smoker in the state.
    16. Maine, New Jersey and Oregon passed legislation increasing their minimum sales ages for tobacco products to 21 in 2017.
    17. Five states and over 280 communities in 18 different states have passed Tobacco 21 laws.
    18. Nationwide, the Medicaid program spends more than $22 billion in healthcare costs for smoking-related diseases each year – more than 11 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. 42 states and Washington D.C. 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 they get from tobacco settlement payments and tobacco taxes to fight tobacco use.
    23. Each day, more than 2,300 kids under 18 try their first cigarette and close to 400 kids become new, regular smokers.
    24. Each day, close to 1,900 kids try their first cigar. On average, close to 80 kids try their first cigar every hour in the United States – equaling close to 690,000 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 $22 million dollars per day marketing their products in 2015.
    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 2012 study of Massachusetts' comprehensive Medicaid quit smoking benefit found that Massachusetts saved $3 for every $1 spent helping smokers quit in just over a year.
    31. In 2017, Kentucky and South Carolina made major improvements to their quit smoking coverage for Medicaid enrollees and others.
    32. Uninsured Americans smoke at a rate two times higher than people with private insurance.
    33. An estimated one third of Americans living in public housing smoke.
    34. One study found persons with behavioral health and substance abuse disorders consume about 40 percent of the cigarettes sold in the U.S.
    35. Native Americans and Alaska Natives have the highest smoking rates among any racial/ethnic group.
    Get more facts »

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