Top 10 Communities 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 overall smoking rates in the U.S. have decreased in the past decade and are near historically low levels. In 2022, 11.6% of U.S. adults smoked cigarettes.1

However, not all people across America are benefiting equally from this decline. Certain parts of the country and different communities continue to smoke at high rates, highlighting the uneven progress where tobacco industry marketing and a lack of policies proven to reduce tobacco use have occurred. Here are ten communities that are disproportionately affected by cigarette smoking and tobacco use, in no particular order:

1. Rural Communities

Adults who live in rural communities smoke at a rate of 18.1% compared to 10.5% among adults that live in urban areas.1 They are also more likely to smoke more heavily, smoking 15 or more cigarettes per day, compared to those who smoke and live in urban areas.1 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.2

2. Residents of Tobacco Nation States

The average smoking rate in the “Tobacco Nation” states (Alabama, Arkansas, Indiana, Kentucky, Louisiana, Michigan, Mississippi, Missouri, Ohio, Oklahoma, Tennessee, and West Virginia)3 is over 40% higher than in other states.1 For decades, tobacco industry lobbying has blocked tobacco control policies in these states; however, over recent years, there has been some progress on implementing proven policies, including smokefree laws in these states and localities. Much more work remains.

3. Military Veterans 

Military veterans smoke at a rate of 21.6%. That number jumps significantly among veterans in certain age groups—the highest being a shocking 50.2% among male veterans aged 18-25.4 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 time in service.

4. Lesbian/Gay/Bisexual Adults (LGB)

Almost one in five LGB* adults smoke cigarettes compared with about one in nine straight adults.1 LGBT individuals often face risk factors such as daily stress related to prejudice and stigma. The tobacco industry has long and aggressively targeted and marketed to the LGBTQ+ community, advertising in publications aimed at LGBTQ+ audiences and depicting tobacco use as an “accepted” part of LGBTQ+ life.5

* The statistic around this smoking rate does not include transgender individuals for whom data is often not collected.

5. Adults Without a High School Degree

Adults with lower levels of educational attainment smoke at higher rates than the general population. Adults who did not graduate high school smoke at a rate of 20.7%, while adults with a high school degree smoke at a rate of 16.3%, and adults with an undergraduate degree smoke at a rate of 4.4%.1

6. Lower Income Individuals

Individuals with incomes below the poverty threshold have a smoking rate of 19.7%.1 People living in poverty smoke cigarettes more heavily and smoke for nearly twice as many years as people with a family income three times higher.6 Lower-income individuals are also more likely to live in public housing, where smoking rates among adults are more than twice the national rate.7 Tobacco companies often target advertising campaigns toward low-income communities8 and a higher density of tobacco retailers can often be found in low-income neighborhoods.9

Americans making less than $35,000 a year have a smoking rate of 20.2%.

7. Individuals Without Health Insurance

Uninsured individuals in the U.S. smoke at a rate of 19.4%, more than double the rate of adults with private insurance, whose smoking rate is 8.7%1 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.1The uninsured population includes approximately 1.9 million people in the 10 states that have not expanded Medicaid that would be eligible for coverage, if their state expanded.11 

Uninsured Americans smoke at a rate more than double that of Americans with private insurance.

8. Indigenous Communities

Indigenous peoples (American Indians/Alaska Natives) smoke commercial tobacco cigarettes at a rate of 19.2% and have the highest prevalence of cigarette smoking among all racial/ethnic groups in the U.S.12

It is important to distinguish between commercial tobacco use and tobacco use in traditional ceremonies as some members of Indigenous communities use tobacco for ceremonial, religious or medicinal purposes.

9. People Living with Anxiety or Depression

Individuals in the U.S. ever diagnosed with anxiety or depression smoke at a rate of 17.1%, compared to 9.8% among those never diagnosed.1   Even more alarming is that people with mental health conditions make up 24% of the population, but account for 37% of all cigarettes smoked.1 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.13

People with mental health conditions and substance abuse make up 22 percent of the population, but account for 38 percent of all cigarettes smoked.

10. Individuals with A Disability

Individuals with a disability smoke at a rate of 18.6%, compared to those without disabilities who smoke at a rate of 10.9%.1 Individuals with disabilities can experience higher levels of stress, anxiety or other mental health conditions than their able-bodied counterparts, which may contribute to a higher rate of smoking.

How Do We Keep Those at Greatest Risk from Being Left Behind?

All individuals deserve the chance to live a full and healthy life. Yet smoking rates are higher in certain parts of the country and among certain communities in the U.S. 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. 

To achieve health equity in tobacco control, tobacco prevention and cessation efforts must focus on the policies called for in our “State of Tobacco Control” report, and ensure resources are directed toward communities disproportionately impacted by tobacco use and exposure to secondhand smoke.

  1. Centers for Disease Control and Prevention. National Center for Health Statistics. National Health Interview Survey, 2022. Analysis performed by the American Lung Association Epidemiology and Statistics Unit using SPSS software.
  2. American Lung Association. Cutting Tobacco’s Rural Roots: Tobacco Use in Rural Communities. Chicago: American Lung Association, 2015.
  3. Truth Initiative. Tobacco Nation A Call to Eliminate Geographic Smoking Disparities in the U.S. June 28, 2023. Available at: Tobacco_Nation_Report_2023_FINAL.pdf (
  4. 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.
  5. American Lung Association. The LGBT Community: A Priority Population for Tobacco Control. Available at: lgbt-issue-brief-update.pdf.pdf (
  6. 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.
  7. Helms V, King B, Ashley P. Cigarette smoking and adverse health outcomes among adults receiving federal housing assistance. Preventative Medicine 2017; 99:171-7.
  8. 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.
  9. ASPire Center. “Tobacco Retailers.” Available at: Tobacco Retailers - ASPiRE Center.
  10. 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.
  11. Rudowitz, R, P. Drake, J. Tolbert and A. Damico. How Many Uninsured Are in the Coverage Gap and How Many Could be Eligible if All States Adopted the Medicaid Expansion?. Kaiser Family Foundation. March 31, 2023. Accessed at: 
  12. Centers for Disease Control and Prevention. National Center for Health Statistics. National Health Interview Survey, 2021-2022. Analysis performed by the American Lung Association Epidemiology and Statistics Unit using SPSS software.
  13. Centers for Disease Control and Prevention. Vital Signs: Adult Smoking Focusing on People With Mental Illness, February 2013.

Page last updated: January 18, 2024