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 over the past decade and are at historically low levels. In 2020, 12.5% of U.S. 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, in no particular order:
1. Adults that Live in Rural Areas
Adults that live in rural areas smoke at a rate of 19.0% compared to 11.4% 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.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
The average smoking rate in traditional tobacco-growing states (Georgia, Kentucky, North Carolina, South Carolina, Tennessee and Virginia) is 15.6%, compared to 13.1% in other states (excluding Florida, for which data was not available).4 For decades, tobacco industry influence has blocked tobacco control policies in these states. Over recent years, there has been some progress on tobacco-control policies and smokefree laws in these states or in their localities.
3. Military Veterans
Military veterans smoke at a rate of 21.6%. That number jumps significantly among certain age groups—the highest being a shocking 50.2% 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 time in service.
4. Lesbian/Gay/Bisexual Adults (LGB)
LGB* individuals have a smoking rate of 16.1%, meaning about one in six LGB adults smoke cigarettes compared with about one in eight straight adults.1 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.6
*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 21.5%, while adults with a high school degree smoke at a rate of 17.6%, and adults with an undergraduate degree smoke at a rate of 5.6%.1
6. Americans Making Less Than $35,000 a Year
Americans making less than $35,000 a year have a smoking rate of 20.2%.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 the poverty rate.7 Lower income individuals who smoke cigarettes suffer more from smoking-caused diseases than individuals who smoke with higher incomes.8 Tobacco companies often target advertising campaigns toward low-income communities9 and a higher density of tobacco retailers can often be found in low-income neighborhoods.10
7. Uninsured Americans
Uninsured Americans smoke at a rate of 21.2%, more than double the rate of adults with private insurance, whose smoking rate is 9.2% 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.11
8. Indigenous Peoples
Indigenous peoples (American Indians/Alaska Natives) smoke commercial tobacco cigarettes at a rate of 27.1% and have the highest prevalence of cigarette smoking among all racial/ethnic groups in the U.S.1
For the Native community, it is important to distinguish between commercial tobacco use and tobacco use in traditional ceremonies as some members of Native communities use tobacco for ceremonial, religious or medicinal purposes.
9. Americans with Mental or Behavioral Health Conditions
Individuals regularly having feelings of anxiety smoke at rates of 21.4%, compared to 11.3% among those without such feelings.1 Rates can be even higher among those with other mental or behavioral health conditions.12 Even more alarming is that people with mental health conditions make up 22% of the population, but account for 36% of all cigarettes smoked.13 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.14
10. Adults in Public Housing
Adults living in public housing smoke at a rate of 33.6%,15 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 people who smoke 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. 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 ensuring resources are directed toward communities disproportionately impacted by tobacco use and exposure to secondhand smoke.
- Cornelius ME, Loretan CG, Wang TW, Jamal A, Homa DM. Tobacco Product Use Among Adults — United States, 2020. MMWR Morb Mortal Wkly Rep 2022;71:397–405.
- Centers for Disease Control and Prevention. National Center for Health Statistics. National Health Interview Survey, 2020. Analysis performed by the American Lung Association Epidemiology and Statistics Unit using SPSS software.
- American Lung Association. Cutting Tobacco’s Rural Roots: Tobacco Use in Rural Communities. Chicago: American Lung Association, 2015.
- Centers for Disease Control and Prevention. Behavioral Risk Factor Surveillance Survey, 2021. Analysis by the American Lung Association Epidemiology and Statistics Unit using SPSS software.
- 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.
- American Lung Association. The LGBT Community: A Priority Population for Tobacco Control. Available at: lgbt-issue-brief-update.pdf.pdf (lung.org)
- 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.
- Campaign for Tobacco-Free Kids. Tobacco and Socioeconomic Status. Washington, D.C., last updated Nov. 9. 2018.
- 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.
- ASPire Center. “Tobacco Retailers.” Available at: Tobacco Retailers - ASPiRE Center..
- 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.
- Centers for Disease Control and Prevention. Behavioral Risk Factor Surveillance Survey, 2018. Analysis by the American Lung Association Epidemiology and Statistics Unit using SPSS software.
- Centers for Disease Control and Prevention. National Center for Health Statistics. National Health Interview Survey, 2018. Analysis performed by the American Lung Association Epidemiology and Statistics Unit using SPSS software.
- Centers for Disease Control and Prevention. Vital Signs: Adult Smoking Focusing on People With Mental Illness, February 2013.
- 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 19, 2023