Tobacco Nation: A Call to Eliminate Geographic Smoking Disparities in the U.S.

Smoking prevalence is nearly 50% higher in a group of Midwestern and Southern states compared to the rest of the country, according to Truth Initiative’s latest analysis of U.S. states with the highest smoking prevalence. In 12 states – a region we call “Tobacco Nation” that spans Alabama, Arkansas, Indiana, Kentucky, Louisiana, Michigan, Mississippi, Missouri, Ohio, Oklahoma, Tennessee, and West Virginia – both adults (19.2% vs. 13%) and young adults (11.2% vs. 7.6%) have 50% higher smoking prevalence and smoke many more cigarettes per capita annually than people living in other states (on average, 53 vs. 29 packs). That means a smoker living in Tobacco Nation could smoke nearly 500 more cigarettes per year than the average smoker in the rest of the U.S.

This persistently high prevalence of cigarette use – still the country’s leading cause of preventable death and disease – has serious consequences, especially at a time when life expectancy has declined for Americans due to a variety of factors including COVID-19 and opioid overdoses. Tobacco Nation residents live shorter lives and face a higher risk of dying than other Americans, with an average life expectancy of 76 years compared to 79 years in the rest of the country. Tobacco Nation’s greater rates of smoking-attributable death and disease compared to the rest of the U.S. likely contribute to this lower life expectancy. 

Yet it is possible to create a future where these geographic disparities do not exist anymore. According to a separate analysis by Truth Initiative^® and HealthPartners Institute, more tobacco policy spending paired with higher cigarette taxes targeted to areas with the highest smoking prevalence can reduce disparities in tobacco use that have existed for decades, bringing adult smoking in Tobacco Nation down to the national average and resulting in considerable health and economic benefits. Specifically, the analysis predicts that implementation of key tobacco policy changes could lead to roughly 100,000 fewer cancer cases, 730,000 fewer hospitalizations, and 170,000 fewer deaths attributed to smoking in the first two decades following policy change as well as saving over $24 billion in smoking-attributable medical costs and increasing productivity by over $100 billion.

Researchers and policymakers have created a road map to end unequal smoking prevalence across the country. Why, then, has it been such a challenge to implement these policies? Disparities in tobacco prevention and cessation measures in Tobacco Nation are not the fault of the region’s residents. Residents of Tobacco Nation have historically supported policies at levels equal to their counterparts in states outside Tobacco Nation. Instead, strong tobacco policies have not gained traction due to a combination of factors, including lack of political will, powerful tobacco industry interference in legislation, and prevention of local jurisdictions from adopting strong tobacco prevention and cessation measures. These obstacles have become evident in recent years as strong local laws restricting the sale of flavored tobacco products, including menthol cigarettes and youth-appealing flavored e-cigarettes, have continued to gain momentum across the country, but very few have been implemented in Tobacco Nation. For example, only three out of nearly 400 flavored tobacco policies in the U.S. have been enacted in Tobacco Nation.

The research points to a clear need for action: without interventions, adult smoking prevalence in Tobacco Nation states is forecasted to be over 40% higher on average over the next 20 years compared to other U.S. states. Steps taken at the federal level – including the Food and Drug Administration’s proposed rules to remove menthol cigarettes and flavored cigars from the market – will likely have large impacts in Tobacco Nation states, but need time to take effect. In the meantime, local and state level protections – including prioritizing tobacco program spending in existing budgets, higher tobacco excise taxes on tobacco products, stronger local tobacco policies supporting smoke-free environments, and restrictions on the sale of flavored tobacco products – are needed to address long-existing inequities in smoking rates and health outcomes in our country.

AN UPDATE ON TOBACCO NATION TODAY

Tobacco use has significantly declined in the United States, with high school student smoking prevalence dropping from 28% in 2000 to 2% in 2022. Much of this decline is attributed to tobacco policy efforts, including price increases, smoke-free air laws, and youth access restrictions, as well as mass media public education and prevention campaigns. However, reductions in tobacco use have not occurred equally across U.S. populations and there are substantial geographic and sociodemographic disparities in tobacco use and associated health outcomes. New issues with uneven implementation of local flavored tobacco policies threaten to exacerbate the situation further.

Smoking prevalence in Tobacco Nation remains higher than the rest of the nation

Tobacco use is disproportionately high in several U.S. states – particularly in the South and Midwest. In our 2017 report, “Tobacco Nation: The deadly state of smoking disparity in the U.S.,” we highlighted a group of 12 states in this region, all of which had higher smoking prevalence than the national average: Alabama, Arkansas, Indiana, Kentucky, Louisiana, Michigan, Mississippi, Missouri, Ohio, Oklahoma, Tennessee and West Virginia. We called these states with very high smoking prevalence “Tobacco Nation.” These states not only have a high prevalence of tobacco use, they also tend to have worse indicators of health, socioeconomic status, and coverage by tobacco policies. Our 2019 follow-up report “Tobacco Nation: An ongoing crisis” found that most smoking, demographic, and health characteristics remained largely unchanged and looked beyond the most current annual estimates to examine trends in smoking over time. It identified the same 12 states as the first report, plus South Carolina, as states that had consistently ranked in the top 25% of U.S. adult smoking since 2011.

This year, we once again identified areas of the U.S. where smoking prevalence among adults was consistently high between 2011 and 2020. Today, Tobacco Nation is comprised of the same 12 states we identified in 2017— Alabama, Arkansas, Indiana, Kentucky, Louisiana, Michigan, Mississippi, Missouri, Ohio, Oklahoma, Tennessee, and West Virginia — with smoking prevalence within the top quarter of adult smoking prevalence in the country. We flagged three additional states to monitor – Alaska, South Dakota, and Wyoming – that may be on the verge of joining Tobacco Nation. While South Carolina, which was included in our last report, still has higher smoking prevalence than the national average, it did not consistently rate in the top 25% of smoking prevalence for states in the period we examined. 

Although smoking prevalence has declined across the U.S. since our 2019 report, residents of all ages in Tobacco Nation are still more likely to smoke than residents living in the rest of the U.S. Smoking prevalence is about 50% higher in Tobacco Nation compared to the rest of the U.S. among both adults (19% vs. 13%) as well as young adults (11% vs. 8%). Youth in the region have a higher prevalence of cigarette smoking compared to the rest of the U.S. as well (6% vs. 4% in 2019). Not only is there a higher smoking prevalence among Tobacco Nation’s residents of all ages,  they also smoke nearly twice as many cigarettes per capita annually (53 packs vs. 29 packs) than those in the rest of the U.S., amounting to nearly 500 more cigarettes a year.

With more than 67 million residents, these states include roughly 21% of the U.S. population but represent more than 28% of all adult current smokers in the country. When compared to the rest of the U.S., residents of Tobacco Nation states are less educated, not as financially well-off, and less likely to be employed, especially in white-collar jobs — trends we noted in our first Tobacco Nation report that remain true today.

Higher smoking prevalence translates to poorer health

We know that smoking is much more prevalent in Tobacco Nation than other states, so what does that mean for the health of its residents? The numbers show us that where tobacco use is high, tobacco-related health conditions and diseases are high, too. Not only does smoking raise the risk of lung and bronchus cancer, it also raises the risk of developing heart disease. Since our last report, we saw nationwide declines in life expectancy and increases in mortality from conditions like heart disease and cancer. However, given the number and frequency of cigarettes smoked in Tobacco Nation, it is both dismaying and unsurprising Tobacco Nation residents are more likely to die from cancer, heart disease, and chronic lower respiratory disease than those living in the rest of the U.S.

More smokers in Tobacco Nation also suffer from other health conditions that accompany tobacco use compared to the general adult smoking population. For example, 26% of smokers in Tobacco Nation report excessive drinking compared to 17% of its total adult population. Smokers in Tobacco Nation also report much higher rates of frequent physical distress, diabetes, poor physical health days, physical inactivity, and chronic obstructive pulmonary disease compared to the total adult population.

Life expectancy across geographic areas is highly correlated with preventable health behaviors such as smoking. In cities with highly educated populations, high incomes and high levels of government spending, individuals with low incomes live longer, report greater physical and mental health, and have healthier behaviors. In places where government support is relatively high and public policies encourage better health for all, its poorest residents fare better than similar residents living in other parts of the country. Conversely, in areas with a high prevalence of smoking and low levels of government spending, low-income individuals have the shortest life expectancy. In these areas, the deck is stacked against them. This adds up to a stark reality for residents of Tobacco Nation who are in areas of greatest smoking prevalence and with typically lower levels of government spending. This reality has become even more apparent throughout the COVID-19 pandemic. Tobacco Nation residents live shorter lives than other Americans, with an average life expectancy of 76 years compared to 79 years in the rest of the country.

Tobacco Nation fares worse in mental health declines

In addition to life expectancy, mental health has declined across the country (in part due to the COVID-19 pandemic) but indicators remain worse in Tobacco Nation than other U.S. states. Adults in Tobacco Nation more often report poor physical and mental health days and report more frequent mental and physical distress compared to the rest of the U.S. Tobacco Nation’s smokers are also more likely to report frequent mental distress (26.9%) than the average Tobacco Nation resident (16.1%). The story is similar for poor mental health days.

This disparity is concerning given the relationship between mental health and nicotine. Individuals with mental health conditions are more likely to report smoking and smoking in greater amounts. In turn, evidence suggests that nicotine can intensify symptoms of anxiety and depression. 

Weak tobacco policies in Tobacco Nation worsen health disparities

When it comes to reducing tobacco use and improving health, tobacco policies like smoke-free laws, restrictions on flavored tobacco products, and increased taxes make a big difference. According to the Centers for Disease Control and Prevention, “because tobacco policies take a population-based approach to improving health, policies have the potential to reach groups most affected by tobacco and reduce disparities,” but these policies are largely enacted and enforced at the state and local level, where there is significant variation. Overall, states within Tobacco Nation have less restrictive tobacco policies compared to much of the nation – with lower taxes, lower spending, and fewer flavored tobacco and smoke-free air policies in place.

Low taxes in Tobacco Nation make cigarettes cheapest in the nation

Cigarettes are cheaper in Tobacco Nation states than they are in the rest of the U.S. On average, a pack of cigarettes costs nearly 20% less in Tobacco Nation than in other states ($6.50 compared with $7.95), with much of the difference attributed to lower state cigarette taxes. The average excise tax on a pack of cigarettes is about half compared to other U.S. states ($1.11 vs $2.12).

Cigarette tax data indicate that Tobacco Nation states have increased excise cigarette taxes by an average of only $0.59 since 2015 compared to an average tax increase of $1.04 in states outside Tobacco Nation, driving tax disparities between the regions. During this time, proposals to increase cigarette taxes failed in five Tobacco Nation states: Indiana, Michigan, Mississippi, Missouri, and Tennessee.

Industry interference in cigarette taxes

The struggle to raise cigarette taxes in Tobacco Nation states may be attributed in part to strong tobacco industry interference. For example, in 2022, Altria spent $198,685 lobbying against bills in Kentucky that would increase the cigarette tax, institute a clean indoor air act, and allow local governments to impose stricter laws around use, display, sale, and distribution of tobacco products and e-cigarettes. Altria has placed first or second in total spending on lobbying in Kentucky in 2019, 2020, and 2022. And in Missouri, which has the lowest cigarette excise tax per pack in the nation at 17 cents, the rate hasn’t changed in over 25 years. A 2020 report by Tom Kruckemeyer, a former economist for Missouri’s state Budget Office, points to the fact that 33 of 34 state senators had accepted some tobacco campaign donations, raising concerns about lawmakers’ willingness to “prioritize public health over profits.”

The industry’s targeting of proposed cigarette tax hikes isn’t limited to Tobacco Nation. In 2020, Colorado voters passed a ballot measure that increases the cigarette tax gradually, instead of imposing the tax more quickly as health advocates would have preferred. Altria was heavily involved in negotiating the bill and helped write the ballot measure that resulted in the gradual timeline.

Spending on tobacco prevention and cessation remains lower in Tobacco Nation states

Research shows that investing in comprehensive tobacco prevention and cessation programs can reduce youth tobacco use, smoking-attributable disease, and health care costs. A 2023 study of the California Tobacco Control Program found that the program prevented the consumption of nearly 16 billion packs of cigarettes from 1989 to 2019, and that spending one more dollar per capita reduced average consumption of cigarettes per adult current smoker by about two packs a year. The CDC provides tobacco prevention and cessation expenditure recommendations for each state, which indicate what the state would need to spend to fully fund and sustain a comprehensive tobacco prevention and cessation program. The CDC recommends directing these expenditures toward efforts such as prevention campaigns, cessation programs, surveillance, evaluation, and the administration and management of tobacco policies.

Unfortunately, no states meet the CDC’s recommended spending level on tobacco prevention and cessation programs, but Tobacco Nation states are doing comparatively worse than others. Overall, Tobacco Nation spends less than 15% of recommended spending on tobacco prevention and cessation programs, which is about half of what states outside of Tobacco Nation spend (30%). Oklahoma is the only state in Tobacco Nation and one of only 10 U.S. states that spends at least 50% of what the CDC recommends the state should spend on tobacco prevention and cessation programs.

Since our last report, tobacco prevention and cessation expenditures in Tobacco Nation states are largely unchanged. Notable exceptions are Tennessee, which decreased spending by 52%, bringing it to less than 5% of CDC-recommended funding. Tennessee also diverted 100% of its tobacco prevention and cessation funding to COVID-19 efforts in 2022, which led to no funding for tobacco programs the following fiscal year. In a bright spot, Louisiana increased expenditures by 92%, but this still only brought the state to 24% of CDC-recommended funding.

Flavored tobacco policies slow to gain traction in Tobacco Nation

Flavored tobacco policies have been increasingly adopted to cover gaps in federal regulation and address the rapid proliferation of flavored tobacco products in recent years. These policies are a growing area of tobacco policy action at the state and local level because they can play a key role in reducing youth tobacco use and racial and socioeconomic disparities in tobacco use. Flavored tobacco products are disproportionately marketed toward youth, racial and ethnic minorities, and low-income communities. Flavor policies – especially when comprehensive – have the potential to reduce youth tobacco use and tobacco use disparities. According to Truth Initiative data, eight states and 380 local jurisdictions have enacted policies to restrict the sale of flavored tobacco. 

Unfortunately, these policies have not been enacted equally across the U.S. Less than one percent of Tobacco Nation residents are protected by flavored tobacco policy restrictions, compared to 34% of the rest of the country who have these protections in place. Only three out of nearly 400 flavored tobacco policies in the U.S. have been enacted in Tobacco Nation. This means that nearly all Tobacco Nation residents are exposed to flavored tobacco product marketing, including young people, low-income individuals, and Black individuals who are overrepresented in Tobacco Nation compared to the rest of the country.

Tobacco Nation’s lack of flavored tobacco policies are not from lack of trying. Five Tobacco Nation states have unsuccessfully attempted to enact statewide flavor policies. West Virginia tried to pass a law in 2013 prohibiting the sale of all flavored tobacco products (except for menthol and mint flavors), but the bill was struck down by the state’s House. In addition, Kentucky, Louisiana, Michigan, and Ohio all drafted bills to restrict the sale of flavored e-cigarettes which were ultimately struck down by state legislators. There are many factors at play in delayed and failed implementation of flavored tobacco policies. Policy makers may be slower to adopt flavored tobacco policies in part because they are relatively new compared to more established policies such as smoke-free air laws. In addition, pre-emption, which is more common in Tobacco Nation states, prevents local jurisdictions in many states from adopting flavor policies.

Tobacco industry opposition to flavored tobacco policies

Industry influence in slowing or halting flavor policies is an issue across the U.S. Tobacco giants Philip Morris International, R.J. Reynolds, and Altria have opposed policies across the country that are proven to decrease cigarette demand and have undermined efforts to enact these types of regulations, such as higher taxes, flavor bans, graphic warning labels and clean indoor air laws.

The industry spent tens of millions of dollars opposing and delaying implementation of California’s 2020 statewide flavored tobacco sales restriction. Despite the opposition, voters overwhelmingly upheld the restriction in November 2022. Similarly, Washington County, Oregon passed a flavored tobacco sales restriction in 2021. The industry reacted by forcing it to the ballot, where voters approved of the law. However, the industry took the law to the courts, which issued a preliminary injunction, leaving the law on hold for now.

The tobacco industry has also attempted to spread fear nationwide that eliminating the sale of menthol cigarettes unfairly targets African Americans and would lead to further criminalization within the community. These efforts are not founded in fact or evidence.  R.J. Reynolds, the maker of the leading menthol cigarette brand, Newport, recruited prominent African Americans including the civil rights leaders the Rev. Al Sharpton and Rev. Horace Sheffield to oppose efforts to eliminate menthol cigarettes. In a 2022 report by the Bureau of Investigative Journalism, Sheffield expressed concerns about the tobacco industry’s pattern of coercing under-funded organizations into supporting efforts that harm the well-being of Black communities.

Policymakers in Tobacco Nation are slow to pass smoke-free air policies

Comprehensive smoke-free laws are also essential to reducing tobacco use and improving health. One national estimate showed that indoor smoke-free policies in workplaces alone would result in 725,000 smokers quitting in the first year. Studies have shown that smoke-free air laws were successful in Tobacco Nation. Indiana’s law prohibiting smoking in restaurants and non-hospitality workplaces was followed by a 16% reduction in adult smoking, and county-level smoke-free air laws in Kentucky were associated with lower smoking prevalence – especially among youth.  

Much like other tobacco policies in Tobacco Nation, the region also features less coverage by smoke-free air policies. Collectively, 47% of Tobacco Nation residents are covered by comprehensive smoke-free policies compared to 64% of the rest of the U.S. Since our previous report, two states – New Mexico and Colorado – have passed smoke-free policies in workplaces, restaurants, and bars, bringing the total number of states with 100% smoke-free policies to 28. Unfortunately, no new states enacted smoke-free air legislation in Tobacco Nation, despite efforts from seven states to pass a policy. Michigan and Ohio remain the only Tobacco Nation states prohibiting smoking in workplaces, restaurants, and bars.

Although local-level comprehensive smoke-free policies were enacted in both Tobacco Nation and other U.S. states since our last report, policies were more frequently implemented outside of Tobacco Nation. Tennessee was the only Tobacco Nation state to enact local comprehensive smoke-free legislation, bringing the total number of Tobacco Nation states with local smoke-free policies from seven to eight, while outside of Tobacco Nation the number of states with some local comprehensive smoke-free policies has more than doubled.

The CDC reported that comprehensive smoke-free laws can benefit “people from all socioeconomic, educational and racial/ethnic backgrounds equally by increasing places where people are protected from tobacco smoke.” These findings signify the importance of comprehensive smoke-free policies being passed at the local and state level and highlight the need for more state and local smoke-free policies in Tobacco Nation.

Pre-emption prevents implementation of strong local policies

Several U.S. states – including many in Tobacco Nation – prohibit local jurisdictions from enacting tax, smoke-free, flavor, and other types of policies, via a limitation called pre-emption. Pre-emption ultimately leads to jurisdictions being restricted from implementing protections that promote the health of their residents, and is a key barrier to effective tobacco policies in Tobacco Nation.

Local policies can generate significant population coverage by tobacco policies that may not be present at the state level. This is evident in our finding that nearly 50% of Tobacco Nation residents are covered by comprehensive smoke-free laws, despite only two states having statewide comprehensive smoke-free laws.

There is constant back and forth between states and local jurisdictions as they pass tobacco legislation at odds with each other. Local jurisdictions in Tennessee were unable to prohibit smoking in age-restricted venues until the state enacted a policy reversing this in 2022. In 2021, Tennessee passed a law which adds e-cigarettes to the state’s smoke-free law, but also pre-empts future laws on e-cigarettes, including flavored e-cigarette restrictions and laws relating to e-cigarette taxes, marketing, and retail licensing. Arkansas enacted a law in 2019 preventing local jurisdictions from enacting tax and youth access laws stricter than state-level laws. In 2022, after Columbus, Ohio passed a flavored tobacco product law, the legislature passed a bill that would preempt local governments from enacting stricter tobacco laws than the state, though the bill was ultimately vetoed by the governor. Other pre-emption policies were proposed but did not pass in Louisiana, Missouri, and West Virginia. Localities must be able to enact strong tobacco policies that protect and improve the health of their residents. Until pre-emption is removed, it will remain a significant barrier to improving the health of Tobacco Nation.

CALL TO ACTION

Although tobacco policies are proven to decrease tobacco use, these policies have not been consistently adopted and implemented across the country, leaving Tobacco Nation residents unprotected by fundamental tobacco prevention and cessation measures. The result is continuing high prevalence of tobacco use in the region. New policies such as flavored tobacco restrictions that include e-cigarettes gaining traction outside of Tobacco Nation and greater declines in mental health within the region compared to the rest of the U.S. mean that Tobacco Nation states are at risk of falling even further behind while other states move quickly to protect their resident’s health from the consequences of tobacco use. Without action, the gulf between tobacco use prevalence in Tobacco Nation and the rest of the U.S. will persist, along with the associated health and economic disparities that accompany tobacco use.

There is hope, however. Research shows that increasing spending on tobacco prevention and cessation programs, paired with raising cigarette taxes, could reduce adult smoking disparities in Tobacco Nation to levels on par with the rest of the country. If implemented, these key tobacco policy changes could also lead to substantial reductions in smoking-attributable disease, death, and health care costs and increase economic benefits.

It is especially important that states do everything they can to push forward policies that protect their residents. Tobacco Nation’s elected officials should prioritize the health of their residents.

Ending the fight against tobacco can start with a series of fundamental tobacco policies and interventions. Here is what we know works:

• Greater funding for tobacco prevention and cessation programs: The recent significant decline in smoking prevalence in the U.S. has erroneously led many in the general public, as well as those in public and private leadership, to believe tobacco is largely “solved,” or at least “addressed,” in our nation. As a result, both government and private funding of tobacco prevention and cessation efforts have languished or been redirected elsewhere. Among private funders, there is a perception that the public sector is adequately dealing with the issue and that the need and opportunity for impact is greater outside the U.S. We must correct this assumption and adequately invest our dollars into programs that work. Investment in tobacco prevention and cessation measures remains one of the most efficient public health interventions for saving and improving lives, with a large return on investment. This is especially true for Tobacco Nation, given its disproportionate share of the smoking population.
• Higher tobacco excise taxes: We know that taxes work to discourage tobacco use, particularly among lower socioeconomic groups and younger individuals. Tobacco taxes can also help to address the price disparity, where current cigarette prices constitute a relatively minor percentage of disposable income compared with cigarette prices around the world.
• Strong flavor policies: Flavors play a significant role in drawing youth and young adults to tobacco products. Tobacco product manufacturers aggressively market flavored products in several ways, including by emphasizing flavors in advertisements, paying to place them on store countertops, using colorful images on packaging and introducing new and limited-edition flavors. While several localities in California, Illinois, Massachusetts, Minnesota, New York and Rhode Island have restricted the sale of flavored tobacco products in some way, only three localities in Tobacco Nation have done so. State and local governments within Tobacco Nation should enact policies that restrict the sale of flavored tobacco products, including menthol, mint and wintergreen flavors. For examples of successful state and local efforts to prohibit the sale of flavored tobacco products, see our flavors fact sheet.
• Reversing pre-emption: Strong local policies are essential to ensure that tobacco policies have the greatest reach. Localities should be allowed to enact stronger policies than the state level. In addition, efforts must be made to ensure future state laws do not introduce other forms of tobacco policy pre-emption.
• Smoke-free policies: Everyone deserves clean air, but just over 50% of the entire population of the U.S. is covered by comprehensive smoke-free air laws. The fact that only two out of 12 states in Tobacco Nation can guarantee an individual the right to clean air on the job, in a restaurant and at a bar, is an inequity that needs to be rectified.
• Public education: Research has consistently demonstrated that tobacco-related public education campaigns save lives, promote quit attempts, reduce youth smoking initiation, lower health costs and blunt the impact of tobacco industry marketing. Effective public education campaigns are adequately funded, guided by scientific research and use multiple media channels to communicate messages that shift knowledge and attitudes to support policy initiatives designed to reduce tobacco use among a target audience.Quitting services: Access to quitting tobacco services can dramatically reduce tobacco use and encourage quitting. The U.S. Public Health Service recommends that treating tobacco use should become part of routine health care for all smokers. States should include the full range of tobacco treatments in their Medicaid policies and provide robust quitting resources for their residents. Policy changes like greater spending on tobacco prevention and cessation and higher excise taxes must be paired with quitting support to be effective.
• Point-of-sale policies: Tobacco companies continue to use the retail environment as a way to encourage smoking behavior through product displays and placement, exterior and interior advertisements and promotional and price incentives to consumers. Youth are particularly affected by this type of marketing. State and local governments within Tobacco Nation should enact point-of-sale policies, such as keeping tobacco products behind the counter and tobacco promotional materials above the eye level of children to restrict accessibility of tobacco for children and teens, and prohibiting tobacco sales in pharmacies. For examples of other successful state and local efforts to limit tobacco exposure to youth in the retail environment, see our Point-of-Sale Fact Sheet and Policy Resource.

Tobacco Nation’s risk of death and disease exacts too great a cost. Tobacco use kills almost half a million people in the U.S. and costs the country more than $300 billion per year, according to the CDC. As a nation, we must protect everyone from these harms by reducing smoking everywhere, but particularly among the hardest-hit region of Tobacco Nation. No longer can we accept the country within a country phenomenon. The residents of Tobacco Nation have the right to live healthy, smoke-free lives just as the rest of the country.