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New Report Finds Major Geographic Smoking Disparities Across Midwest and Southern States

Truth Initiative “Tobacco Nation” report shows how 12 states lag behind rest of country on tobacco-related issues

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A new report released today shows how major geographic smoking disparities are impacting residents of 12 contiguous states throughout the Midwest and South, creating a region dubbed “Tobacco Nation.” The report from Truth Initiative, the national public health organization inspiring lives free from smoking, vaping, and nicotine, analyzes how smoking prevalence is nearly 50% higher in these 12 states compared to the rest of the nation, with a smoker living in Tobacco Nation smoking on average nearly 500 more cigarettes per year than the average smoker elsewhere in the United States. These states frequently have fewer key policies proven to reduce tobacco usage, significantly contributing to these major disparities. This third Tobacco Nation report released since 2017 further demonstrates how, with smoking remaining the leading cause of preventable death in the U.S., Tobacco Nation residents live shorter lives and face a higher risk of dying than other Americans, as well as what steps can be taken to end these dangerous disparities.

“No matter where you choose to live, you should have the right to a safe, tobacco-free life. And unfortunately, that just isn’t the case right now in the United States,” stated Dr. Barbara Schillo, Chief Research Officer at Truth Initiative. “Due in part to policies that favor the tobacco industry over public health, residents of ‘Tobacco Nation’ are too often suffering from shorter life expectancy, worse indicators of health, and high prevalence of tobacco use. We owe it to all those who live in these states to take strong actions to close these geographic disparities and give them a fighting chance for a healthy, smoke-free life.”

This year’s report reveals that in the 12 “Tobacco Nation” states – 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 a 50 percent higher prevalence of smoking cigarettes, and smoke significantly more cigarettes per capita annually (53 vs. 29 packs) than people living in other states. Other key findings include:

  • 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 U.S.;
  • Adult smoking prevalence in Tobacco Nation states is forecasted to be over 40% higher on average compared to other U.S. states over the next 20 years; and
  • With more than 67 million residents, the Tobacco Nation states include roughly 21 percent of the U.S. population, but represent more than 28 percent of all adult current smokers nationwide.

While residents of Tobacco Nation have historically supported strong tobacco control policies at an equal level to residents of states outside the region, a combination of factors have prevented them from gaining traction. Overall, states within Tobacco Nation have less restrictive tobacco policies, including:

  • Lower taxes, leading to a pack of cigarettes costing nearly 20% less in Tobacco Nation than in other states ($6.50 compared with $7.95);
  • Lower spending on tobacco prevention and cessation programs, spending less than 15% of CDC-recommended expenditures compared to 30% of CDC-recommended expenditures outside of Tobacco Nation;
  • Virtually no flavored tobacco sales restrictions, with less than one percent of Tobacco Nation residents being protected by flavored product restrictions, compared to 34% of the rest of the country; and
  • Fewer comprehensive smoke-free policies, which cover 47% of Tobacco Nation residents compared to 64% of the rest of the U.S.

The way forward out of Tobacco Nation is clear – policies proven to decrease tobacco use need to be adopted and implemented in the region as they have been throughout the country. Without these measures in place, Tobacco Nation residents are subject to unchecked industry influence and suffering from high prevalence of tobacco use. A separate analysis by Truth Initiative and HealthPartners Institute found that that increasing spending on tobacco prevention and cessation programs, paired with raising cigarette taxes, could reduce adult smoking disparities in the region to levels on par with the rest of the country. The analysis also predicted that implementation of key policies in Tobacco Nation could lead, over the next two decades, to:

  • Roughly 100,000 fewer cancer cases;
  • 730,000 fewer hospitalizations;
  • 170,000 fewer deaths attributed to smoking following policy changes;
  • Savings of over $24 billion in smoking-attributable medical costs; and
  • Increasing productivity by over $100 billion.

It is time for Tobacco Nation’s elected officials to set aside the influence of the tobacco industry and prioritize the health of their residents, now and in the future. To read the full report, visit

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