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Tobacco Tale of Two Nations: New Report Shows 13 States Have Higher Smoking Rates and Greater Health Consequences Than Rest of U.S.

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Truth Initiative® today released “Tobacco Nation: An Ongoing Crisis – Examining the Health and Policy Disparities of U.S. States with the Highest Smoking Rates.” The report underscores a tale of two nations when it comes to tobacco use - one of dramatic declines in smoking rates, and one where a huge swath of the U.S. has been left behind due to systemic disparities and tobacco industry interference. This report updates the findings in the first edition of “Tobacco Nation” released in 2017 that identified 12 contiguous states that consistently exceeded the national adult smoking rates, and adds South Carolina to the list. 

Today, Tobacco Nation is home to more than 71 million Americans, or roughly 22% of the U.S. population. The 13 states studied for the report include Alabama, Arkansas, Indiana, Kentucky, Louisiana, Michigan, Mississippi, Missouri, Ohio, Oklahoma, South Carolina, Tennessee and West Virginia. In these states, 21% of adults smoke, compared with just 15% of adults in the rest of the nation and consistently ranked in the top 25% of U.S. adult smoking since 2011.

While there has been a dramatic decline in overall U.S. smoking rates, the new report finds these 13 states have made little to no progress in reducing tobacco use and provides an updated look at the health, policy and extensive tobacco use disparities within the U.S. In Tobacco Nation, residents smoke more, live shorter lives, are more likely to get and die from cancer, and are at a serious disadvantage in terms of access to health care, policy progress, and income. Tobacco Nation residents live with 5% fewer physicians in their area, a major deficit of smoke-free laws in public places, and cheaper tobacco products — making tobacco more accessible than in other parts of the country.

“Many people think cigarettes are a thing of the past, but more than 34 million Americans still smoke and tobacco remains the leading cause of preventable death, killing more than 540,000 Americans each year," said Robin Koval, CEO and president of Truth Initiative. "Tobacco is not an equal opportunity killer with glaring disparities in who still smokes and why. Tobacco Nation’s high smoking rates, relatively poor health outcomes and lack of access to care make it a disadvantaged country within a country. The U.S. can and should do better.”

The new report also finds: 

  • Individuals living in Tobacco Nation earn nearly 25% less per year than the typical resident within the rest of the U.S. 
  • Not only do Tobacco Nation’s youth and adults smoke at higher rates, its residents also smoke many more cigarettes per capita annually (59.2 packs) than those in the rest of the U.S. (32.1 packs).
  • On average, Tobacco Nation residents live shorter lives and face a higher risk of dying than other Americans. Average life expectancy in Tobacco Nation is 76.3 years, compared with 79.3 years in the rest of the U.S.
  • Tobacco Nation as a whole fares poorly in mental and physical markers of well-being, compared with the rest of the nation. Tobacco Nation residents report more than 20% more “poor” physical and mental health days than the average American. 
  • Cigarette packs on average are 19% cheaper in Tobacco Nation.
  • Only two states in Tobacco Nation, Michigan and Ohio, have laws forbidding smoking in workplaces, restaurants and bars. 
  • In a 2018 study of support for tobacco control policies, residents of Tobacco Nation supported policies at almost exactly the same level as their other American counterparts. Support for policies, including requiring tobacco products to be kept out of view in stores where youth shop and requiring stores that sell tobacco to purchase licenses from state or local government, was actually higher in Tobacco Nation than in remaining states. This finding demonstrates that disparities are not the result of a lack of public will but rather the result of systemic disparities and tobacco industry influence that make it difficult for the residents of Tobacco Nation to get the protections more readily available elsewhere in the U.S. 

The disparities in Tobacco Nation are due to their deficiency of proven tobacco prevention measures, including higher taxes, comprehensive smoke-free laws, effective tobacco-prevention policies, public education efforts, access to quit smoking resources and laws like raising the legal sale age for tobacco products to 21. One factor clearly suppressing the adoption of tobacco control policies is opposition by the tobacco industry. For example, Altria (the maker of #1 brand Marlboro) and British American Tobacco (the maker of #2 brand Newport) continue to aggressively oppose policies, legislation and regulations that are proven to decrease cigarette demand such as higher taxes, flavor bans, graphic warning labels and clean indoor air laws. More specifically, in 2018, Altria spent nearly $380,000 lobbying the Kentucky legislature to pass a paltry 50-cent cigarette tax increase—significantly lower than tobacco control advocates had been seeking. The result, cigarettes remain cheaper in Kentucky than in 35 other states. 

The challenges shared by the Tobacco Nation states make this portion of the United States similar in many regards to less-developed countries around the world – a very disturbing reality for the richest nation in the world. When compared to countries with a fraction of the financial, scientific and healthcare resources available in the U.S., Tobacco Nation had the fifth-highest rate of tobacco use by youth in the world, behind Indonesia, Ukraine, Mexico and the Philippines. Tobacco Nation ranks sixth in the world for adult smoking prevalence rates, behind countries like Indonesia, China and Ukraine. 

Along with the updated report, researchers developed “Tobacco Nation: A Geographic Perspective,” an innovative, web-based mapping tool which presents a geographic look at the region, along with detailed, county-level smoking, demographic and policy data.

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