Where Are You Most Likely to Find Americans Who Still Smoke?

Not that long ago, it seemed like everyone in America smoked cigarettes. Several states in the nation had built their economies on growing and producing tobacco, and savvy marketing by big tobacco companies made it seem cool and normal for everyone to smoke. It was just what people did.

But by the 1950s, researchers had begun connecting the simple act of smoking a cigarette to a higher chance of developing lung cancer, and by the 1960s, widespread efforts to curb smoking had gotten underway. This was also about the time that smoking's prevalence peaked in the U.S.; the Centers for Disease Control and Prevention report that in 1965, 42.4 percent of adults in the United States smoked.

[See: 7 Things You Didn't Know About Lung Cancer.]

Fast forward nearly six decades, and smoking rates have dramatically declined. The CDC reports that in 2016, the adult smoking rate was just 15.5 percent. (The American Lung Association pegs that national average somewhat higher at 16.8 percent.) This steep decline is great news: The more we learn about how cigarettes impact the body, the more we know that they should be avoided as much as possible.

But before we get too excited about the impressive strides against a known public health threat at the national level, let's zoom in a little more on where those 37.8 million still-smokers are most likely to live.

The nonprofit, anti-tobacco advocacy organization the Truth Initiative, reported last October that 12 contiguous states stretching from the upper Midwest to the South have higher smoking rates than the rest of the country.

Robin Koval, CEO and president of the Truth Initiative, says the report highlights that some areas of the country are still disproportionately impacted by tobacco use. The Truth Initiative has dubbed these states with the highest adult smoking prevalence rates "Tobacco Nation," and Koval says "if you look at it on a map, it really does look like a separate country. And it almost behaves that way." She notes that if this region were a separate country, it would rank among the top five nations with the highest tobacco use targeted for reduction efforts by the Bloomberg Initiative to Reduce Tobacco Use, a World Health Organization--affiliated international grant program to curb tobacco use in low- and middle-income nations. Only Indonesia, Ukraine, China and the Philippines have higher smoking rates than "Tobacco Nation," the report found.

The 12 states included in "Tobacco Nation" are: Alabama, Arkansas, Indiana, Kentucky, Louisiana, Michigan, Mississippi, Missouri, Ohio, Oklahoma, Tennessee and West Virginia. These states are home to more than 66 million Americans, "roughly 20 percent of the U.S. population," the report notes. The entire population of France is 66.9 million, and the United Kingdom is home to 65.6 million people, so this part of America really is the size of a whole country.

Across these 12 states, the smoking rate is 22 percent, a good bit higher than the national average. Smoking rates for these 12 states vary from 25.9 percent in Kentucky to 20.6 percent in Indiana. Koval says that while a few of these states were once major tobacco producers, that's not why smoking rates are higher here. "The reliance on tobacco as an economic base is much less significant than it once was." Rather, the bigger issue is that there's "a culture of smoking," where smoking is viewed as a more normal activity in these states than in states that have lower rates.

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Another reason smoking is more prevalent in the "Tobacco Nation" states, Koval says, is because tobacco is cheaper in this region than other areas of the country. On average, a pack of cigarettes in these 12 states costs $5.48 versus $6.72 in the rest of the United States. The variance comes from local and state taxation levels, which some states and municipalities use to help curb smoking. In New York City, for example, a pack of cigarettes now costs a minimum of $13 after the city council voted in 2017 to raise prices as part of an anti-smoking push. (That total includes $4.35 in state taxes, the highest state taxes on tobacco in the nation.) Meanwhile, in St. Louis, Missouri, a pack of cigarettes will set you back an average of $5.70, according to the cost-of-living website Expatistan. That cost includes a mere $0.17 in state taxes, the lowest in the nation. (The national average for state tax per pack of cigarettes is $1.72, the Campaign for Tobacco-Free Kids reports.)

Even worse than just having higher rates of smoking, Koval notes that in these states, "cancer rates, cancer mortality rates and lung cancer rates are also dramatically higher." These findings echo those of a study published last month in Cancer Epidemiology, Biomarkers & Prevention, which looked at county-level lung cancer data and found that the rates of women dying of lung cancer were highest in two "hotspots" -- Appalachia and the Midwest. According to the study, in these areas, lung cancer death rates among women had increased by 7 to 13 percent between 1990 and 2015.

The American Lung Association is also looking at the question of where people who smoke live and how that relates to incidence of cancer. Using data made available by the North American Association of Central Cancer Registries, which gathers myriad data related to cancer across the country, the ALA released the first iteration of what is expected to become an annual report on the " State of Lung Cancer" in February 2018.

Zach Jump, director of epidemiology and statistics at the ALA, says the report aims to look beyond the connection between smoking and cancer to find where the burden is greatest. "What we were hoping to do with this report was to see beyond just [which states have the highest and lowest burden], to identify" the states in the middle where smoking prevalence or incidence of cancer didn't line up with projected expectations based on population size. "We didn't come up with any perfect explanation because there are so many things going on and we can only assess so many. But we found that the burden varies a lot by state, and every state can do more in some area." For example, he notes that even in states with lower smoking rates, a look at factors such as survival rates or early diagnosis and access to screening centers could yield insight into ways the burden of lung cancer could be reduced.

It seems logical that states with higher smoking rates also experience higher lung cancer rates, and the data largely bore out that assumption, Jump says. But it also pointed out that even the states with the lowest smoking rates can do more to reduce the incidence and mortality of lung cancer. For example, even though Utah has the lowest smoking rate in the country at just 9 percent and also the lowest lung cancer incidence rate at 29.1 cases per 100,000 people, the Beehive State also has the fewest lung cancer screening centers of any state in the country.

At the other end of the spectrum, Kentucky had both the highest smoking rate -- 25.9 percent -- and the highest lung cancer incidence rate with 95.9 cases per 100,000 people. The national lung cancer incidence rate is 63 per 100,000, so Kentucky is much higher than average, and no doubt its high smoking rate is a major culprit. But other contributing factors may include environmental and occupational hazards and genetics. Taken all together, "our big finding was that the [cancer] burden really is different for each state. It tends to be high overall and there's more that each state can do," to reduce the burden of lung cancer, Jump says.

[See: What Not to Say to Someone With Lung Cancer.]

To help reduce this burden for all states, Koval and Jump both say that a multi-pronged, comprehensive approach to curbing tobacco use will be required. A combination of educational, regulatory and enforcement efforts are all being levied in various ways in different parts of the country. Koval says initiatives such as the Tobacco 21 campaign to raise the legal age to buy tobacco products to 21 would help make tobacco less accessible to young people. (As of April 2018, only five states had raised the minimum legal age for tobacco purchases to 21, but more than 300 municipalities around the country have raised the age and several states are considering doing so, too.) "If you're 16, you might have a friend who's 18, but you probably don't have a friend who's 21," making it harder for teenagers to get cigarettes. She also notes that a recent FDA proposal to reduce the amount of nicotine in cigarettes to non-addictive or less-addictive levels would "no doubt disproportionately benefit this part of the United States. So we're very interested in that." She also says continuing to raise prices via tax initiatives will price some would-be smokers out of the market and make tobacco inaccessible to more people.

To support these efforts and to keep reminding the public and our elected officials that reducing smoking rates and lung cancer incidence is an achievable goal, Jump says the ALA will be updating its report on the state of lung cancer regularly to continue shining a spotlight on the varying lung cancer burden different states experience. "We really want people to be aware of that and get some focus on it at the advocacy level and the personal action level."

Elaine K. Howley is a freelance Health reporter at U.S. News. An award-winning writer specializing in health, fitness, sports and history, her work has appeared in numerous print and online publications, including AARP.org, espnW, SWIMMER magazine and Atlas Obscura. She's also a world-record holding marathon swimmer with a passion for animals and beer. Contact her via her website: elainekhowley.com.