It's written plain as day on a pack of cigarettes: Smoking can kill you. Yet Americans in some states continue to light up in high numbers.
West Virginia tops the list of states with the highest rate of smoking: 26.2 percent of West Virginia’s adult population regularly smoked in 2009 and 2010, a rate that has changed little from a decade earlier.
Kentucky and Oklahoma have similarly high levels of smokers, with 25.2 percent and 24.6 percent of adults smoking, respectively. These are nearly double the rates in states that have long held the lowest levels of tobacco use in the nation, such as California (12.5 percent) and Connecticut (14.3 percent). The national average is 20 percent.
The analysis was recently released by the University of Minnesota's State Health Access Data Assistance Center (SHADAC) under a grant from the Robert Wood Johnson Foundation. Tobacco use was defined as adults who reported smoking 100 or more cigarettes (about 5 packs) in their lifetime and continue to smoke some days or every day.
So, why are some states having a harder time kicking the habit?
“It has to do with whether we're putting in place evidence-based interventions,” said Danny McGoldrick, Vice President of Research for the Campaign for Tobacco-Free Kids (CTFK).
Some states have turned their backs on anti-smoking policies, while others are on the forefront of discouraging tobacco use by taxing cigarettes and banning smoking in public places, among other measures. Smoking prevention programs are also effective in deterring smoking.
The evidence bears this out. In the 10 states with the lowest adult smoking rates, the average tax rate on a pack of cigarettes is $2.32, and nine out of those states have smoke-free restaurants and bars, according to CTFK. In the 10 states with the highest adult smoking rates, the average state tax rate is $0.72, and only one state in the group is smoke-free in restaurants and bars.
“We know when we put these things in place we get dramatic declines in smoking,” McGoldrick said.
First to go smoke free
California, which after Utah has the lowest rate of smoking in the nation, was the first to go smoke-free in public places in 1998. In the 1990s, it also passed the highest cigarette tax in the nation, which it used to fund the longest-lasting tobacco prevention program. However, the California cigarette tax rate of $0.87 has not been updated in some time, and a state ballot measure in November 2012 to raise the tax by $1 was narrowly defeated.
“California has had a lot of success,” said Bronson Frick, the associate director of Berkeley-based Americans for Nonsmokers' Rights. “But California is just like anywhere else and that success has been hard fought and none of it has been easy and it could slip away very quickly because the industry is relentless in its efforts to maintain smoking rates in California.”
States have the money to implement smoking prevention programs, said McGoldrick. Tobacco settlement money from the 1998 agreement between U.S. tobacco companies and the states has been pumping a total of $206 billion into state coffers over the lifetime of the agreement, in exchange for exemption from tort liability regarding harm from tobacco use.
However, states can spend the money as they choose, and by 2012 less than 2 percent of the tobacco settlement dollars states received that year were spent on programs to prevent children from smoking and to help adults quit, according a report released by the Campaign for Tobacco-Free Kids and other anti-smoking groups.
“Hundreds of millions of dollars a year are not being invested in programs that work,” said McGoldrick.
Education is a factor
Meanwhile, certain groups in the population – namely the less educated – are finding it harder to say 'no' to the allure of a cigarette. The SHADAC analysis finds that high school graduates and drop-outs (who usually have lower incomes) are roughly three times as likely to smoke as college graduates.
“The tobacco industry has a long history of targeting lower income communities with tobacco advertising,” said Meg Riordan, policy research director at the Campaign for Tobacco-Free Kids.
These are the same individuals who have less access to smoking cessation resources and cannot afford cessation medication.
On a positive note, change is afoot at the federal level. In 2009, the federal tax rate for cigarettes jumped from $0.39 per pack to $1.01 per pack, and the passage of the Family Smoking Prevention and Tobacco Control Act gave the Food and Drug Administration the power to regulate the tobacco industry for the first time.
In 2012, the Centers for Disease Control and Prevention (CDC) launched a $48 million campaign to discourage smoking, which has continued as a second round in 2013. Finally, the Affordable Care Act will mandate that health insurance plans cover smoking cessation programs.
At the local level, municipalities and anti-smoking groups are also looking for the new frontier in smoke-free laws, including expansion into multi-unit housing, casinos, parks and beaches, and college campuses.
“There's a lot of discussion of what will it take to get to the next phase? What will it take to get down to a 5 percent smoking rate?” said Frick. “The decline in the smoking rate has stalled and we know it could be much lower.”
Sources and Notes:
State results were based on SHADAC analysis of Behavioral Risk Factor Surveillance System (BRFSS) data from the Centers for Disease Control and Prevention.
National results were based on SHADAC analysis of National Health Interview Survey (NHIS) data from the U.S. Census Bureau