Cigarette Smoking Prevalence and Policies in the 50 States: An Era of Change

The report bore a simple, understated title: “Smoking and Health”. But when it was issued in 1964 by the United States Surgeon General, it signaled the beginning of a massive public health campaign to curtail tobacco consumption (Figure 1). Now, more than 40 years later, we recognize that smoking harms nearly every organ in the body, causing multiple forms of cancer, cardiovascular and respiratory diseases, pregnancy complications and other diseases (Figure 2). Tobacco use remains the single largest preventable cause of death in the United States, in part because of the addictiveness of nicotine and in part because of the efforts of the tobacco companies to increase use and weaken public health activities designed to control the epidemic . A number of effective programs and policies have been enacted in model states (e.g., California, Massachusetts, New York) and communities (e.g., New York City), but coverage is far from complete.

Since 1964, tobacco use, primarily in the form of cigarettes, has caused more than 15 million premature deaths in the United States. In addition, the health of non-smokers is harmed by exposure to tobacco smoke pollution (Figure 2). According to the Centers for Disease Control and Prevention, 49,000 nonsmokers die annually from conditions caused by exposure to tobacco smoke pollution. Meanwhile, cigarette companies continue to aggressively advertise and promote their products, spending $13 billion in 2005 — $1.5 million every hour of every day. Since 1963, the first year the Federal Trade Commission reported data, cigarette companies have spent more than $240 billion (inflation adjusted to April 2008 dollars) marketing cigarettes in the United States.

Since 1964, tobacco use, primarily in the form of cigarettes, has caused more than 15 million premature deaths in the United States. In addition, the health of non-smokers is harmed by exposure to tobacco smoke pollution (Figure 2). According to the Centers for Disease Control and Prevention, 49,000 nonsmokers die annually from conditions caused by exposure to tobacco smoke pollution. Meanwhile, cigarette companies continue to aggressively advertise and promote their products, spending $13 billion in 2005 — $1.5 million every hour of every day. Since 1963, the first year the Federal Trade Commission reported data, cigarette companies have spent more than $240 billion (inflation adjusted to April 2008 dollars) marketing cigarettes in the United States.

About one-fifth of American adults still smoke (Figure 3). Prevalence is especially high among populations with lower levels of education (Figure 4) and income (Figure 5), among Native Americans (Figure 6), and among those with psychiatric and substance abuse problems. Future success at reducing the tobacco use epidemic will be facilitated by an understanding of specific needs of these populations. Effective targeting will require understanding how proven tobacco control programs and policies may differentially impact these high-risk populations, understanding how tobacco industry marketing tactics may specifically influence them, and applying this knowledge for maximum benefit to those least well protected or served by current efforts.

Given the scope and magnitude of the problem after more than 4 decades of tobacco control efforts, achieving further reductions in tobacco
consumption will be facilitated by in-depth knowledge of how various prevention and control strategies have been implemented throughout the country, a keen understanding of current usage patterns, and an understanding of whether the population of smokers is becoming more or less “hard-core.” This chart book serves these purposes. It provides a detailed portrait of contemporary use rates by state and age group, along with indicators of hard-core smoking, and carefully chronicles the extent to which individual states have adopted lifesaving policies.

Ultimately, this information can provide templates and reference points for policymaking and research priorities — optimizing measurement can facilitate change. It reveals geographically and by age group where smoking is most prevalent and where particular tobacco control measures have (or have not) been adopted.