Filling in the Research Gaps About High-Tobacco-Burden US States

ACS Researchers published a special supplement with 10 original articles on tobacco-related disparities in the 13 states with the most cigarette smokers.

map with orange, gold, blue, and gray states

Current Cigarette Smoking Prevalence by State for Adults Age 18 and Older in 2022

This United States map shows the states with the highest cigarette smoking prevalence in blue: Alabama, Arkansas, Kentucky, Mississippi, Missouri, Ohio, Tennessee, and West Virginia. The next highest use states (in orange) are Indiana, Louisiana, Michigan, Oklahoma, and South Carolina. Yellow and gray states have a lower prevalence of cigarette smoking.

More than 60 years ago, the United States Surgeon General reported that using tobacco was deadly. Since then, smoking in the US has continually decreased—from 42% in 1965 to 10% in 2024. Yet, using tobacco is still the leading cause of disease, disability, and preventable death in the US.

Progress has not been equal across the country, and it’s most delayed in the states where many people smoke. Scientists describe these Midwest and Southern regions as high-tobacco-burden states. In these states, the prevalence of tobacco use is 35%:

Alabama
Arkansas
Indiana
Kentucky
Louisiana
Michigan
Mississippi
Missouri
Ohio
Oklahoma
South Carolina
Tennessee
West Virginia

In comparison, stronger tobacco control in 4 low-tobacco-burden states—California, Illinois, Maryland, and Virginia—reduces the use to 28%.

The highest overall tobacco use is in Arkansas—at 43%. Cigarette smoking is highest in West Virginia—at 26%. (California has the lowest cigarette use at 11%.)

Another problem in these high-use states is the widespread use of new, rapidly evolving tobacco products. These include e-cigarettes and nicotine pouches. Plus, it’s now common for people to use more than one type of tobacco or nicotine product at a time or using tobacco with another substance like cannabis or alcohol. Regions with a high density of cigarette smoking may be most vulnerable because of this “polytobacco use.” The result may not only increase the risk of tobacco-related health problems but also make it harder for people to quit using tobacco.

Despite the dense tobacco use in these states, few have explored what causes them to be different from the rest of the country. In February 2026, the American Cancer Society (ACS) offered scientific evidence in a supplement of the American Journal of Preventive Medicine (AJPM) focused on: “Mitigating Tobacco-Related Disparities: A Subnational View of Tobacco Use Behaviors and Tobacco Control in High-Tobacco-Burden US States.”

The ACS goal was for their regionally focused research to improve the understanding about the relationships between social, economic, and policy issues driving the use of tobacco. With that data, the ACS and others can develop tailored tobacco control plans that will reduce the geographic differences in tobacco-related health problems.

To speed progress against the inequities within these states requires changing tobacco control policies to better target the needs of the region and for at-risk subgroups.”

Nigar Nargis, PhD

Senior Scientific Director, Tobacco Control Research

Surveillance, Prevention, & Health Services Research, American Cancer Society

Research on High-Tobacco-Burden States

Our Tobacco Control Research team studied original research and reviews from 2009 to 2024 about any high-tobacco-burden state. They learned that facts about these key issues were scarce:

Use of novel tobacco products, including e-cigarettes, oral nicotine pouches, hookahs.

Knowledge, beliefs, attitudes, and psychological conditions linked with the use of tobacco.

Effect of poverty, education level, rural residency, physical and mental health, health insurance coverage, homelessness, veteran status, and gender/sexual identities on the use of tobacco.
Availability of services to help people quit smoking.
How tobacco control policies in high-use states compare with other states, including differences in attitude about those laws and policies. (9 states have premption laws that make it difficult to introduce and implement new tobacco control policies.)

Black square white letters say DO IT and red letters are crossed out Don't Quit

This ACS rapid response survey had 3 main findings:

Overall use of tobacco and of each product (like cigarettes, e-cigarettes, and cigars) is more common in high-tobacco-burden states than those with stronger tobacco control (which is why they’re low use states).

These groups in both high- and low- states need targeted programs to help people who have a higher risk for using tobacco.
- Adults between 25 and 65
- People who live with someone
- Black people because they’re more likely to use cigars than White people
- Hispanic people and people who identify as multiracial because they’re more likely to use e-cigarettes than White people

Many people in both high- and low-burden states use more than one product, which highlights the need for tobacco control policies that include targeted cessation programs and state-level funding for them.

wooden desk with glasses, mug, plant and hands typing on laptop

ACS researchers developed an online, cost-effective survey that collects and analyzes data to provide up-to-date insights that are adaptive to changes in tobacco use and policy.

This method reaches hard-to-include populations and allows for speedier interventions informed by yearly cross-sectional data that represents the population of the high-burden states—before national data is available.

This ACS rapid response survey identified two groups that need increased smoking cessation support in high-tobacco-burden states to reduce smoking disparities among US states:

Adults age 40 and older.
People with less than a high school level education.

ACS researchers found that more than 2 out of every 10 e-cigarette sales in a high-tobacco-burden state are from informal/social sources or online retailers, who are mostly unregulated. Most e-cigarettes from formal retail sources are not also authorized by the FDA.

While previous studies often focused on e-cigarette use in teens or young adults, this one looked at use between those 18 to 65.

Although, the legal age for buying e-cigarettes (and all tobacco products) is 21:

Nearly 4 out of every 10 young adults ages 18 to 20 got e-cigarettes from an informal source—a much higher proportion than older adults. These buyers are less likely to be stopped because of age limits. (Hispanic people, people who are not employed, and people who don’t use e-cigarettes every day also more likely to get e-cigarettes from an informal source.)
The almost 6 out of every 10 young adults ages 18 to 20 who bought e-cigarettes from a formal store highlights the need for stronger enforcement and standardized age verification methods across all states. (College graduates and those who use refillable or mod e-cigarettes are more likely to buy them online.)

The study’s authors conclude that it’s “imperative to strengthen e-cigarette market surveillance, especially in the high-tobacco-burden states, to uncover and close regulatory loopholes of informal and online access to e-cigarettes.”

Sign with icons No Smoking No Vaping No Marijuana

Results of this rapid response survey included:

45% of people who currently used cigarettes in a high-tobacco-burden state also used cannabis, compared to 25% of those who formerly smoked cigarettes, and 12% of people who had never smoked.
Current cigarette users were more likely to also use cannabis if they’re male, 18 to 24, Black, single, or had a mental or physical disability. (The subgroups are considered to be at-risk for adding cannabis use.)
Dual users used almost 13 cigarettes a day and cannabis 19 days a month.
People who used both cigarettes and cannabis used about the same amount of each as those who used only one of those products, which means dual users were using both products at “relatively high frequencies.”

Increased monitoring of cannabis and cigarette co-use must be part of tobacco control in high-burden states, especially among at-risk subgroups, say the study’s authors because:

The health risks are additive from using both products.
There’s evidence that cannabis use may make it harder to quit smoking cigarettes.

Orange sign in front of trees and blue sky: Thank you for not smoking or vaping

This ACS rapid response survey found that almost 4% of people living in a high-tobacco-burden state used both cigarettes and e-cigarettes, compared to a national average of 1%. The study also showed evidence that individuals engaging in dual use still smoked at a relatively high rate:

Most did not use e-cigarettes each day. Average use was about 18 days each month.

Most smoked fewer cigarettes a day (11) than those who used only cigarettes (15). Those who did not smoke every day smoked about 8 cigarettes a day.

These results show the potential for dual use to increase health disparities among those living in high-tobacco-burden states.

People with dual use in a high-burden state were more likely to try at least once to quit using more than one strategy, but many did not use FDA-approved quitting methods. This highlights the need in these states for increased access to FDA-approved, evidence-based methods to quit successfully.

People in high-tobacco-burden states smoke at higher rates (about 2 more cigarettes a day) and pay significantly less for a pack of cigarettes (because of lower excise taxes) compared to those in low-burden states.

This large, online rapid response survey asked US adults 18 to 65: How many packs of your usual brand of cigarettes would you buy and use in the next week at: $2, increasing by $2 up to $20, and $40 a pack?

This ACS study found that in high-tobacco-burden states, compared to low-tobacco-burden states:

Individuals who smoked cigarette were overall more sensitive to changes in prices per pack, including being less willing to buy cigarettes at higher prices;
Demand for cigarettes was lower when packs cost $6 or more;
Cigarette smoking may decline by increasing the price of cigarettes to about $13 a pack, compared to $17 a pack in low-burden states.

These results imply that cigarette smoking in those who live in high-tobacco-burden states may be decreased with cigarette tax increases that lead to even modest increases in cigarette prices.

Stop menthol cigarettes. Vector illustration.

The soothing sensation of menthol masks the harshness of cigarette smoking, which may increase the number of people who start smoking and who get addicted to nicotine. People who use menthol cigarettes are also less likely to quit smoking.

The percentage of those who use only menthol cigarettes among individuals who cigarettes is significantly higher in high-tobacco-burden states (57%) than in low-burden states (48%). People in high-burden states who are most likely to use them are:

Females who are divorced/separated/widowed
White
Have only a high school diploma
Lower income (earn between $25,000 to $49,999 a year)

In the United States, since 2009, menthol has been the only flavor allowed in combustible tobacco products. In 2022, the FDA proposed a rule to restrict menthol flavor in cigarettes. As of March 2026, the FDA’s proposal is delayed indefinitely.

This ACS large, online rapid response survey asked adults 18 to 65 who smoked menthol cigarettes about their intended response if menthol flavor was banned nationally.

The results showed

About 40% of people in a high-tobacco-burden states and 35% in a low-burden states who smoked menthol cigarettes intended to quit all tobacco, quit or reduce cigarette smoking, or quit smoking menthol cigarettes by using a nicotine replacement thera.
Percentages were higher among those who only used menthol cigarettes—46% and 44%, respectively.
Percentages were even higher for Black adults (54% and 49%) compared to White adults (34% and 37)

These results suggest banning menthol cigarettes nationwide may:

Reduce racial smoking disparities.
Not lead to as many people quitting as a ban on all mentholated tobacco products.
Substantially benefit population health if the ban is accompanied with improved access to smoking cessation resources.

A reminder from the study’s authors: “States and local jurisdictions are encouraged to prohibit the sale of menthol cigarettes to mitigate any missed opportunities associated with the indefinite delay in the federal menthol ban.”

In this study, ACS researchers focused on cigarette smoking and “quitting behavior” for people with a history of heart conditions, lung conditions, and cancer in the 13 high-tobacco-burden states compared with 4 low-tobacco-burden states.

They found that in comparison with low-tobacco-burden states, high-burden states had:

A higher prevalence of heart conditions and worse lung conditions.
People with lung conditions are more likely to be currently smoking.
Less access to comprehensive, easy-to-access quit-smoking resources even though people in both high- and low-burden states had similar health insurance coverage. Less than half of the residents in high-tobacco-burden states had access to high-quality quitting programs under Medicaid.

These results highlight an ongoing and potentially growing health disparity based on where a person lives. Plus, continuing to smoke with existing health conditions may:

Worsen health status.
Contribute to the development of new health conditions.
Reduce the effectiveness of ongoing treatment.
Further decrease life expectancy.

To reduce the tobacco-related disease burden may require increased smoking cessation resources targeted to people with existing lung conditions to help with disease management and reversal of progression.