Tobacco Use Behaviors and Related Disparities in 13 High-Tobacco-Burden U.S. States: An Overview of Evidence

Progress in reducing cigarette smoking prevalence in the U.S. substantially varies by states, with the prevalence up to 50% higher than the national average in many states (Alabama, Arkansas, Indiana, Kentucky, Louisiana, Michigan, Mississippi, Missouri, Ohio, Oklahoma, South Carolina, Tennessee, and West Virginia; high-tobacco-burden states). However, potential correlates and causes of tobacco use and health disparities have not been well documented in this region. The authors aimed to (1) establish recent estimates of lung cancer incidence, mortality, and smoking-attributable cancer rates and (2) review existing research on tobacco use behaviors in these states. Recent prevalence of lung cancer incidence/mortality and smoking-attributable mortality by states were obtained from the Behavioral Risk Factor Surveillance System, National Center for Health Statistics, Centers for Disease Prevention and Control (2020), American Cancer Society, and published meta-analyses or pooled analyses. Original research and systematic reviews were assessed using PubMed and Medline through November 2024 to document the prevalence of cigarette, E-cigarette, and other tobacco use and related risk factors and health outcomes. Age-adjusted lung cancer incidence/mortality and smoking-attributable mortality were high in the high-tobacco-burden states. Only 2 states had comprehensive smokefree air laws, whereas 9 states had pre-emption laws that hinder additional policy implementation. Research on tobacco use patterns, tobacco control policies, and regulations specific to the high-tobacco-burden states was scarce. Despite higher than national average cancer incidence and mortality rates, existing research in these states lacks the systematic and comparative approach needed to draw strong conclusions.