Tobacco Use in High-Tobacco-Burden States

Tobacco use remains disproportionately high in 13 U.S. states—primarily in the South and Midwest—where smoking prevalence, tobacco-related cancer mortality, and poly-tobacco use exceed national averages (Map 2.7.1). To examine these tobacco-related burdens, the American Cancer Society sponsored an online rapid-response survey conducted by The Harris Poll (Box 1).

The population in the 13 high-tobacco-burden states is predominantly Non-Hispanic White (70.5%), with a significant proportion reporting lower educational attainment (45.3% with a high school diploma or some college) and limited income (46.6% with household income below $75,000). The largest age group was 55–65 years old (23.3%), and 47.2% of respondents identified themselves as male. Most respondents reported having health insurance (92.6%), though 7.4% remained uninsured, and 29.1% reported a mental or physical disability (Figure 2.7.1).

More than a third of adults (35.3%) in high-tobacco-burden states currently used any tobacco product, compared to 28.3% in low-tobacco-burden states (Figure 2.7.3). More specifically, cigarette use was highest in West Virginia (25.8%) and lowest in South Carolina (17.6%) compared to 14.7% in low-tobacco-burden states. E-cigarette use was highest in Arkansas (21.8%) and lowest in Missouri (13.8%), compared to 14.5% in low-tobacco-burden states. In low-tobacco-burden states, cigar and cigarillo use were reported by 6.3% and 5.5% of adults, respectively, while smokeless tobacco use—including snus and oral nicotine pouches—was reported by 6.3% (Figure 2.7.3). In low-tobacco-burden states, cigar and cigarillo use in high-tobacco-burden states were reported by 6.3% and 5.5% of adults, respectively, while smokeless tobacco use—including snus and oral nicotine pouches—was reported by 6.3%.

High-tobacco-burden states are characterized by widespread use of multiple tobacco products and high nicotine dependence that pose additional challenges and complexity in addressing the high burden of tobacco in these states. Dual and poly-tobacco use of cigarettes with other tobacco products was prevalent: 66% of individuals currently reporting cigarette use also used another tobacco product, with 44% concurrently using e-cigarettes.

Among e-cigarette users, 42% preferred disposable devices, and fruit flavors were the most popular, with 65.8% of individuals in high-tobacco-burden states reporting "fruit" as the favorite flavor, followed by "menthol/mint" (37.8%) and "candy" (30.2%) (Figure 2.7.5). The most commonly used nicotine concentrations in e-cigarettes reported was 1–6 mg (25.9%), followed by 7–12 mg (17.1%). Very low (0 mg) and very high (40+ mg) concentrations were less commonly used, at 0.7% and 14.6% respectively, and 17.7% of individuals did not know their nicotine concentration (Figure 2.7.6).

Among tobacco users in 13 high-tobacco-burden states, over half (53.3%) reported making 2–3 quit attempts in the past year, with nearly equal proportions making only one (23.2%) or four or more (23.5%) attempts (Figure 2.7.7). Access to nicotine replacement therapy (NRT) and cessation services through insurance varied, with many respondents unsure of their coverage for NRT (31%) or cessation programs (29.3%) (Figure 2.7.8). The most common sources of NRT access were through private insurance (12.7%) and Medicaid (11.5%) (Figure 2.7.8). Similarly, cessation services were most often available through private insurance (16.2%) and Medicaid (13.1%) (Figure 2.7.9). Despite these resources, 66.1% of respondents used no formal program during their last quit attempt, with internet programs (16.4%) and one-on-one counseling (14.1%) being the most utilized among those who did (Figure 2.7.10). Notably, 44.6% of cigarette users tried switching to e-cigarettes, and 19% reported switching to smokeless tobacco products, both of which are non-FDA-approved tools, highlighting a reliance on unapproved methods (Figure 2.7.11).