Call to Action
Tobacco use continues to impose a disproportionate health burden on residents of high-tobacco-burden states, where smoking prevalence and tobacco-related cancer rates remain significantly higher than national averages. These disparities are deeply rooted in the unique sociodemographic, economic, and policy environments of these states. National-level data and interventions often fail to capture these nuances, underscoring the need for regionally tailored research and policy responses.
To effectively reduce tobacco-related harm and inform targeted interventions, future research must focus on four key areas:
1) Regional and State-Level Research
There is a pressing need for more granular, context-specific data to understand why tobacco use remains so prevalent in these states. This includes examining patterns of poly-tobacco use, co-use with other substances, and the influence of local norms and access to cessation resources. Collecting detailed sociodemographic and behavioral data at the state and sub-state levels will enable more precise identification of at-risk populations and more effective allocation of resources. This data source allows capturing some of this relevant information to inform policy development.
2) Policy Research
While some high-burden states have adopted policies such as Tobacco 21 laws and flavor restrictions, the effectiveness and enforcement of these measures vary widely. Research is needed to evaluate how these policies function in different contexts, particularly in areas with weaker tobacco control environments. Understanding the impact of policy preemption, enforcement challenges, and emerging product trends (e.g., e-cigarettes) will be essential for refining and strengthening state-level tobacco control strategies.
3) Tobacco-Related Health Disparities
Tobacco use does not affect all populations equally. In high-burden states, racial and ethnic minorities, low-income individuals, and rural residents often face higher exposure to tobacco marketing, limited access to cessation services, and greater vulnerability to tobacco-related diseases. Research that explores how these social determinants intersect with tobacco use behaviors and health outcomes is critical for designing equitable interventions that address the root causes of disparities.
4) Cessation Support
Expanding access to effective cessation services is a cornerstone of reducing tobacco use. However, barriers such as cost, limited provider engagement, and inconsistent coverage through Medicaid and Medicare continue to impede progress. Research into how public insurance programs can better support cessation—particularly in underserved communities—can inform advocacy for more comprehensive and accessible cessation coverage.
Policy Action
The persistently high rates of tobacco use in high-tobacco-burden states demand urgent and targeted policy action. Policymakers should prioritize:
1) Expanding access to cessation services, particularly in rural and underserved communities where healthcare infrastructure is limited. This includes ensuring comprehensive Medicaid coverage for evidence-based cessation treatments such as counseling, nicotine replacement therapies, and quitlines.
2) Regulation of flavored tobacco products—especially menthol cigarettes and fruit-flavored e-cigarettes—should be strengthened, given their popularity among all adults, and especially among younger populations and dual users.
3) States should also eliminate preemption laws that restrict local tobacco control efforts and increase excise taxes to reduce tobacco affordability.
4) Tailored public health strategies are also needed to reach rural and underserved populations. This includes culturally appropriate cessation programs, community-based outreach, and integration of tobacco treatment into primary care. Without targeted efforts to address the unique challenges faced by high-burden states, national declines in tobacco use may mask persistent and widening disparities at the regional level. Public health agencies and advocacy groups can use these data to tailor interventions and allocate resources more effectively.
Integrating these policies into broader health equity strategies will be essential to reducing the disproportionate burden of tobacco-related disease in these regions.
More resources are available in the American Journal of Preventive Medicine Supplement titled “Mitigating Tobacco-Related Disparities: A Subnational View of Tobacco Use Behaviors and Tobacco Control in High-Tobacco-Burden U.S. States”.