A group of 12 contiguous U.S. states in the Midwest and South has the highest rate of adult tobacco use in the nation. If taken as a country, this group would rank among those with the highest smoking rates in the world.
This is according to a released by Truth Initiative last week. Indiana is one of these twelve states, along with neighboring Ohio, Michigan, West Virginia, Kentucky, Tennessee, Alabama, Mississippi, Louisiana, Arkansas, Oklahoma and Missouri.
The Washington-based tobacco control nonprofit has termed this group, 鈥渢obacco nation.鈥�
Three non-contiguous states 鈥擲outh Carolina, Maine and North Dakota 鈥� have also have .
According to the report, if these 12 contiguous states made up a 鈥渘ation,鈥� it would rank fifth among the countries with the highest smoking rates behind Indonesia, Ukraine, China and the Philippines 鈥斺�渃ountries with a fraction of our financial, scientific and healthcare resources,鈥� said Truth Initiative CEO Robin Koval.
For instance, in the Philippines, 23 percent of adults use tobacco. In the 鈥渢obacco nation,鈥� 22 percent of adults do. The U.S. .
In Indiana, smoking is still the leading cause of preventable death, causing a host of illnesses including cancer, heart disease and stroke. The Centers for Disease Control and Prevention ranks Indiana鈥檚 adult smoking rate the 10th highest in the country.
Richard M. Fairbanks School of Public Health Dean Paul Halverson was not surprised to see Indiana highlighted in the report.
鈥淲e are horrible when it comes to funding public health,鈥� he said. 鈥淲e鈥檙e ranked 49th in 50 states in our per capita investment in public health.鈥�
Furthermore, while the CDC recommends a state the size of Indiana should in tobacco control and prevention. Halverson said Indiana only invests $7 million annually.
Beside their proclivity for smoking, the twelve states have other characteristics in common, too.
One is poverty. Compared with the other 38 states, 鈥渢obacco nation鈥� states earn nearly 21 percent less per year, the report said.
Additionally, this region has weak smoke-free laws and tobacco control policies.
In April, Indiana lawmakers proposed increasing the tax levied on a pack of cigarettes, but it failed to pass. The is around a dollar, one of the lowest in the county, and well below the national average, $1.71.
Indiana also has a preemptive law, common in the other 鈥渢obacco nation鈥� states, that restricts tobacco control efforts at a local level.
For instance, even if local governments wanted to raise the minimum age for purchasing cigarettes to 21, the preemptive law would prevent them from passing policies more stringent than state law.
While the U.S. smoking rate has declined in recent years, it remains high in rural communities.
鈥淚n fact, in some of our areas, it has actually increased,鈥� said Alana Knudson, co-director of the Walsh Center for Rural Health Analysis.
鈥淢any of the counties in 鈥榯obacco nation鈥� are rural, and when you look at the public health infrastructure in our rural communities, it has greatly diminished,鈥� Knudson said.
She said not enough federal funding flows into smaller communities.
鈥淲e already know 70 percent of smokers want to quit,鈥� said Corinne Graffunder, director of the CDC鈥檚 Office on Smoking and Health.
However, she said those who live below the poverty line have the hardest time .
Dr. Kasisomayajula Viswanath, who teaches behavioral sciences at Harvard鈥檚 T.H. Chan School of Public Health, said it鈥檚 important to study tobacco use within 鈥渢he context of class, place and race.鈥�
While the data show high rates of poverty in this region, Viswanath said researchers should take into account what compels people to smoke.
In many of these states the manufacturing industry has disappeared, said Viswanath. The threat of losing work demoralizes residents.
鈥淚t is a challenge of micro-humiliations where they鈥檙e constantly under stress,鈥� he said 鈥淥ne part of it is mental health, but the other part is just not mental. It鈥檚 the stress associated with navigating and maneuvering through life.鈥�
This story was produced by, a reporting collaborative focused on public health.
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