Key Findings

“State of Tobacco Control” 2022: 20 Years of “State of Tobacco Control” – Celebrating the Progress Made and Recognizing the Work that Remains to be Done

The American Lung Association’s annual “State of Tobacco Control” report evaluates states and the federal government on actions taken to eliminate the nation’s leading cause of preventable death – tobacco use – and save lives with proven-effective and urgently needed tobacco control laws and policies.

The Lung Association proudly marks the 20^th anniversary of releasing its “State of Tobacco Control” report in 2022 by reflecting on the progress made over the past 20 years and looking ahead to the significant amount of work that remains to be done to end tobacco-caused death and disease in this country.

A new generation of tobacco products, including e-cigarettes, threatens the progress made, as more than two million middle and high school students reported using e-cigarettes in 2021.¹ In response to the youth vaping epidemic, new public policies, including ending the sale of all flavored tobacco products, have risen in importance as well. Key themes in “State of Tobacco Control” this year include:

• FDA Opportunities in 2021 to Reduce Tobacco Use: The U.S. Food and Drug Administration (FDA) took several actions in 2021 that could signal a beginning to meaningful action in its oversight of tobacco products.
  • On April 29, 2021, FDA made an important announcement indicating its intention to issue proposed rules no later than April 2022 to remove menthol cigarettes and most flavored cigars from the marketplace. If FDA follows through on its commitment, it will be an historic achievement for public health in the U.S. given the disproportionate impact menthol cigarettes and flavored cigars have on many different communities and populations, especially Black Americans.
  • FDA had an opportunity to remove e-cigarettes and other tobacco products from the market that did not meet its public health standard through its pre-market tobacco authorization (PMTA) authority under the Family Smoking Prevention and Tobacco Control Act. FDA was under a court-ordered deadline of September 9, 2021, to review millions of PMTAs submitted by e-cigarettes and other tobacco product companies in 2020. Unfortunately, as of the end of 2021, FDA has not acted on the products most responsible for the youth e-cigarette epidemic such as JUUL, leaving them on the market.
• Health Disparities Related to Tobacco Use: An unfortunate constant over the past 20 years is the unequal burden of tobacco use and exposure to secondhand smoke on some communities and populations. The overall adult smoking rate has declined significantly from 21.6% in 2003 to 14.0% in 2019, a 35% decline.² However, this overall rate masks significant disparities among races/ethnicities and due to socio-economic factors. Smoking remains particularly high among Native Americans and Alaskan Natives at 20.9% and Lesbian, Gay and Bisexual adults at 19.2%.³ Smoking among persons with lower incomes and lower levels of education also remains high.⁴ Certain populations are also disproportionately exposed to secondhand smoke, including: children ages 3-11, Black Americans, persons living in poverty and people with a high school education or less.⁵ Parts of the country, especially many Southern and Appalachian states remain unprotected from secondhand smoke in public places and workplaces as well.
• State Progress to Reduce Tobacco Use: The country has made substantial progress on several of the state public policies measured in “State of Tobacco Control” over the past 20 years. These include:
  • Progressing from  2 to 28 smokefree states;
  • Increasing the average state cigarette tax from $0.62 in January 2003 to $1.91 in January 2022; and
  • Improving state Medicaid program coverage of quit smoking treatments since “State of Tobacco Control” first began tracking these data in 2008.

In 2021, the tobacco industry brought back to the forefront an old roadblock it has used for more than 30 years: preemption, or lobbying state legislatures to pass laws that prevent local communities from passing tobacco control policies stronger than state law. This severely hampers the ability of local communities to prevent and reduce tobacco use. Unfortunately, the tobacco industry was successful in instituting new preemptive state laws on sales of tobacco products in Florida and Montana in 2021.

The COVID-19 pandemic’s impact on tobacco use is still being assessed. According to a  Federal Trade Commission report in 2020, cigarette sales increased for the first time in 20 years.⁶ It is unclear if this signals higher adult smoking rates, or existing smokers smoking more cigarettes. In addition, the rate of youth vaping in the Centers for Disease Control and Prevention’s 2021 National Youth Tobacco Survey varied significantly if a student took the survey at home or in a school buildings.⁷ Therefore, it is unclear if the level of youth vaping seen in 2021 will be a one-year blip or a durable trend.

During 2020, many casinos both tribal and non-tribal re-opened smokefree after being closed initially during the COVID-19 pandemic. Unfortunately, 2021 saw some backsliding in this area with smoking returning to casinos in New Jersey and Pennsylvania after emergency orders issued by governors preventing them from allowing smoking expired. Activity on tobacco tax increases ended up being much slower than expected in 2021 as well, due to many state budgets being more robust than expected.

In 2022, the country needs to redouble its efforts to pass the proven policies called for in “State of Tobacco Control.” This will require an ongoing partnership at the federal, state and local levels to restart declines in adult and youth tobacco use rates and reduce the 480,000 lives lost to tobacco each year. Our elected officials must take stronger actions to put the country on a path to finally end tobacco use over the next 20 years.

20th Anniversary of “State of Tobacco Control” Shows Policymakers at All Levels of Government Haven’t Fully Embraced Importance of Preventing and Reducing Tobacco Use

Since the American Lung Association first launched its “State of Tobacco Control” report in January 2003, the country has, overall, made tremendous progress in its efforts to prevent and reduce tobacco use. Adult cigarette smoking rates have declined from 21.6% in 2003 to 14% in 2019.⁸ Youth cigarette smoking rates have fallen even faster among high school students from 22.5% in 2002 to 4.6% in 2020.⁹

• At the state level, the country has seen significant progress on several tobacco control policies, including: 1) smokefree workplace laws, 2) tobacco taxes and 3) Medicaid coverage of tobacco cessation treatments. 
• At the federal level: 1) the U.S. Food and Drug Administration (FDA) gained comprehensive authority over the manufacture, marketing and sales of tobacco products; 2) flavored cigarettes, with the glaring exception of menthol, were prohibited; and 3) the federal age of sale for tobacco products was increased to 21 nationwide.

Tobacco remains the leading cause of preventable death and disease in America, killing 480,000 people each year. In addition, 16 million Americans live with a tobacco-related disease.¹⁰

However, in other ways, federal, state and local policy makers have yet to take the steps necessary to eliminate tobacco use or protect another generation of youth from becoming addicted. Significant social, racial, geographic and sexual orientation disparities in who uses tobacco products and who is exposed to secondhand smoke in the U.S. have only become more pronounced as overall tobacco use rates have decreased. While there have been some promising announcements and actions taken by FDA in 2021, unnecessary addiction, disease and death could have been prevented by more assertive federal government action on flavored tobacco products. State progress on comprehensive smokefree workplace laws appears successful over the course of 20 years but has completely stalled since 2012. Tobacco tax increases have slowed in terms of frequency over the past few years, and only one state, Maryland, increased its tobacco taxes in 2021.

The country continues to endure the most significant public health crisis of the last 100 years, COVID-19, and yet it has failed to convince officials that they must sufficiently invest in public health infrastructure and prioritize policies that will protect people during a public health epidemic. The Lung Association’s “State of Tobacco Control” 2022 report continues to offer a road map with solutions for many of these challenges, but the country needs federal, state and local lawmakers to implement them to further drive down smoking and tobacco use rates.

FDA Crawls Forward Towards More Comprehensive Regulation of Tobacco Products; Leaves Products Most Responsible for the Youth E-Cigarette Epidemic on the Market

Facing a court-ordered deadline, in 2021, FDA finally began to implement and enforce pre-market tobacco authorization (PMTA) requirements for e-cigarettes, hookah, pipe tobacco, most cigars and other tobacco products after many years of delay. This progress was due to a court decision in a lawsuit filed by the Lung Association and several public health partners ordering tobacco product manufacturers to submit PMTA applications to FDA by September 9, 2020, and for FDA to review and make decisions on those applications by September 9, 2021.  

FDA did issue marketing denial orders for many non-menthol flavored e-cigarettes in 2021.  However, when it came to the e-cigarette products with the highest market share and that are the most responsible for the youth vaping epidemic such as JUUL and Vuse, FDA delayed decision on their PMTAs for a significant period of time after the court’s deadline. FDA also issued marketing orders for several high nicotine Vuse tobacco-flavored e-cigarettes and took no action on any PMTA related to menthol e-cigarettes. The Lung Association has repeatedly called for all flavored tobacco products, including e-cigarettes, to be removed from the marketplace. Flavors are a key driver of youth tobacco use, and no evidence has been presented that flavored products can meet the public health standard that the law requires.  

A new, potentially large loophole emerged in 2021 in the form of synthetic nicotine, as the FDA’s Center for Tobacco Products asserts its authority only covers nicotine derived from tobacco. E-cigarette companies, including PuffBar, the most used e-cigarette product among teens, appear to be exploiting this legal loophole. Synthetic nicotine flavored e-cigarettes are being used to attempt to evade the Tobacco Control Act. The Lung Association has called for FDA to regulate synthetic nicotine as a drug; if it is to be regulated as a tobacco product, it will require action by Congress.  

In Response to Significant Disparities in Tobacco Use in U.S., FDA Makes an Important Announcement on Menthol

Overall, adult cigarette smoking, and tobacco use rates remained level from the previous year in 2019, the latest year of data. As has been the case since “State of Tobacco Control” was first published 20 years ago though, the overall rates mask significant disparities among racial, ethnic, socio-economic and LGBTQ+ communities. Use of commercial tobacco products remains particularly high among Native Americans and Alaskan Natives at 20.9% and lesbian, gay and bisexual adults at 19.2%.¹¹ Adults with lower incomes, lower levels of education and experiencing mental illness or substance abuse also endure significantly higher rates of smoking. While regular, national data is lacking on this topic, studies have shown that smoking and tobacco use can vary significantly amongst sub-populations of Hispanic and Asian Americans as well.

In addition, the declines in cigarette smoking rates observed in recent years has been due almost entirely to non-menthol cigarettes. Menthol cigarettes are used by close to 81% of Black Americansxii and disproportionately by pregnant women, youth and LGBTQ Americans.¹² In fact, a study released in 2021 found that menthol cigarettes were responsible for 1.5 million new smokers, 157,000 smoking-related premature deaths and 1.5 million life years lost among African Americans from 1980–2018.¹³ These disparities in menthol cigarette use are largely the result of targeted marketing by the tobacco industry.

This makes an April 2021 announcement by FDA of its intention to issue proposed rules removing menthol cigarettes and many flavored cigars from the marketplace an important development. However, FDA has said it will take until April 2022 just to propose rules. Then it may take several years to finalize the rule and defend against the inevitable industry lawsuits. This is on top of years of delay from when FDA’s Tobacco Product Scientific Advisory Committee in 2011 and FDA itself in 2013 issued separate reports saying it would be beneficial to public health to remove menthol cigarettes from the market. The American Lung Association applauded this long overdue announcement and urges FDA to act with urgency on this issue in light of the years of delay and the disproportionate burden menthol cigarettes place on many communities experiencing health disparities.

20 Years of Uneven Change in State Tobacco Prevention Policies

The past 20 years in state tobacco prevention policies can best be summarized as uneven progress with significant differences by policy, decade and geographic region. The country saw significant progress on smokefree workplace laws and tobacco taxes during the 2000s, only to see that progress stall completely during the 2010s. Certain parts of the country continue to lag significantly behind in putting in place the proven policies called for in “State of Tobacco Control,” including states in the South, Appalachia as well as parts of the Midwest and Great Plains. States where tobacco is or was previously grown and have significant tobacco industry presences, such as North Carolina and Virginia, remain particularly challenging. 

• Increasing State Tobacco Taxes: Increasing tobacco taxes by $1.00 per pack or more is one of the most effective ways to reduce tobacco use, especially among kids. Many states have significantly increased their taxes on cigarettes and other tobacco products over the past 20 years. However, this has created a wide disparity in cigarette tax rates, with the lowest state cigarette tax in Missouri at a meager 17 cents per pack and the District of Columbia the highest at $4.50 per pack. Maryland was the only state to increase its cigarette tax in 2021, to $3.75 per pack, 5th highest in the country. 
• Smokefree Public Places and Workplaces: From 2003 to 2012, there was a significant expansion of the number of states with laws prohibiting smoking in public places and workplaces, however no additional states have passed such laws since then. Some states with comprehensive smokefree laws have closed additional loopholes in their laws, including Connecticut in 2021. Ohio also added e-cigarettes to its comprehensive smokefree law in 2021. During 2020, more than 200 tribal and non-tribal casinos re-opened smokefree¹⁵ after being closed due to COVID-19. During 2021, many tribal casinos kept their smokefree policies in place but there was some backsliding among state-regulated casinos when state COVID-19 emergency orders expired. In addition, the Navajo Nation approved legislation in 2021 after a 12 plus year effort that made all public places and workplaces, including tribal casinos smokefree.  
• Expanding Medicaid and Tobacco Cessation Coverage:  Since 2009, the “State of Tobacco Control” report began reporting on states’ tobacco cessation coverage Over the past 13 years, state Medicaid programs have increased the number treatments they covered, and because of provisions in the Affordable Care Act (ACA) have increased the number of people eligible for Medicaid coverage. The 2009 report showed only 20 states covering all 7 FDA-approved cessation medications. This year’s report shows that 43 states now provide that coverage. The report has tracked the progress states have made in providing these treatments not only to Medicaid enrollees, but also to State Employees through their health plans. The report also recognizes the importance of adequately funding state quitlines in helping smokers quit. While the last 13 years of “State of Tobacco Control” reports have shown progress in policies to access quit smoking services, there is still more work to be done.

Medicaid Expansion and Tobacco Cessation
The Affordable Care Act expanded Medicaid coverage to individuals at 138% of the federal poverty level ($30,305 per year for a family of three) or lower. In 2022, 38 states and the District of Columbia have all expanded their Medicaid programs. Individuals with incomes less than $35,000 a year smoke at rate of 21.4%, higher than the general population (14%). It is not surprising that increasing access to healthcare coverage, including a comprehensive cessation benefit, results in more people making quit attempts. Research shows Medicaid quit attempts in expansion states increased by over 20%.

• Funding for State Tobacco Prevention and Cessation Programs: This issue has seen the least progress among the four areas that states have been graded on longest in the “State of Tobacco Control” report. The majority of states have kept their levels of funding steady from year to year, but most states remain far short of the funding levels recommended by CDC. Properly funding state tobacco control programs can bring crucial focus and resources to alleviate disparities in who uses tobacco products and help achieve health equity in tobacco control. People from disproportionately affected communities should be empowered to lead the effort to address these disparities, including providing funding to organizations that directly serve the communities. In the current state fiscal year, fiscal year 2022, two states – Alaska and Oregon funded their state tobacco control programs at or close to the level recommended by CDC.

New Tobacco Products and New Public Policies Rise to the Forefront

Over the 20 years of “State of Tobacco Control,” both new tobacco products and new public policies to prevent and reduce tobacco use have emerged. The most prominent and concerning of the new tobacco products to come onto the market have been e-cigarettes, which have been sold in the U.S. since 2007. The American Lung Association has been consistently warning of the potential dangers of these products since their debut. Our fears were unfortunately validated when youth use of e-cigarettes rose substantially from 2011 to 2015 and then to an even greater degree from 2017 to 2019. This caused the U.S. Surgeon General to declare youth vaping an epidemic in 2018.

“To help address the continuing youth e-cigarette epidemic and achieve its mission focal point of reducing youth vaping to 15% by 2025, the American Lung Association launched its End  Youth Vaping initiative on September 1, 2020. It is an integrated, multi-component campaign to support parents, schools and students. Major components of the campaign include our Vape-Free Schools Initiative, which helps schools navigate this public health emergency with tools to protect and support both schools and students and the “Get Your Head Out of the Cloud” youth vaping awareness campaign from the American Lung Association and the Ad Council to provide parents with a discussion guide to address the dangers of vaping with their kids, while they’re still willing to listen.”

In 2021, youth vaping rates were 11.3% among high school students and 2.8% among middle school students.¹⁶ However, with some schools closed for in-person learning due to the COVID-19 pandemic, some kids had less access to e-cigarettes. Youth vaping rates in 2021 varied substantially based on whether a student took the survey at school (15.0%) or home/some other place (8.1%).¹⁵ Other new tobacco and nicotine products introduced to the U.S. market in the past few years include heated tobacco products such as Philip Morris International’s IQOS product, and nicotine pouches, such as Velo. Youth use of these new products will need to be monitored closely and FDA must be prepared to remove these products from the marketplace. 

One thing is clear: kids overwhelmingly prefer flavored tobacco products. In the 2021 National Youth Tobacco Survey, 85.8% of high school students and 79.2% of middle school students who used e-cigarettes, used flavored products.¹⁸ This has led to a new public policy rising in importance, prohibiting the sale of all flavored tobacco products, including menthol cigarettes, flavored cigars and flavored e-cigarettes. Starting with the “State of Tobacco Control” 2021 report, states are now graded on whether they prohibit the sale of all flavored tobacco products, and the FDA removing flavored tobacco products from the marketplace has been incorporated into the federal government’s grades for close to 10 years.

With removal of menthol cigarettes and flavored cigars by FDA several years in the future at a minimum, it is imperative that states and localities act to end the sale of all flavored tobacco products. In 2021, the District of Columbia approved a law that would prohibit the sale of all flavored tobacco products in virtually all locations. However, funding will need to be provided in the city’s budget in 2022 for the law to take effect. Implementation of California’s flavored tobacco product law was also delayed until 2022 at the earliest due to a successful ballot referendum on the measure filed by the tobacco industry. 

Other new public policies have become more prominent at the state level in recent years, including: 

• Increasing the Tobacco Sales Age to 21
  Starting in 2015 with the state of Hawaii, close to 20 states, and then the federal government in December 2019, increased the age of sale for tobacco products, including e-cigarettes, to 21. A 2015 report from the National Academy of Medicine found that increasing the minimum sales age to 21 nationwide could prevent 223,000 deaths among people born between 2000 and 2019, including 50,000 fewer dying from lung cancer, the nation’s leading cancer killer.¹⁹ A handful of states continued to pass legislation in 2021, aligning their state minimum ages with the increased federal minimum age.
• Reducing the Availability and Accessibility of Tobacco Products
  One question that urgently needs to be answered is why there are so many tobacco retailers in the United States. A study of tobacco product retailers in 30 cities, found that there are 31 times more retailers than McDonalds and 16 times more retailers than Starbucks. In addition, in most cities, tobacco product retailers were concentrated in the lowest-income neighborhoods.²⁰ States and communities should enact legislation to reduce the number of tobacco product retailers and prohibit them from being clustered together or near youth-focused locations like schools and childcare facilities. Along these lines, at the state level, two states – Massachusetts and New York – have prohibited tobacco sales in pharmacies, and Utah has prohibited new retail tobacco specialty businesses from locating in certain areas.

An Old Threat to State Policies Re-Emerges in 2021 

In 2021, legislation was introduced in many states that would prevent local governments from passing stronger tobacco control laws, which is referred to as preemption. These types of laws are a favorite tactic of the tobacco industry and its allies as it denies local governments the ability to pass meaningful public policies to prevent and reduce tobacco use, including addressing the youth vaping epidemic. Unfortunately, legislation was approved in two states – Florida and Montana – that prevents communities from passing almost anything stronger than state law to regulate tobacco product sales. The Lung Association expects the tobacco industry to continue its full court press on this issue in 2022.  

On its 20th anniversary, “State of Tobacco Control” 2022 continues to provide a blueprint that states, and the federal government can follow to put in place proven policies that will have the greatest impact on reducing tobacco use and exposure to secondhand smoke in the U.S. The real question is: Will federal and state lawmakers put us on a path to end the death and disease caused by the tobacco use over the next 20 years?