Weakest Smoking Laws Linked to Highest Rates of Lung Cancer, Heart Disease, and COPD

The biggest cause of preventable disease, disability, and death in the United States is cigarette smoking.

In a new report, the Healthnews team has pinpointed a stark correlation. States grappling with the highest rates of lung cancer, heart disease, and COPD — key indicators of the lethal impact of smoking — are those with the most lenient smoking regulations.

This analysis focuses on the newest lung cancer, heart disease mortality, and the prevalence of Chronic Obstructive Pulmonary Disease (COPD) data obtained from the Centers for Disease Control and Prevention. This data is correlated with the particular smoking regulations — or lack thereof — implemented in each state.

The report findings show a troubling link between weak smoking laws and heightened health crises, underscoring the need for strict tobacco control policies.

Lung cancer rates

StateType of restrictionLung cancer: age-adjusted rate per 100,000
KentuckyNo Law - designated areas - or separate ventilation Law75.8
West VirginiaNo Law - designated areas - or separate ventilation Law67.1
Maine100% smokefree in three locations63.5
MissouriNo Law - designated areas - or separate ventilation Law62.8
Tennessee100% smokefree in one location60.1
MississippiNo Law - designated areas - or separate ventilation Law58.9
Arkansas100% smokefree in one location58.6
Ohio100% smokefree in three locations57.3
OklahomaNo Law - designated areas - or separate ventilation Law55.6
North Carolina100% smokefree in two locations55.6
Iowa100% smokefree in three locations55.5
Louisiana100% smokefree in two locations53.4
New Hampshire100% smokefree in one location53.2
Massachusetts100% smokefree in three locations52.5
Illinois100% smokefree in three locations52.4
AlabamaNo Law - designated areas - or separate ventilation Law52.2
South CarolinaNo Law - designated areas - or separate ventilation Law52.1
Michigan100% smokefree in three locations51.8
GeorgiaNo Law - designated areas - or separate ventilation Law51.4
Wisconsin100% smokefree in three locations51
Pennsylvania100% smokefree in one location50.7
North Dakota100% smokefree in three locations50.3
Rhode Island100% smokefree in three locations49.4
Minnesota100% smokefree in three locations49.3
AlaskaNo Law - designated areas - or separate ventilation Law49.2
Florida100% smokefree in two locations48.3
South Dakota100% smokefree in three locations48.1
New York100% smokefree in three locations47.8
Kansas100% smokefree in three locations47
Connecticut100% smokefree in three locations46.8
Vermont100% smokefree in three locations46.7
VirginiaNo Law - designated areas - or separate ventilation Law46.7
Delaware100% smokefree in three locations46.1
New Jersey100% smokefree in three locations44.9
Nebraska100% smokefree in three locations44.2
Maryland100% smokefree in three locations43.9
Washington100% smokefree in three locations41.4
Oregon100% smokefree in three locations41.3
Montana100% smokefree in three locations40.6
TexasNo Law - designated areas - or separate ventilation Law39.9
Idaho100% smokefree in one location39.8
Arizona100% smokefree in three locations36.1
WyomingNo Law - designated areas - or separate ventilation Law35.6
Colorado100% smokefree in three locations35.3
Hawaii100% smokefree in three locations34.8
California100% smokefree in three locations32.2
New Mexico100% smokefree in three locations27.2
Utah100% smokefree in three locations19.8
Nevada100% smokefree in two locationsN/A
Indiana100% smokefree in two locationsN/A

The following is what each type of restriction in the table means:

  • "No law - designated areas - or separate ventilation law": In these places, there are no specific rules against smoking indoors. Some places may have designated smoking areas or separate ventilation systems, but no comprehensive smoke-free laws.
  • "100% smokefree in three locations": This means smoking is completely banned indoors in three types of places, usually public spaces, workplaces, and restaurants.
  • "100% smokefree in one location": Similar to the previous type, it signifies a complete indoor smoking ban, but in just one specific type of place, such as a workplace or a restaurant.

States without any smoking provisions (Kentucky and West Virginia) have the most cases of lung cancer, indicating a potential link between the lack of restrictions and higher lung cancer rates. Four out of five states with the highest lung cancer rates are part of the "Tobacco Nation" region, which has 50% more smokers than the rest of the country. It is Kentucky, West Virginia, Missouri, and Tennessee.

Nonetheless, Maine has the strictest smoking ban among the top 5 states, yet its lung cancer rate of 63.5 is still the third highest in the country. A closer look reveals a concerning trend: while tobacco use among U.S. high school students overall dropped from 16.5% to 12.6% in 2022–2023, in Maine, the rate is much higher at 33%. This stark contrast points to the need for more effective tobacco prevention programs targeting young people in Maine.

Even in states with a high prevalence of lung cancer, more stringent smoking restrictions may help mitigate the rates.

Heart disease mortality rates

StateType of restrictionHeart disease mortality rate per 100,000
OklahomaNo Law - designated areas - or separate ventilation Law264.2
MississippiNo Law - designated areas - or separate ventilation Law255.2
AlabamaNo Law - designated areas - or separate ventilation Law247.5
Louisiana100% smokefree in two locations235.5
Arkansas100% smokefree in one location231
Tennessee100% smokefree in one location223.8
West VirginiaNo Law - designated areas - or separate ventilation Law223
KentuckyNo Law - designated areas - or separate ventilation Law217.5
Michigan100% smokefree in three locations209.6
Nevada100% smokefree in two locations208.1
Ohio100% smokefree in three locations204.7
MissouriNo Law - designated areas - or separate ventilation Law202.4
GeorgiaNo Law - designated areas - or separate ventilation Law195.2
Indiana100% smokefree in two locations191.2
South CarolinaNo Law - designated areas - or separate ventilation Law189.1
Iowa100% smokefree in three locations184.9
TexasNo Law - designated areas - or separate ventilation Law180.7
Pennsylvania100% smokefree in one location180.6
Kansas100% smokefree in three locations176.1
Vermont100% smokefree in three locations175.7
Montana100% smokefree in three locations175.2
Wisconsin100% smokefree in three locations171.7
North Carolina100% smokefree in two locations170.9
Illinois100% smokefree in three locations169.8
Maine100% smokefree in three locations168.4
VirginiaNo Law - designated areas - or separate ventilation Law167.2
Idaho100% smokefree in one location166.4
Maryland100% smokefree in three locations165.2
Delaware100% smokefree in three locations162.7
Utah100% smokefree in three locations162.4
New York100% smokefree in three locations162.3
Nebraska100% smokefree in three locations160.8
WyomingNo Law - designated areas - or separate ventilation Law159.4
Rhode Island100% smokefree in three locations158.7
Arizona100% smokefree in three locations158.3
New Jersey100% smokefree in three locations157.5
New Mexico100% smokefree in three locations156.5
AlaskaNo Law - designated areas - or separate ventilation Law154.7
New Hampshire100% smokefree in one location154.1
South Dakota100% smokefree in three locations153
North Dakota100% smokefree in three locations152.8
Florida100% smokefree in two locations151.3
Oregon100% smokefree in three locations148.5
California100% smokefree in three locations147.8
Washington100% smokefree in three locations147.7
Connecticut100% smokefree in three locations136.7
Colorado100% smokefree in three locations135.1
Massachusetts100% smokefree in three locations134
Hawaii100% smokefree in three locations126.5
Minnesota100% smokefree in three locations123.9

Out of the top five, states with the least restrictive smoking policies (Oklahoma, Mississippi, and Alabama) have the highest heart disease mortality rates compared to the states with more comprehensive smoking bans, like Louisiana and Arkansas.

The data suggests a potential correlation between stricter smoking restrictions and lower heart disease mortality rates. Similar to the lung cancer rates, the relationship is not strictly linear, as states with partial restrictions (like Alabama) do not necessarily have intermediate heart disease rates.

In 2012, Alabama stood out as one of the states least impacted by health-promoting changes in tobacco policy. The recorded cigarette excise tax was exceptionally low at $0.42 per pack, ranking among the nation's lowest. The state's investment in tobacco prevention and control was meager, dedicating only 13% ($7.5 million) of the $56.7 million funding amount recommended by the CDC. Alabama had not yet established statewide smoke-free legislation for either restaurants or bars at that time.

It’s no surprise that all five states with the highest rates of heart disease mortality are part of the "Tobacco Nation."

Prevalence of COPD (%)

StateType of restrictionAge-adjusted prevalence of COPD (%)
West VirginiaNo Law - designated areas - or separate ventilation Law12
Tennessee100% smokefree in one location10
KentuckyNo Law - designated areas - or separate ventilation Law10
MississippiNo Law - designated areas - or separate ventilation Law9
AlabamaNo Law - designated areas - or separate ventilation Law8
Louisiana100% smokefree in two locations8
Arkansas100% smokefree in one location8
Michigan100% smokefree in three locations8
Ohio100% smokefree in three locations8
Indiana100% smokefree in two locations8
OklahomaNo Law - designated areas - or separate ventilation Law7
MissouriNo Law - designated areas - or separate ventilation Law7
Maine100% smokefree in three locations7
Nevada100% smokefree in two locations6
GeorgiaNo Law - designated areas - or separate ventilation Law6
South CarolinaNo Law - designated areas - or separate ventilation Law6
Pennsylvania100% smokefree in one location6
Kansas100% smokefree in three locations6
North Carolina100% smokefree in two locations6
VirginiaNo Law - designated areas - or separate ventilation Law6
Delaware100% smokefree in three locations6
WyomingNo Law - designated areas - or separate ventilation Law6
Rhode Island100% smokefree in three locations6
South Dakota100% smokefree in three locations6
Florida100% smokefree in two locations6
Iowa100% smokefree in three locations5
TexasNo Law - designated areas - or separate ventilation Law5
Vermont100% smokefree in three locations5
Montana100% smokefree in three locations5
Wisconsin100% smokefree in three locations5
Illinois100% smokefree in three locations5
Idaho100% smokefree in one location5
Nebraska100% smokefree in three locations5
Arizona100% smokefree in three locations5
AlaskaNo Law - designated areas - or separate ventilation Law5
New Hampshire100% smokefree in one location5
North Dakota100% smokefree in three locations5
Oregon100% smokefree in three locations5
Connecticut100% smokefree in three locations5
Massachusetts100% smokefree in three locations5
Maryland100% smokefree in three locations4
Utah100% smokefree in three locations4
New York100% smokefree in three locations4
New Jersey100% smokefree in three locations4
New Mexico100% smokefree in three locations4
California100% smokefree in three locations4
Washington100% smokefree in three locations4
Colorado100% smokefree in three locations4
Minnesota100% smokefree in three locations4
Hawaii100% smokefree in three locations3

States with the most relaxed smoking policies, specifically West Virginia, Kentucky, and Mississippi, report the nation's higher COPD prevalence rates, marked at 12%, 10%, and 9%, respectively. This contrasts with other states that have implemented partial or full smoking bans, where there's a consistently lower average COPD prevalence of around 8%. "Tobacco Nation" includes all the first 10 states.

Tennessee stands out because it bans smoking in enclosed public places and workplaces. However, its high COPD rank might be related to the vaping situation. A 2024 Forbes study shows that Tennessee has the highest rate of vaping across all 50 states. Vaping, just like traditional smoking, plays a crucial role in the rates of COPD.

The Healthnews analysis shows that states with the highest lung cancer, heart disease, and COPD rates are attributed to weaker local policies on tobacco prevention and cessation. This highlights the critical role robust smoking laws play in reducing the prevalence of these diseases.


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