Cigarettes and smoking in the USA

Cigarette smoking causes more than 480,000 deaths a year in the United States, including deaths from secondhand smoke exposure. That is about one in every five deaths in the country, and it makes smoking the leading preventable cause of disease, disability and death.

It causes roughly 90 percent of lung cancer deaths and about 80 percent of deaths from chronic obstructive pulmonary disease. Beyond the lungs it causes cancers of the mouth, throat, esophagus, larynx, stomach, pancreas, liver, kidney, bladder, cervix and colon, plus acute myeloid leukemia.

It causes coronary heart disease, stroke and peripheral vascular disease, and it damages blood vessels throughout the body. It causes type 2 diabetes, rheumatoid arthritis, reduced fertility, and in pregnancy raises the risk of preterm birth, low birth weight, stillbirth and sudden infant death syndrome.

The mechanism is combustion. Burning tobacco produces thousands of chemicals, including at least 70 known carcinogens, delivered as tar deep into lung tissue, alongside carbon monoxide which displaces oxygen in the blood. Nicotine is what sustains the habit; combustion products are what cause the disease.

Secondhand smoke has no safe level of exposure. It causes heart disease, stroke and lung cancer in non-smoking adults, and in children causes more frequent and severe asthma attacks, respiratory infections, ear infections and sudden infant death syndrome.

The economic figure is comparably large: cigarette smoking cost the United States more than $600 billion in 2018, more than $240 billion in direct healthcare spending and nearly $372 billion in lost productivity.

The Family Smoking Prevention and Tobacco Control Act of 2009 gave the FDA authority over tobacco products. It banned characterizing flavors in cigarettes other than menthol and tobacco, restricted advertising and marketing, banned free samples and most brand sponsorship, prohibited terms such as 'light', 'mild' and 'low tar' without authorization, and required ingredient disclosure.

Menthol was carved out of the 2009 flavor ban and has remained the central unfinished question in US tobacco policy since. A proposed federal rule to prohibit menthol as a characterizing flavor in cigarettes has been repeatedly delayed and is not in force. Massachusetts and California prohibit menthol cigarette sales under their own state flavored tobacco bans.

Health warnings are required on packs and in advertising. A rule mandating larger graphic warnings with photographs has been the subject of prolonged litigation and its implementation has been repeatedly delayed.

The federal minimum age of sale has been 21 for all tobacco products since December 2019, with no exceptions.

Everything else is state and local: excise tax rates, retail licensing, where smoking is permitted, and whether local governments may go further than the state. This is why the experience of smoking in the US varies so much by location.

There is no single US cigarette price. The federal excise tax is uniform, but state excise taxes range from well under a dollar a pack to several dollars, some cities and counties add their own on top, and state sales tax applies to the total.

The result is that the same pack can differ by roughly a factor of three between the cheapest tobacco-producing states and the most heavily taxed cities. That gap drives large-scale interstate cigarette smuggling, which is what the PACT Act was originally written to address.

A further layer comes from the 1998 Master Settlement Agreement between the major manufacturers and 46 states, which resolved state litigation over smoking-related healthcare costs. It requires perpetual annual payments to states, restricts marketing — the reason American cigarette billboards and cartoon mascots disappeared — and funds anti-smoking programs, though states have wide discretion over how much settlement money actually goes to tobacco control.

We do not quote current pack prices or state tax rates on this site, because they change annually and a page that states a rate will eventually state a wrong one. Your state department of revenue publishes the current excise rate.

Cost is not incidental to health policy. Price increases are among the best-evidenced interventions for reducing smoking, with a consistently stronger effect on young people and lower-income smokers, which is also the basis for the regressivity objection to tobacco taxes.

There is no national indoor smoking ban. Smoke-free air law is state and local, and coverage is genuinely uneven — many states prohibit smoking in all enclosed workplaces including bars and restaurants, others cover some venue types, and a few have no comprehensive statewide law at all, leaving it to cities.

Where a state law exists, cities and counties may usually go further, and many do. Some states preempt local action, which freezes coverage at the state level.

Federal rules apply regardless of state: smoking and vaping are banned on all commercial flights, in federal buildings, and in public housing operated by public housing agencies under a HUD rule covering indoor areas and immediate surroundings.

Private rules are separate from law and frequently stricter. Landlords may prohibit smoking in leases, hotels may charge substantial cleaning fees, employers may ban it on their property, hospitals and universities are commonly entirely smoke-free campuses, and car rental companies charge for smoking in a vehicle.

Whether e-cigarettes are covered by a smoking ban depends on how that jurisdiction's law is drafted. Many clean indoor air acts have been amended to include vaping explicitly; some have not, leaving it to the venue's discretion. Assume you must ask.

Some states restrict smoking in a vehicle carrying a minor. This is worth knowing because it is easy to breach without realising.

Around 11.6 percent of US adults smoked cigarettes as of 2022 — roughly 28.8 million people — down from more than 40 percent in the mid-1960s. Youth cigarette smoking has fallen to the lowest levels ever recorded.

The decline has not been evenly distributed, and the resulting inequality is now one of the defining features of American smoking. Prevalence is substantially higher among adults with lower incomes and less formal education, among people with mental health conditions and substance use disorders, among LGBT adults, among uninsured adults and those on Medicaid, and among American Indian and Alaska Native populations.

Menthol is central to this pattern. The overwhelming majority of Black adults who smoke use menthol cigarettes, a disparity with a well-documented history of targeted marketing, and it is the core of the public health case for prohibiting menthol as a characterizing flavor.

Geographic variation is large, tracking state tobacco control investment, tax rates, smoke-free law coverage and the historic tobacco-growing regions.

The practical implication is that the remaining American smoking problem is increasingly concentrated among people with the least access to cessation support — which is precisely why the free quitline and no-cost-sharing insurance coverage of cessation medication matter more than they appear to.