In 1964, the Surgeon General’s Report on Smoking and Health linked for the first time smoking and adverse health outcomes. The pivotal report aimed to shift public opinion on smoking by identifying the dangers of tobacco use. The smoking rate in the United States has fallen precipitously in the last 50 years, dropping from 42.4% in 1965 to 18.0% in 2012.

Nearly one in five adults nationwide report a smoking habit today — and this rate varies considerably across the nation. 24/7 Wall St. reviewed adult smoking rates in each state from the Centers for Disease Control and Prevention. West Virginia has the highest adult smoking rate at 26.7%. In Utah, by contrast, only 9.7% of adults smoke, the lowest rate in the nation.

To help curb tobacco use, many state governments levy heavy excise taxes — a tax the consumer pays when buying certain goods such as tobacco, alcohol, or gasoline. The states with the highest excise tax on tobacco products tend to have some of the lowest smoking rates in the country, suggesting these taxes may effective in lowering the smoking rate. New York has the highest tax on cigarettes at $4.35 per pack — and one of the lowest smoking rates in the nation at 14.4%. West Virginia, by contrast, has the sixth lowest excise tax on tobacco, at 55 cents per pack.

Click here to see the states with the most smokers.

The United States spends around $170 billion a year to treat tobacco-related illnesses, including lung cancer, stroke, diabetes, and cardiovascular diseases. Cigarette smoke contains more than 7,000 chemicals of which 69 are known carcinogens. As a result, smoking is the leading cause of cancer. Utah, the state with the lowest smoking rate, also has the lowest rate of cancer death in the country. The 10 states with the highest smoking rates all have cancer death rates above the national average.

Ultimately, smoking and its related illnesses lead to shorter life spans. Smoking is the leading cause of preventable death in the country, killing 480,000 Americans prematurely each year. On average, smokers die 10 years younger than non-smokers.

To identify the states with the highest adults smoking rates, 24/7 Wall St. reviewed the rate of adult smokers by state from the Centers for Disease Control and Prevention’s Behavioral Risk Factor Surveillance System. Cancer deaths per capita came from the 2015 America’s Health Rankings annual report from the United Health Foundation. Premature death rates — deaths before the age of 75 — per capita are from the County Health Rankings & Roadmaps, a Robert Wood Johnson Foundation and University of Wisconsin Population Health Institute joint program.

These are the states with the highest adult smoking rates.

50. Utah
> Pct. adults smokers: 9.7%
> State cigarette tax/pack: $1.70 (19th highest)
> Cancer deaths per 100,000: 146.1 (the lowest)
> Premature deaths per 100,000: 287.7 (11th lowest)

49. California
> Pct. adults smokers: 12.9%
> State cigarette tax/pack: $0.87 (16th lowest)
> Cancer deaths per 100,000: 170.1 (6th lowest)
> Premature deaths per 100,000: 272.5 (4th lowest)

48. Hawaii
> Pct. adults smokers: 14.1%
> State cigarette tax/pack: $3.20 (5th highest)
> Cancer deaths per 100,000: 155.4 (2nd lowest)
> Premature deaths per 100,000: 278.7 (5th lowest)

47. New York
> Pct. adults smokers: 14.4%
> State cigarette tax/pack: $4.35 (the highest)
> Cancer deaths per 100,000: 179.9 (12th lowest)
> Premature deaths per 100,000: 282.5 (8th lowest)

46. Texas
> Pct. adults smokers: 14.5%
> State cigarette tax/pack: $1.41 (25th lowest)
> Cancer deaths per 100,000: 182.3 (15th lowest)
> Premature deaths per 100,000: 340.0 (23rd highest)

45. Maryland
> Pct. adults smokers: 14.6%
> State cigarette tax/pack: $2.00 (11th highest)
> Cancer deaths per 100,000: 188.0 (21st lowest)
> Premature deaths per 100,000: 317.4 (22nd lowest)

44. Massachusetts
> Pct. adults smokers: 14.7%
> State cigarette tax/pack: $3.51 (4th highest)
> Cancer deaths per 100,000: 185.6 (20th lowest)
> Premature deaths per 100,000: 268.9 (3rd lowest)

43. New Jersey
> Pct. adults smokers: 15.1%
> State cigarette tax/pack: $2.70 (9th highest)
> Cancer deaths per 100,000: 183.6 (17th lowest)
> Premature deaths per 100,000: 285.7 (10th lowest)

42. Washington
> Pct. adults smokers: 15.3%
> State cigarette tax/pack: $3.03 (7th highest)
> Cancer deaths per 100,000: 182.8 (16th lowest)
> Premature deaths per 100,000: 284.8 (9th lowest)

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41. Connecticut
> Pct. adults smokers: 15.4%
> State cigarette tax/pack: $3.65 (3rd highest)
> Cancer deaths per 100,000: 174.6 (8th lowest)
> Premature deaths per 100,000: 266.3 (2nd lowest)

40. Colorado
> Pct. adults smokers: 15.7%
> State cigarette tax/pack: $0.84 (15th lowest)
> Cancer deaths per 100,000: 162.2 (3rd lowest)
> Premature deaths per 100,000: 279.4 (6th lowest)

39. Idaho
> Pct. adults smokers: 15.9%
> State cigarette tax/pack: $0.57 (8th lowest)
> Cancer deaths per 100,000: 175.8 (9th lowest)
> Premature deaths per 100,000: 308.5 (17th lowest)

38. Minnesota
> Pct. adults smokers: 16.3%
> State cigarette tax/pack: $3.00 (8th highest)
> Cancer deaths per 100,000: 179.5 (11th lowest)
> Premature deaths per 100,000: 262.4 (the lowest)

37. Rhode Island
> Pct. adults smokers: 16.3%
> State cigarette tax/pack: $3.75 (2nd highest)
> Cancer deaths per 100,000: 192.4 (23rd highest)
> Premature deaths per 100,000: 299.3 (13th lowest)

36. Vermont
> Pct. adults smokers: 16.4%
> State cigarette tax/pack: $3.08 (6th highest)
> Cancer deaths per 100,000: 191.0 (25th highest)
> Premature deaths per 100,000: 288.7 (12th lowest)

35. Arizona
> Pct. adults smokers: 16.5%
> State cigarette tax/pack: $2.00 (11th highest)
> Cancer deaths per 100,000: 169.6 (5th lowest)
> Premature deaths per 100,000: 321.0 (25th lowest)

34. Illinois
> Pct. adults smokers: 16.5%
> State cigarette tax/pack: $1.98 (16th highest)
> Cancer deaths per 100,000: 198.6 (17th highest)
> Premature deaths per 100,000: 321.0 (25th lowest)

33. Nevada
> Pct. adults smokers: 17.0%
> State cigarette tax/pack: $1.80 (17th highest)
> Cancer deaths per 100,000: 188.1 (22nd lowest)
> Premature deaths per 100,000: 360.7 (16th highest)

32. Oregon
> Pct. adults smokers: 17.0%
> State cigarette tax/pack: $1.32 (22nd lowest)
> Cancer deaths per 100,000: 192.1 (24th highest)
> Premature deaths per 100,000: 308.5 (17th lowest)

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31. Nebraska
> Pct. adults smokers: 17.3%
> State cigarette tax/pack: $0.64 (12th lowest)
> Cancer deaths per 100,000: 185.4 (19th lowest)
> Premature deaths per 100,000: 302.1 (14th lowest)

30. Georgia
> Pct. adults smokers: 17.4%
> State cigarette tax/pack: $0.37 (3rd lowest)
> Cancer deaths per 100,000: 192.8 (22nd highest)
> Premature deaths per 100,000: 372.0 (13th highest)

29. Wisconsin
> Pct. adults smokers: 17.4%
> State cigarette tax/pack: $2.52 (10th highest)
> Cancer deaths per 100,000: 193.3 (21st highest)
> Premature deaths per 100,000: 302.4 (15th lowest)

28. New Hampshire
> Pct. adults smokers: 17.5%
> State cigarette tax/pack: $1.78 (18th highest)
> Cancer deaths per 100,000: 190.8 (24th lowest)
> Premature deaths per 100,000: 280.1 (7th lowest)

27. Florida
> Pct. adults smokers: 17.7%
> State cigarette tax/pack: $1.34 (23rd lowest)
> Cancer deaths per 100,000: 182.0 (14th lowest)
> Premature deaths per 100,000: 325.4 (25th highest)

26. Kansas
> Pct. adults smokers: 18.1%
> State cigarette tax/pack: $1.29 (21st lowest)
> Cancer deaths per 100,000: 191.0 (25th highest)
> Premature deaths per 100,000: 341.7 (21st highest)

25. Iowa
> Pct. adults smokers: 18.5%
> State cigarette tax/pack: $1.36 (24th lowest)
> Cancer deaths per 100,000: 193.7 (20th highest)
> Premature deaths per 100,000: 309.4 (18th lowest)

24. South Dakota
> Pct. adults smokers: 18.6%
> State cigarette tax/pack: $1.53 (25th highest)
> Cancer deaths per 100,000: 184.8 (18th lowest)
> Premature deaths per 100,000: 320.3 (23rd lowest)

23. North Carolina
> Pct. adults smokers: 19.1%
> State cigarette tax/pack: $0.45 (5th lowest)
> Cancer deaths per 100,000: 195.2 (18th highest)
> Premature deaths per 100,000: 362.1 (15th highest)

22. New Mexico
> Pct. adults smokers: 19.2%
> State cigarette tax/pack: $1.66 (21st highest)
> Cancer deaths per 100,000: 167.3 (4th lowest)
> Premature deaths per 100,000: 362.6 (14th highest)

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21. Maine
> Pct. adults smokers: 19.3%
> State cigarette tax/pack: $2.00 (11th highest)
> Cancer deaths per 100,000: 204.3 (12th highest)
> Premature deaths per 100,000: 314.4 (20th lowest)

20. Virginia
> Pct. adults smokers: 19.5%
> State cigarette tax/pack: $0.30 (2nd lowest)
> Cancer deaths per 100,000: 189.2 (23rd lowest)
> Premature deaths per 100,000: 314.7 (21st lowest)

19. Wyoming
> Pct. adults smokers: 19.5%
> State cigarette tax/pack: $0.60 (10th lowest)
> Cancer deaths per 100,000: 174.6 (8th lowest)
> Premature deaths per 100,000: 341.0 (22nd highest)

18. Alaska
> Pct. adults smokers: 19.9%
> State cigarette tax/pack: $2.00 (11th highest)
> Cancer deaths per 100,000: 194.1 (19th highest)
> Premature deaths per 100,000: 345.3 (18th highest)

17. Delaware
> Pct. adults smokers: 19.9%
> State cigarette tax/pack: $1.60 (22nd highest)
> Cancer deaths per 100,000: 199.1 (15th highest)
> Premature deaths per 100,000: 343.0 (19th highest)

16. Montana
> Pct. adults smokers: 19.9%
> State cigarette tax/pack: $1.70 (19th highest)
> Cancer deaths per 100,000: 180.1 (13th lowest)
> Premature deaths per 100,000: 339.1 (24th highest)

15. North Dakota
> Pct. adults smokers: 19.9%
> State cigarette tax/pack: $0.44 (4th lowest)
> Cancer deaths per 100,000: 176.0 (10th lowest)
> Premature deaths per 100,000: 314.4 (20th lowest)

14. Pennsylvania
> Pct. adults smokers: 19.9%
> State cigarette tax/pack: $1.60 (22nd highest)
> Cancer deaths per 100,000: 199.6 (14th highest)
> Premature deaths per 100,000: 342.8 (20th highest)

13. Missouri
> Pct. adults smokers: 20.6%
> State cigarette tax/pack: $0.17 (the lowest)
> Cancer deaths per 100,000: 206.3 (11th highest)
> Premature deaths per 100,000: 381.1 (11th highest)

12. Ohio
> Pct. adults smokers: 21.0%
> State cigarette tax/pack: $1.60 (22nd highest)
> Cancer deaths per 100,000: 207.6 (10th highest)
> Premature deaths per 100,000: 376.6 (12th highest)

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11. Alabama
> Pct. adults smokers: 21.1%
> State cigarette tax/pack: $0.68 (13th lowest)
> Cancer deaths per 100,000: 211.6 (8th highest)
> Premature deaths per 100,000: 461.0 (3rd highest)

10. Oklahoma
> Pct. adults smokers: 21.1%
> State cigarette tax/pack: $1.03 (18th lowest)
> Cancer deaths per 100,000: 215.8 (6th highest)
> Premature deaths per 100,000: 452.7 (4th highest)

9. Michigan
> Pct. adults smokers: 21.2%
> State cigarette tax/pack: $2.00 (11th highest)
> Cancer deaths per 100,000: 198.7 (16th highest)
> Premature deaths per 100,000: 356.5 (17th highest)

8. South Carolina
> Pct. adults smokers: 21.5%
> State cigarette tax/pack: $0.57 (8th lowest)
> Cancer deaths per 100,000: 203.2 (13th highest)
> Premature deaths per 100,000: 400.2 (9th highest)

7. Indiana
> Pct. adults smokers: 22.9%
> State cigarette tax/pack: $1.00 (17th lowest)
> Cancer deaths per 100,000: 208.8 (9th highest)
> Premature deaths per 100,000: 382.4 (10th highest)

6. Mississippi
> Pct. adults smokers: 23.0%
> State cigarette tax/pack: $0.68 (14th lowest)
> Cancer deaths per 100,000: 225.8 (2nd highest)
> Premature deaths per 100,000: 487.0 (the highest)

5. Louisiana
> Pct. adults smokers: 24.0%
> State cigarette tax/pack: $1.08 (19th lowest)
> Cancer deaths per 100,000: 217.9 (4th highest)
> Premature deaths per 100,000: 445.9 (6th highest)

4. Tennessee
> Pct. adults smokers: 24.2%
> State cigarette tax/pack: $0.62 (11th lowest)
> Cancer deaths per 100,000: 213.7 (7th highest)
> Premature deaths per 100,000: 429.5 (8th highest)

3. Arkansas
> Pct. adults smokers: 24.7%
> State cigarette tax/pack: $1.15 (20th lowest)
> Cancer deaths per 100,000: 216.9 (5th highest)
> Premature deaths per 100,000: 446.0 (5th highest)

2. Kentucky
> Pct. adults smokers: 26.2%
> State cigarette tax/pack: $0.60 (10th lowest)
> Cancer deaths per 100,000: 228.8 (the highest)
> Premature deaths per 100,000: 443.3 (7th highest)

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1. West Virginia
> Pct. adults smokers: 26.7%
> State cigarette tax/pack: $0.55 (6th lowest)
> Cancer deaths per 100,000: 221.6 (3rd highest)
> Premature deaths per 100,000: 466.4 (2nd highest)

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