Cigаrette sales climbed in the U.S. in 2020 for the first time in two decades. Americans bought a total of 203.7 billion сigarettes last year, up from 202.9 billion the year before, according to a Federal Trade Commission report. The uptick coincided with increased сigarette promotional and ad spending by tobacco companies.

The trend is a cause for alarm, as smоking is already the leading cause of preventable death in the United States, claiming nearly half a million American lives annually, according to the Centers for Disease Control and Prevention. Another 16 million Americans are living with a serious illness caused by smоking.

Tobacco use also has an economic impact, including more than $225 billion each year spent on medical expenses to treat the smоking-related illness in the U.S. and over $156 billion in lost productivity.

Using data from County Health Rankings & Roadmaps, a Robert Wood Johnson Foundation and University of Wisconsin Population Health Institute joint program, 24/7 Tempo identified the county with the most smоkers in every state. Counties and county equivalents are ranked on the adult smоking rate — the share of the 18 and older population who smоke every day or most days and have smоked at least 100 сigarettes in their lifetime.

Though each county and county equivalent on this list has the highest smоking rate in its state, the share of adults who are smоkers varies considerably, from 16.4% to 44.6%. Nationwide, 16.6% of the adult population smоke.

Given the detrimental effects of smоking, it is perhaps not surprising that some important health outcome measures tend to be worse than average in counties with higher smоking rates. For example, in nearly every county or county equivalent on this list, the share of adults who report being in fair or poor health is greater than the comparable share across the state as a whole.

The correlation between smоking rates and life expectancy is also strong. In the vast majority of counties and county equivalents on this list, average life expectancy at birth is below the statewide average.

Click here for the county with most smоkers in every state
Click here for our detailed methodology