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
Source: BOB WESTON / iStock via Getty Images
Alabama: Perry County
> Smoking rate: 27.3% (Alabama: 20.0%)
> Adults reporting poor or fair health: 34.6% (Alabama: 21.4%)
> Premature deaths per 100,000: 643.9 (Alabama: 471.6)
> Life expectancy at birth (years): 72.34 (Alabama: 75.55)
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Alaska: Kusilvak Census Area
> Smoking rate: 44.6% (Alaska: 18.5%)
> Adults reporting poor or fair health: 41.9% (Alaska: 15.6%)
> Premature deaths per 100,000: 678.7 (Alaska: 350.9)
> Life expectancy at birth (years): 67.19 (Alaska: 79.03)
Source: Oralleff / Getty Images
Arizona: Apache County
> Smoking rate: 25.0% (Arizona: 14.5%)
> Adults reporting poor or fair health: 31.2% (Arizona: 18.6%)
> Premature deaths per 100,000: 611.5 (Arizona: 331.1)
> Life expectancy at birth (years): 73.10 (Arizona: 79.99)
Arkansas: Lee County
> Smoking rate: 28.9% (Arkansas: 23.7%)
> Adults reporting poor or fair health: 33.6% (Arkansas: 23.3%)
> Premature deaths per 100,000: 588.3 (Arkansas: 457.4)
> Life expectancy at birth (years): 74.59 (Arkansas: 76.05)
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California: Del Norte County
> Smoking rate: 19.2% (California: 11.5%)
> Adults reporting poor or fair health: 22.6% (California: 17.6%)
> Premature deaths per 100,000: 480.1 (California: 268.4)
> Life expectancy at birth (years): 76.45 (California: 81.68)
Colorado: Crowley County
> Smoking rate: 23.7% (Colorado: 14.7%)
> Adults reporting poor or fair health: 23.8% (Colorado: 13.8%)
> Premature deaths per 100,000: 414.0 (Colorado: 281.6)
> Life expectancy at birth (years): 79.24 (Colorado: 80.61)
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Connecticut: Windham County
> Smoking rate: 16.4% (Connecticut: 12.5%)
> Adults reporting poor or fair health: 15.5% (Connecticut: 13.0%)
> Premature deaths per 100,000: 345.8 (Connecticut: 278.1)
> Life expectancy at birth (years): 78.54 (Connecticut: 80.87)
Source: David Osberg / Getty Images
Delaware: Kent County
> Smoking rate: 19.7% (Delaware: 17.4%)
> Adults reporting poor or fair health: 21.0% (Delaware: 16.3%)
> Premature deaths per 100,000: 389.3 (Delaware: 360.1)
> Life expectancy at birth (years): 77.82 (Delaware: 78.47)
Source: suwanneeredhead / iStock via Getty Images
Florida: Dixie County
> Smoking rate: 30.9% (Florida: 14.9%)
> Adults reporting poor or fair health: 27.4% (Florida: 19.5%)
> Premature deaths per 100,000: 536.0 (Florida: 336.7)
> Life expectancy at birth (years): 75.36 (Florida: 80.17)
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Georgia: Clinch County
> Smoking rate: 28.0% (Georgia: 16.3%)
> Adults reporting poor or fair health: 30.9% (Georgia: 18.4%)
> Premature deaths per 100,000: 669.6 (Georgia: 378.1)
> Life expectancy at birth (years): 72.56 (Georgia: 77.94)
Source: Boogich / iStock via Getty Images
Hawaii: Hawaii County
> Smoking rate: 18.7% (Hawaii: 14.4%)
> Adults reporting poor or fair health: 17.1% (Hawaii: 15.4%)
> Premature deaths per 100,000: 327.6 (Hawaii: 283.2)
> Life expectancy at birth (years): 80.63 (Hawaii: 82.28)
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Idaho: Shoshone County
> Smoking rate: 22.9% (Idaho: 15.0%)
> Adults reporting poor or fair health: 21.5% (Idaho: 15.1%)
> Premature deaths per 100,000: 464.2 (Idaho: 303.7)
> Life expectancy at birth (years): 75.52 (Idaho: 79.44)
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Illinois: Alexander County
> Smoking rate: 27.0% (Illinois: 15.9%)
> Adults reporting poor or fair health: 26.0% (Illinois: 15.9%)
> Premature deaths per 100,000: 572.1 (Illinois: 328.1)
> Life expectancy at birth (years): 73.51 (Illinois: 79.38)
Indiana: LaGrange County
> Smoking rate: 29.2% (Indiana: 21.7%)
> Adults reporting poor or fair health: 23.1% (Indiana: 18.2%)
> Premature deaths per 100,000: 323.2 (Indiana: 400.8)
> Life expectancy at birth (years): 78.88 (Indiana: 77.11)
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Iowa: Wayne County
> Smoking rate: 23.2% (Iowa: 17.4%)
> Adults reporting poor or fair health: 17.7% (Iowa: 13.5%)
> Premature deaths per 100,000: 376.8 (Iowa: 321.7)
> Life expectancy at birth (years): 78.28 (Iowa: 79.36)
Kansas: Woodson County
> Smoking rate: 25.0% (Kansas: 17.9%)
> Adults reporting poor or fair health: 21.1% (Kansas: 16.3%)
> Premature deaths per 100,000: 397.8 (Kansas: 354.3)
> Life expectancy at birth (years): 79.14 (Kansas: 78.45)
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Kentucky: Clay County
> Smoking rate: 33.6% (Kentucky: 24.1%)
> Adults reporting poor or fair health: 35.7% (Kentucky: 21.8%)
> Premature deaths per 100,000: 697.8 (Kentucky: 469.6)
> Life expectancy at birth (years): 71.73 (Kentucky: 75.63)
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Louisiana: East Carroll Parish
> Smoking rate: 34.3% (Louisiana: 21.1%)
> Adults reporting poor or fair health: 40.5% (Louisiana: 21.4%)
> Premature deaths per 100,000: 658.1 (Louisiana: 452.9)
> Life expectancy at birth (years): 72.08 (Louisiana: 76.14)
Maine: Somerset County
> Smoking rate: 25.8% (Maine: 19.4%)
> Adults reporting poor or fair health: 20.0% (Maine: 17.1%)
> Premature deaths per 100,000: 429.3 (Maine: 338.4)
> Life expectancy at birth (years): 76.52 (Maine: 78.69)
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Maryland: Somerset County
> Smoking rate: 21.8% (Maryland: 12.6%)
> Adults reporting poor or fair health: 23.8% (Maryland: 15.2%)
> Premature deaths per 100,000: 480.1 (Maryland: 338.8)
> Life expectancy at birth (years): 75.50 (Maryland: 79.22)
Source: DenisTangneyJr / iStock via Getty Images
Massachusetts: Bristol County
> Smoking rate: 19.5% (Massachusetts: 13.7%)
> Adults reporting poor or fair health: 16.1% (Massachusetts: 13.5%)
> Premature deaths per 100,000: 350.4 (Massachusetts: 279.4)
> Life expectancy at birth (years): 78.73 (Massachusetts: 80.62)
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Michigan: Lake County
> Smoking rate: 29.1% (Michigan: 20.1%)
> Adults reporting poor or fair health: 25.7% (Michigan: 18.3%)
> Premature deaths per 100,000: 436.1 (Michigan: 364.5)
> Life expectancy at birth (years): 76.93 (Michigan: 78.14)
Minnesota: Mahnomen County
> Smoking rate: 30.0% (Minnesota: 15.5%)
> Adults reporting poor or fair health: 24.3% (Minnesota: 12.9%)
> Premature deaths per 100,000: 754.5 (Minnesota: 266.7)
> Life expectancy at birth (years): 70.14 (Minnesota: 80.92)
Source: Tiago_Fernandez / iStock Editorial via Getty Images
Mississippi: Issaquena County
> Smoking rate: 31.1% (Mississippi: 21.0%)
> Adults reporting poor or fair health: 37.4% (Mississippi: 22.1%)
> Premature deaths per 100,000: 595.4 (Mississippi: 501.8)
> Life expectancy at birth (years): N/A (Mississippi: 74.88)
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Missouri: Wayne County
> Smoking rate: 30.7% (Missouri: 20.1%)
> Adults reporting poor or fair health: 26.9% (Missouri: 19.5%)
> Premature deaths per 100,000: 520.5 (Missouri: 403.6)
> Life expectancy at birth (years): 74.85 (Missouri: 77.30)
Source: Chris LaBasco / iStock via Getty Images
Montana: Glacier County
> Smoking rate: 33.6% (Montana: 18.9%)
> Adults reporting poor or fair health: 27.2% (Montana: 14.1%)
> Premature deaths per 100,000: 686.6 (Montana: 333.8)
> Life expectancy at birth (years): 70.94 (Montana: 78.91)
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Nebraska: Thurston County
> Smoking rate: 27.1% (Nebraska: 16.6%)
> Adults reporting poor or fair health: 23.5% (Nebraska: 13.8%)
> Premature deaths per 100,000: 756.3 (Nebraska: 312.9)
> Life expectancy at birth (years): 69.54 (Nebraska: 79.57)
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Nevada: Mineral County
> Smoking rate: 24.1% (Nevada: 15.7%)
> Adults reporting poor or fair health: 24.4% (Nevada: 19.1%)
> Premature deaths per 100,000: 611.1 (Nevada: 359.9)
> Life expectancy at birth (years): 73.38 (Nevada: 78.67)
Source: BOB WESTON / Getty Images
New Hampshire: Coos County
> Smoking rate: 19.8% (New Hampshire: 16.6%)
> Adults reporting poor or fair health: 18.5% (New Hampshire: 12.8%)
> Premature deaths per 100,000: 390.0 (New Hampshire: 304.9)
> Life expectancy at birth (years): 77.34 (New Hampshire: 79.69)
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New Jersey: Cumberland County
> Smoking rate: 22.6% (New Jersey: 13.2%)
> Adults reporting poor or fair health: 25.2% (New Jersey: 15.5%)
> Premature deaths per 100,000: 482.6 (New Jersey: 292.0)
> Life expectancy at birth (years): 75.26 (New Jersey: 80.49)
New Mexico: McKinley County
> Smoking rate: 27.6% (New Mexico: 15.9%)
> Adults reporting poor or fair health: 31.3% (New Mexico: 20.3%)
> Premature deaths per 100,000: 648.0 (New Mexico: 399.5)
> Life expectancy at birth (years): 71.91 (New Mexico: 77.98)
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New York: Herkimer County
> Smoking rate: 24.9% (New York: 13.0%)
> Adults reporting poor or fair health: 16.8% (New York: 16.3%)
> Premature deaths per 100,000: 323.7 (New York: 276.3)
> Life expectancy at birth (years): 79.44 (New York: 81.44)
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North Carolina: Robeson County
> Smoking rate: 30.0% (North Carolina: 17.9%)
> Adults reporting poor or fair health: 31.2% (North Carolina: 18.0%)
> Premature deaths per 100,000: 587.6 (North Carolina: 369.6)
> Life expectancy at birth (years): 72.80 (North Carolina: 78.13)
North Dakota: Sioux County
> Smoking rate: 36.2% (North Dakota: 19.7%)
> Adults reporting poor or fair health: 33.9% (North Dakota: 13.6%)
> Premature deaths per 100,000: 898.5 (North Dakota: 319.7)
> Life expectancy at birth (years): 68.46 (North Dakota: 79.72)
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Ohio: Vinton County
> Smoking rate: 31.3% (Ohio: 21.4%)
> Adults reporting poor or fair health: 24.2% (Ohio: 17.8%)
> Premature deaths per 100,000: 517.5 (Ohio: 406.8)
> Life expectancy at birth (years): 74.53 (Ohio: 76.98)
Oklahoma: Adair County
> Smoking rate: 32.1% (Oklahoma: 19.9%)
> Adults reporting poor or fair health: 33.4% (Oklahoma: 20.9%)
> Premature deaths per 100,000: 600.7 (Oklahoma: 456.6)
> Life expectancy at birth (years): 73.21 (Oklahoma: 76.05)
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Oregon: Josephine County
> Smoking rate: 22.9% (Oregon: 15.7%)
> Adults reporting poor or fair health: 21.9% (Oregon: 18.2%)
> Premature deaths per 100,000: 430.8 (Oregon: 303.0)
> Life expectancy at birth (years): 76.58 (Oregon: 79.88)
Source: zrfphoto / Getty Images
Pennsylvania: Forest County
> Smoking rate: 25.7% (Pennsylvania: 17.9%)
> Adults reporting poor or fair health: 23.5% (Pennsylvania: 17.6%)
> Premature deaths per 100,000: 338.6 (Pennsylvania: 354.5)
> Life expectancy at birth (years): 78.83 (Pennsylvania: 78.45)
Rhode Island: Kent County
> Smoking rate: 18.5% (Rhode Island: 15.2%)
> Adults reporting poor or fair health: 15.4% (Rhode Island: 16.5%)
> Premature deaths per 100,000: 309.7 (Rhode Island: 304.4)
> Life expectancy at birth (years): 79.19 (Rhode Island: 79.84)
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South Carolina: Dillon County
> Smoking rate: 26.7% (South Carolina: 18.7%)
> Adults reporting poor or fair health: 29.9% (South Carolina: 17.8%)
> Premature deaths per 100,000: 620.4 (South Carolina: 410.6)
> Life expectancy at birth (years): 72.93 (South Carolina: 77.12)
South Dakota: Oglala Lakota County
> Smoking rate: 40.9% (South Dakota: 20.2%)
> Adults reporting poor or fair health: 34.9% (South Dakota: 13.4%)
> Premature deaths per 100,000: 1,036.3 (South Dakota: 335.4)
> Life expectancy at birth (years): 64.41 (South Dakota: 78.91)
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Tennessee: Lake County
> Smoking rate: 30.9% (Tennessee: 20.8%)
> Adults reporting poor or fair health: 30.4% (Tennessee: 21.2%)
> Premature deaths per 100,000: 599.2 (Tennessee: 453.1)
> Life expectancy at birth (years): 72.39 (Tennessee: 75.98)
Texas: Hall County
> Smoking rate: 23.8% (Texas: 14.2%)
> Adults reporting poor or fair health: 31.2% (Texas: 18.7%)
> Premature deaths per 100,000: 369.0 (Texas: 338.6)
> Life expectancy at birth (years): 77.45 (Texas: 79.17)
Source: AlexMcGuffie / Getty Images
Utah: San Juan County
> Smoking rate: 18.8% (Utah: 9.1%)
> Adults reporting poor or fair health: 25.4% (Utah: 14.8%)
> Premature deaths per 100,000: 466.1 (Utah: 282.4)
> Life expectancy at birth (years): 76.41 (Utah: 80.07)
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Source: DenisTangneyJr / E+ via Getty Images
Vermont: Orleans County
> Smoking rate: 21.2% (Vermont: 14.7%)
> Adults reporting poor or fair health: 15.9% (Vermont: 12.8%)
> Premature deaths per 100,000: 351.4 (Vermont: 302.2)
> Life expectancy at birth (years): 78.55 (Vermont: 79.83)
Virginia: Buchanan County
> Smoking rate: 29.1% (Virginia: 15.1%)
> Adults reporting poor or fair health: 28.0% (Virginia: 16.6%)
> Premature deaths per 100,000: 555.7 (Virginia: 320.0)
> Life expectancy at birth (years): 74.03 (Virginia: 79.55)
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Washington: Ferry County
> Smoking rate: 21.7% (Washington: 12.1%)
> Adults reporting poor or fair health: 22.3% (Washington: 15.0%)
> Premature deaths per 100,000: 441.1 (Washington: 288.1)
> Life expectancy at birth (years): 77.70 (Washington: 80.42)
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West Virginia: McDowell County
> Smoking rate: 34.7% (West Virginia: 26.9%)
> Adults reporting poor or fair health: 36.5% (West Virginia: 23.6%)
> Premature deaths per 100,000: 841.4 (West Virginia: 504.8)
> Life expectancy at birth (years): 69.01 (West Virginia: 74.79)
Wisconsin: Menominee County
> Smoking rate: 33.6% (Wisconsin: 17.2%)
> Adults reporting poor or fair health: 28.7% (Wisconsin: 14.8%)
> Premature deaths per 100,000: 732.7 (Wisconsin: 308.2)
> Life expectancy at birth (years): 71.55 (Wisconsin: 79.46)
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Wyoming: Niobrara County
> Smoking rate: 22.8% (Wyoming: 19.2%)
> Adults reporting poor or fair health: 19.5% (Wyoming: 15.3%)
> Premature deaths per 100,000: 320.8 (Wyoming: 344.2)
> Life expectancy at birth (years): 80.15 (Wyoming: 78.91)
Methodology
To determine the county with the most smоkers in every state, 24/7 Tempo reviewed the share of adults who are current smоkers from the Robert Wood Johnson Foundation and the University of Wisconsin Population Health Institute joint program’s 2021 County Health Rankings & Roadmaps report. While the CHR report is from 2021, adult smоking rates are from 2018.
Of the 3,220 counties or county equivalents, 3,141 had boundaries that fell within one of the 50 states, while the rest were in the District of Columbia or Puerto Rico. Counties with a 2019 five-year population estimate from the U.S. Census Bureau of less than 1,000 were excluded.
The remaining 3,105 places were ranked within their state based on the adult smоking rate. Additional information on the share of adults reporting poor or fair health, the number of deaths among residents under age 75 per 100,000 (premature death rate), and average life expectancy at birth are also from the 2021 CHR.
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