Higher cigarette taxes, smoke-free policies, exposure to aggressive media campaigns and access to cessation programs that include counseling are among the biggest factors that help smokers kick the habit, according to recent studies from the Centers for Disease Control and the North American Quitline Consortium, a nonprofit that promotes quit-smoking hotlines.
On the one hand, smoking reduction is one of the country's biggest public-health victories. The portion of Americans 18 and older who smoke has dropped substantially from 42.4 percent in 1965, the first year the CDC tracked that data, to 20.6 percent in 2008, said Thomas Glynn, director of cancer science and trends for the American Cancer Society.
But declines plateaued with virtually no change from 2004 to 2008, and many public-health advocates worry that state budget cutbacks will make it even harder for the 70 percent of smokers who say they want to quit.
If all states spent between $9 and $18 per resident on comprehensive tobacco-control programs, which the CDC recommends, 5 million fewer people would smoke five years from now, it says. Just one state, North Dakota, meets that funding level, and 31 states and the District of Columbia allocate less than a quarter of it.
Twenty years of research show that smoking rates decline after policy changes that make it less accessible, less attractive and less affordable to light up, said Terry Pechacek, associate director for science for CDC's Office on Smoking and Health.
For example, in California, which has the nation's oldest statewide tobacco-control program, only 14 percent of adults and 6.9 percent of youth smoke, and lung-cancer rates have decreased four times as rapidly in the state as in the U.S. overall. The state saved $86 billion in tobacco-related health-care costs between 1989 and 2004, according to the CDC.
New York has some of the highest state cigarette taxes at $2.75 a pack, stringent indoor smoke-free-air laws, and the nation's second-most intensive tobacco counter-marketing campaign. The Empire State has reduced its percentage of adult smokers to 16.7 percent in 2008 from 22.3 percent in 2002, according to the state health department.
Compare that to South Carolina, which spends only 5.4 percent of the CDC's recommended investment and has no indoor smoke-free-air laws. About 20 percent of South Carolina adults and 11.8 percent of youth smoked in 2008, but the Palmetto state appears to be changing its approach.
On Thursday, South Carolina lawmakers voted to override Gov. Mark Sanford's veto of a bill that would raise the cigarette tax to 57 cents a pack from 7 cents. The new tax rate hike would take effect July 1.
Overall, state per-pack taxes average $1.36, but 23 states had tobacco taxes of less than $1 as of May 1, according to the American Lung Association. While 24 states and the District of Columbia have comprehensive smoke-free-air state laws for almost all public spaces including work sites, restaurants and bars, 15 have weak or no smoke-free laws.
Insurance coverage matters, too. Only 39 percent of employers provided smoking-cessation programs as a benefit in their insurance plans, according to a 2009 survey from the Society for Human Resource Management. Seven states have laws or insurance regulations that require cessation coverage in some or all private insurance plans in the state.
HELP ON THE LINE
Ted Williams of Tucson, Ariz., was a pack-a-day smoker for 45 years. He tried to quit multiple times, unsuccessfully using nicotine patches and other medications. Per-pack prices in his area hit $7 after federal cigarette taxes increased a year ago, and the recession slowed his home-building and design business, but still all he could do was adapt by buying less-expensive loose tobacco and rolling papers and purchasing cheaper packs at a nearby Indian reservation.
"I started at age 15 with peer pressure because everybody that was cool smoked," said Williams, who is now 60. "I would sit at the computer and smoke nonstop."
A massive heart attack in January finally convinced Williams his life depended on quitting now. But he still might not have succeeded if hospital staff hadn't arranged a call with a counselor at his state's free "quitline," he said. Williams said he received not only encouragement to quit but also help in developing a plan to combat his urges.
"I don't think the cravings will ever go away, but what I've done is change my habits," he said. "I used to get up in the morning and have a cup of coffee and four cigarettes, but now I have a glass of tomato juice or brush my teeth - things that make a cigarette taste bad."
Tobacco use is the No. 1 preventable cause of disease, disability and death worldwide. About 443,000 Americans die from either smoking or secondhand exposure to it annually, according to the CDC.