Smoking rates are decreasing across the country, but those declines may be driven by relatively few counties that have big populations or are part of larger cities, according to a new study.
The study by the Institute for Health Metrics and Evaluation at the University of Washington surveyed almost 5 million smokers in counties across the U.S. and established rates of daily smokers, and those who have smoked occasionally from 1996 to 2012.
The study appearing in the journal Population Health Metrics found most smoking rates for those who have smoked occasionally (at least 100 cigarettes in their life) have declined in the last 10 years. Rates among men fell from 27.3% to 22.2% and women from 22.2% to 17.9%. Three-quarters of the adult male population showing significant declines lived in less than half (1,244) of the 3,127 counties studied while two-thirds of the adult female population lived in just 507 counties that showed significant drops.
Researchers say these counties are usually near metropolitan areas, where clean air legislation -- banning smoking in bars, restaurants and buildings, along with resources and social stigma -- could be driving the decrease. The city with the lowest rate of daily smokers in 2012 was Falls Church City, Va., a suburb of Washington, D.C., with daily smoking for men and women at 5.4%, down from 14% in 1996. Not far behind was Utah County in Utah, with a 5.8% daily smoking rate in 2012 compared with 10% in 1996.
The study looked at counties as well as some cities or Census areas that were considered county-equivalents.
"There is still enormous variation across the country in smoking rates, and even within states, where one county has smoking rates of 7 to 8% for men, and in the same state a few counties over, there is a 30% or higher rate," said Christopher Murray, the director of the Institute for Health Metrics and Evaluation, and researcher on the study.
For example, in Virginia men in Falls Church had a 5% smoking rate in 2012, but in Covington County on the western side of the state that rate was almost five times higher, and life expectancy was almost a decade less.
Bill Blatt, director of tobacco programs at the American Lung Association, said while smoking rates have been decreasing, work still needs to be done in areas of the country with slower reduction rates, especially rural areas.
"One problem in rural areas is access," Blatt said. "Broad campaigns around tobacco use and cessation tend to be concentrated in major media markets. On top of that the small areas don't have the same societal pressures as larger areas."
The study found counties in the South, particularly Kentucky, Tennessee and West Virginia had the highest rates of total cigarette smoking, while counties in Utah and other Western states have the lowest. Those rates also varied by gender and income, with more men smoking at higher rates than women across the country. They found those living in counties with a higher average income smoked less over time. In 75% of counties with higher average incomes there was a decline in male smoking from 1996 to 2012, compared with only 14% of counties that saw decline in the lowest average income group.
"My interpretation is in higher income communities and higher levels of education they may be more likely to adopt tobacco control policies," Murray said. "They may also have more resources to act on information to improve."
Clay County, Ky., had one of the highest daily smoking rates with 30.7% in 2012; that number was 33% in 1996. Ellen Hahn, a professor and director of the Kentucky Smoke Free Policy at the University of Kentucky, said while things have been moving slowly, in the last 10 years huge progress has been made in Kentucky.
"This state has a legacy of tobacco. It becomes a cycle from generation to generation," Hahn said. "But communities are taking action, we have 38 communities with smoke free laws."
Hahn said the Kentucky Center for Smoke Free-policy, provides support for communities that want to go smoke free. The center compiles reports on the air quality in communities before and after they introduce smoke-free policies.
Two years ago, Manchester County, passed a comprehensive smoke free work policy that banned smoking in bars, restaurants and work places.
"Places like Manchester are a ray of hope," Hahn said. "When small towns take bold steps and do the right thing it sends a bigger message to the county and the state."
Two bills were introduced this session that would pass a statewide ban on smoking in all public places and places of employment in Kentucky, Hahn says in the past few years similar bills have come and gone. In the meantime, she says she hopes smaller counties will continue to implement their own tobacco control policies and programs.
"In states with high legacies of smoking, we should look at what areas are making progress and define the ingredients for success – whether that's clean air legislation, advertising bans or taxation on cigarettes," Murray said. "Shifting the focus to what we know works in reducing smoking."