State preemption of local tobacco control policies restricting smoking, advertising, and youth access--United States, 2000-2010

Preemptive state tobacco control legislation prohibits localities from enacting tobacco control laws that are more stringent than state law. State preemption provisions can preclude any type of local tobacco control policy. The three broad types of state preemption tracked by CDC include preemption of local policies that restrict 1) smoking in workplaces and public places, 2) tobacco advertising, and 3) youth access to tobacco products. A Healthy People 2020 objective (TU-16) calls for eliminating state laws that preempt any type of local tobacco control law. A previous study reported that the number of states that preempt local smoking restrictions in one or more of three settings (government worksites, private-sector worksites, and restaurants) has decreased substantially in recent years. To measure progress toward achieving Healthy People 2020 objectives, this study expands on the previous analysis to track changes in state laws that preempt local advertising and youth access restrictions and to examine policy changes from December 31, 2000, to December 31, 2010. This new analysis found that, in contrast with the substantial progress achieved during the past decade in reducing the number of states that preempt local smoking restrictions, no progress has been made in reducing the number of states that preempt local advertising restrictions and youth access restrictions. Increased progress in removing state preemption provisions will be needed to achieve the relevant Healthy People 2020 objective.     

Mexico SimSmoke: how changes in tobacco control policies would impact smoking prevalence and smoking attributable deaths in Mexico

We examined the effect of tobacco control policies in Mexico on smoking prevalence and smoking-related deaths using the Mexico SimSmoke model. The model is based on the previously developed SimSmoke simulation model of tobacco control policy, and uses population size, smoking rates and tobacco control policy data for Mexico. It assesses, individually, and in combination, the effect of six tobacco control policies on smoking prevalence and smoking-related deaths. Policies included: cigarette excise taxes, smoke-free laws, anti-smoking public education campaigns, marketing restrictions, access to tobacco cessation treatments and enforcement against tobacco sales youth. The model estimates that, if Mexico were to adopt strong tobacco control policies compared to current policy levels, smoking prevalence could be reduced by 30% in the next decade and by 50% by 2053; an additional 470,000 smoking-related premature deaths could be averted over the next 40 years. The greatest impact on smoking and smoking-related deaths would be achieved by raising excise taxes on cigarettes from 55% to at least 70% of the retail price, followed by strong youth access enforcement and access to cessation treatments. Implementing tobacco control policies in Mexico could reduce smoking prevalence by 50%, and prevent 470,000 smoking-related deaths by 2053.     

Predictors of government officials' support for youth tobacco control policies.

Preventing youth access to tobacco products is a crucial public health goal. This study examines support by elected city and county officials in Colorado for enacting youth tobacco control policies in the State of Colorado. Participating city and county officials (n = 684) were surveyed regarding their attitudes and opinions on tobacco-related issues and policy control efforts. The officials surveyed were generally supportive of efforts to restrict youth access to tobacco. A number of predictors of support for youth tobacco control policies were identified, including official's perceptions of community norms, their political party, the presence of citizen anti-tobacco events, educational background of the officials, and their attitudes about tobacco. Recommendations for theory and citizen action are provided.     

Tobacco Policies in Louisiana: Recommendations for Future Tobacco Control Investment from SimSmoke,a Policy Simulation Model

Despite the presence of tobacco control policies, Louisiana continues to experience a high smoking burden and elevated smoking-attributable deaths. The SimSmoke model provides projections of these health outcomes in the face of existing and expanded (simulated) tobacco control polices. The SimSmoke model utilizes population data, smoking rates, and various tobacco control policy measures from Louisiana to predict smoking prevalence and smoking-attributable deaths. The model begins in 1993 and estimates are projected through 2054. The model is validated against existing Louisiana smoking prevalence data. The most powerful individual policy measure for reducing smoking prevalence is cigarette excise tax. However, a comprehensive cessation treatment policy is predicted to save the most lives. A combination of tobacco control policies provides the greatest reduction in smoking prevalence and smoking-attributable deaths. The existing Louisiana excise tax ranks as one of the lowest in the country and the legislature is against further increases. Alternative policy measures aimed at lowering prevalence and attributable deaths are: cessation treatments, comprehensive smoke-free policies, and limiting youth access. These three policies have a substantial effect on smoking prevalence and attributable deaths and are likely to encounter more favor in the Louisiana legislature than increasing the state excise tax.     

The role of public policies in reducing smoking prevalence in California: results from the California tobacco policy simulation model

Tobacco control policies are examined utilizing a simulation model for California, the state with the longest running comprehensive program. We assess the impact of the California Tobacco Control Program (CTCP) and surrounding price changes on smoking prevalence and smoking-attributable deaths. Modeling begins in 1988 and progresses chronologically to 2004, and considers four types of policies (taxes, mass media, clean air laws, and youth access policies) independently and as a package. The model is validated against existing smoking prevalence estimates. The difference in trends between predicted smoking rates from the model and other commonly used estimates of smoking prevalence for the overall period were generally small. The model also predicted some important changes in trend, which occurred with changes in policy. The California SimSmoke model estimates that tobacco control policies reduced smoking rates in California by an additional 25% relative to the level that they would have been if policies were kept at their 1988 level. By 2004, the model attributes 59% of the reduction to price increases, 28% of the overall effect to media policies, 11% to clean air laws, and only a small percent to youth access policies. The model estimates that over 5000 lives will be saved in the year 2010 alone as a result of the CTCP and industry-initiated price increases, and that over 50,000 lives were saved over the period 1988-2010. Tobacco control policies implemented as comprehensive tobacco control strategies have significantly impacted smoking rates. Further tax increases should lead to additional lives saved, and additional policies may result in further impacts on smoking rates, and consequently on smoking-attributable health outcomes in the population.     

Long-Term Effects of Laws Governing Youth Access to Tobacco

Objectives. We sought to examine the association between policies governing access to tobacco during adolescence and subsequent adult smoking.Methods. We analyzed adult smoking data from the 1998 through 2006–2007 administrations of the US Current Population Survey Tobacco Use Supplement by employing a quasi experimental approach. Participants (n = 105 519) were adults, aged 18 to 34 years at the time of the survey. Smoking outcomes included having ever smoked 100 cigarettes, smoking at the time of the survey, and having smoked 10 or more cigarettes a day conditioned on being an ever smoker. These were predicted from exposure to state youth access policies at age 17 years.Results. Four of the 9 policies exhibited significant associations with reduced prevalence of 1 or more smoking outcomes, primarily among women. Lesser effects for other policies could not be ruled out.Conclusions. Restrictions on youth access to tobacco might lead to reduction in smoking prevalence later in adulthood. The effect might be limited to women; we estimate that having all policies in place could be associated with a 14% reduction in lifetime smoking prevalence for women, and an additional 29% reduction in heavy smoking among ever smokers.Both opponents of smoking and purveyors of cigarettes have recognized the significance of adolescence as the period during which smoking behaviors are typically developed.1,2 Accordingly, initiatives to curb youth smoking were among the first federal policy restrictions placed on cigarette sales in the United States.3,4 Adoption of these initiatives was accelerated by passage of the 1992 Synar Amendment to the Federal Alcohol, Drug Abuse, and Mental Health Administration Reorganization Act, which mandated withholding federal block-grant money from states that failed to prohibit distribution of tobacco products to persons younger than 18 years, or failed to enforce such prohibitions. Various measures were implemented by individual states to increase retailer compliance with de jure purchase ages, such as restricting physical access to cigarette vending machines and banning the sale of single cigarettes.5,6Adaptation of these policies was partly motivated by community intervention studies suggesting that more uniform compliance with legal purchase age policies would reduce smoking rates among youths.7–11 Some postimplementation studies have suggested that youth access restrictions are effective at reducing smoking among adolescents,12–14 whereas other studies have cast doubt on their effectiveness.6,15–17 Furthermore, opponents argue that youth access policies could inadvertently glamorize smoking as a sophisticated adult behavior, thus reinforcing messages historically associated with tobacco advertising.18 Hence, some argue that youth access restrictions divert resources away from well-established and universally targeted tobacco control policies, such as clean indoor air policies, price increases, and media campaigns.16,19Youth access measures were not designed to merely delay smoking, but presumably to deter progression by delaying onset or reducing the intensity of smoking during adolescence. As such, reductions in smoking that persist into adulthood are the proper benchmarks by which these policies should be assessed. In the current study, we examined whether youths who face a restrictive policy environment are less likely to smoke as adults. We analyzed long-term associations between state youth access policies and subsequent adult smoking by taking advantage of state-by-state and year-by-year policy differences as states adopted various measures in response to the Synar Amendment. We expect that policies effective in mitigating youth smoking also influence subsequent adult smoking. It has been shown, for example, that exposure to stricter drinking age laws are associated with lower prevalence of alcohol problems in adulthood, but to our knowledge, parallel studies have not been conducted for tobacco policy.20–22 Hence, we examined whether policy encountered during adolescence is associated with smoking behaviors during adulthood. This hypothesis is consistent with contemporary neurobiological views of adolescence as a critical period for the development of addiction.23–25     

The role of public policies in reducing smoking and deaths caused by smoking in Vietnam: results from the Vietnam tobacco policy simulation model

A simulation model is developed for Vietnam to project smoking prevalence and associated premature mortality. The model examines independently and as a package the effects of five types of tobacco control policies: tax increases, clean air laws, mass media campaigns, advertising bans, and youth access policies. Predictions suggest that the largest reductions in smoking rates will result from implementing a comprehensive tobacco control policy package. Significant inroads may be achieved through tax increases. A media campaign along with programs to publicize and enforce clean air laws, advertising bans and youth access laws would further reduce smoking rates. Tobacco control policies have the potential to make large dents in smoking rates, which in turn could lead to many lives saved. In the absence of these measures, deaths from smoking will increase. The model also helps to identify information gaps pertinent both to modeling and policy-making.     

Kentucky legislators' views on tobacco policy.

CONTEXT: Kentucky leads the nation in adult and teen smoking prevalence. Even though Kentucky is one of the most tobacco-dependent states, tobacco policy is subject to change in light of possible national tobacco legislation. OBJECTIVE: To describe the degree of agreement among Kentucky legislators regarding tobacco control and tobacco farming policy, and to discover whether use of the policy Delphi method produces a shift toward consensus on tobacco policy. DESIGN: A two-round policy Delphi study was conducted using in-person interviews. SETTING: Legislators' offices in Frankfort, Kentucky. PARTICIPANTS: Volunteer sample of 116 Kentucky legislators (84% response rate). MAIN OUTCOME MEASURES: Degree of agreement on tobacco control and tobacco farming policies. RESULTS: Lawmakers were highly supportive of policies to lessen the state's dependence on tobacco, and were favorable toward stronger tobacco control policies. There were discrepancies, however, between what policies legislators thought were desirable and what policies were realistic. Tobacco interests were identified as possible explanations for this disparity. Tobacco allotment ownership was associated with less support for tobacco control and tobacco farming policies. A shift toward consensus on tobacco policy was achieved in the second round for 45% of the interview items common to both rounds. CONCLUSIONS: Kentucky legislators were highly supportive of reducing the state's dependence on tobacco and more supportive of tobacco control policies than expected. The policy Delphi method has the potential for shifting opinions about tobacco policies among state legislators. The findings of this study identify opportunities for public health policy change in one of the most tobacco-dependent states in the United States.     

The role of public policies in reducing smoking prevalence and deaths caused by smoking in Arizona: results from the Arizona tobacco policy simulation model.

Arizona was one of the first few states to implement a comprehensive tobacco control program. The effect of that program is examined using a computer-simulation model (SimSmoke) developed for the purposes of evaluation, planning, and justifying policies. This approach assesses the impact to date of tobacco control policies on smoking prevalence and generates predictions about the effects of tobacco control policies on past and future smoking prevalence and associated future premature mortality. SimSmoke estimates indicate that tobacco control policies reduced smoking rates in Arizona by about 20 percent over the period 1993-2002. A previous CDC study obtains similar effects, but does not net out the effects of individual policies. SimSmoke attributes much of the reduction, about 61 percent, to price increases and attributes 38 percent of the overall effect to media policies, leaving only a small percentage of the smoking reductions attributed to quitlines, youth access policies, and the weak clean air laws. Tobacco control policies implemented as comprehensive strategies have significantly affected smoking rates in Arizona, which leads to large reductions in deaths attributable to smoking. It will be important to maintain these efforts over time to reduce or keep smoking prevalence down and to minimize smoking-attributable deaths.     

State laws on tobacco control--United States, 1998.

PROBLEM/CONDITION: State laws addressing tobacco use, the leading preventable cause of death in the United States, are summarized. Laws address smoke-free indoor air, minors' access to tobacco products, advertising of tobacco products, and excise taxes on tobacco products. REPORTING PERIOD COVERED: Legislation effective through December 31, 1998. DESCRIPTION OF SYSTEM: CDC identified laws addressing tobacco control by using an on-line legal research database. CDC's findings were verified with the National Cancer Institute's State Cancer Legislative Database. RESULTS: Since a previous surveillance summary on state tobacco-control laws published in November 1995 (covering legislation effective through June 30, 1995), several states have enacted new restrictions or strengthened existing legislation that addresses smoke-free indoor air, minors' access to tobacco, tobacco advertising, and tobacco taxes. Five states strengthened their smoke-free indoor air legislation. All states and Washington, D.C., continued to prohibit the sale and distribution of tobacco products to minors; however, 21 states expanded minors' access laws by designating enforcement authorities, adding license suspension or revocation for sale to minors, or requiring signage. Since the 1995 report, eight additional states (a total of 19 states and Washington, D.C.) now ban vending machines from areas accessible to minors. Thirteen states restrict advertising of tobacco products, an increase of four states since the 1995 report. Although the number of states that tax cigarettes and smokeless tobacco did not change, 13 states increased excise taxes on cigarettes, and five states increased excise taxes on smokeless tobacco products. The average state excise tax on cigarettes is 38.9 cents per pack, an increase of 7.4 cents compared with the average tax in the 1995 report. INTERPRETATION: State laws addressing tobacco control vary in relation to restrictiveness, enforcement and penalties, preemptions, and exceptions. ACTIONS TAKEN: The data summarizing state tobacco-control laws are available through CDC's State Tobacco Activities Tracking and Evaluation (STATE) System; the laws are collected and updated every quarter. The STATE System also contains state-specific data on the prevalence of tobacco use, tobacco-related deaths, and the costs of tobacco use. Information from the STATE System is available for use by policy makers at the state and local levels to plan and implement initiatives to prevent and reduce tobacco use. In addition, CDC is using this information to assess the ongoing impact of tobacco-control programs and policies on tobacco use.     

Italy SimSmoke: the effect of tobacco control policies on smoking prevalence and smoking attributable deaths in Italy

ABSTRACT: BACKGROUND: While Italy has implemented some tobacco control policies over the last few decades, which resulted in a decreased smoking prevalence, there is still considerable scope to strengthen tobacco control policies consistent with the World Health Organization (WHO) policy guidelines. The present study aims to evaluate the effect of past and project the effect of future tobacco control policies on smoking prevalence and associated premature mortality in Italy. METHODS: To assess, individually and in combination, the effect of seven types of policies, we used the SimSmoke simulation model of tobacco control policy. The model uses population, smoking rates and tobacco control policy data for Italy. RESULTS: Significant inroads to reducing smoking prevalence and premature mortality can be achieved through tobacco price increases, high intensity media campaigns, comprehensive cessation treatment program, strong health warnings, stricter smoke-free air regulations and advertising bans, and youth access laws. With a comprehensive approach, the smoking prevalence can be decreased by as much as 12 % soon after the policies are in place, increasing to a 30 % reduction in the next twenty years and a 34 % reduction by 30 years in 2040. Without effective tobacco control policies, a total of almost 300 thousand lives will be prematurely lost due to smoking by the year 2040. CONCLUSION: Besides presenting the benefits of a comprehensive tobacco control strategy, the model helps identify information gaps in surveillance and evaluation schemes that will promote the effectiveness of future tobacco control policy in Italy.     

State tobacco control spending and youth smoking

OBJECTIVE: We examined the relationship between state-level tobacco control expenditures and youth smoking prevalence and cigarette consumption. METHODS: We estimated a 2-part model of cigarette demand using data from the 1991 through 2000 nationally representative surveys of 8th-, 10th-, and 12th-grade students as part of the Monitoring the Future project. RESULTS: We found that real per capita expenditures on tobacco control had a negative and significant impact on youth smoking prevalence and on the average number of cigarettes smoked by smokers. CONCLUSIONS: Had states represented by the Monitoring the Future sample and the District of Columbia spent the minimum amount of money recommended by the Centers for Disease Control and Prevention, the prevalence of smoking among youths would have been between 3.3% and 13.5% lower than the rate we observed over this period.     

State-level tobacco control policies and youth smoking cessation measures

ObjectiveResearch on the effects of state-level tobacco control policies targeted at youth has been mixed, with little on the effects of these policies and youth smoking cessation. This study explored the association between state-level tobacco control policies and youth smoking cessation behaviors from 1991 to 2006.MethodsThe study design was a population-based, nested survey of students within states. Study participants were 8th, 10th, and 12th graders who reported smoking “regularly in the past” or “regularly now” from the Monitoring the Future study. Main cessation outcome measures were: any quit attempt; want to quit; non-continuation of smoking; and discontinuation of smoking.ResultsResults showed that cigarette price was positively associated with a majority of cessation-related measures among high school smokers. Strength of sales to minors’ laws was also associated with adolescent non-continuation of smoking among 10th and 12th graders.ConclusionsFindings suggest that increasing cigarette price can encourage cessation-related behaviors among high school smokers. Evidence-based policy, such as tax increases on tobacco products, should be included as an important part of comprehensive tobacco control policy, which can have a positive effect on decreasing smoking prevalence and increasing smoking cessation among youth.     

The role of public policies in reducing smoking prevalence and deaths: the Argentina Tobacco Policy Simulation Model.

OBJECTIVES: To compare tobacco control policies independently and as a package through a simulation model to project smoking prevalence and associated future premature mortality in Argentina beginning in 2001. METHODS: A simulation model of tobacco control policies known as SimSmoke was modified using data for Argentina on population, fertility and mortality, smoking prevalence, and tobacco control policies in effect between 2001 and 2004. We used the Argentina Tobacco Policy Simulation model (ATPSM) to consider the effect on smoking prevalence of changes in taxes and prices, clean air laws, media campaigns, cessation programs, and youth access policies on smoking initiation and cessation rates. Smoking prevalence and relative risks of smoking were used to estimate smoking-attributable mortality. The ATPSM was used to project smoking prevalence and smoking-attributable deaths during the period 2001-2034. RESULTS: The largest reductions in smoking prevalence and premature mortality were predicted for a comprehensive tobacco control policy package, but relative reductions of as much as 30% were also predicted for large tax increases. Adding a media campaign along with programs to publicize and enforce clean air laws, advertising bans, and youth access laws would further reduce smoking rates by up to 45% by the year 2034, and would save almost 16 000 lives per year. CONCLUSIONS: Tobacco control policies can substantially reduce smoking rates, which can save many lives. Without such policies, deaths from smoking, and associated medical costs, will increase. The ATPSM is expected to provide guidance in filling the most important information gaps pertinent to both modeling and policy-making in Argentina, e.g., the lack of data on initiation and cessation rates, and the need for studies on the impact of policies. Similar models might be developed for other Latin American countries.     

The effects of community policies to reduce youth access to tobacco.

OBJECTIVES: This study tested the hypothesis that adoption and implementation of local policies regarding youth access to tobacco can affect adolescent smoking. METHODS: A randomized community trial was conducted in 14 Minnesota communities. Seven intervention communities participated in a 32-month community-organizing effort to mobilize citizens and activate the community. The goal was to change ordinances, merchant policies and practices, and enforcement practices to reduce youth access to tobacco. Outcome measures were derived from surveys of students before and after the intervention and from tobacco purchase attempts in all retail outlets in the communities. Data analyses used mixed-model regression to account for the clustering within communities and to adjust for covariates. RESULTS: Each intervention community passed a comprehensive youth access ordinance. Intervention communities showed less pronounced increases in adolescent daily smoking relative to control communities. Tobacco purchase success declined somewhat more in intervention than control communities during the study period, but this difference was not statistically significant. CONCLUSIONS: This study provides compelling evidence that policies designed to reduce youth access to tobacco can have a significant effect on adolescent smoking rates.     

Local tobacco policy and tobacco outlet density: associations with youth smoking

PurposeThis study investigates the associations between local tobacco policy, tobacco outlet density, and youth smoking. A primary focus is on whether local tobacco policy moderates the relation between outlet density and youth smoking.MethodsIn all, 1,491 youth (51.9% male, mean age = 14.7 years, standard deviation = 1.05) in 50 midsized California cities were surveyed through a computer-assisted telephone interview. Measures of local clean air policy and youth access policy were created based on a review of tobacco policies in these cities. Outlet density was calculated as the number of retail tobacco outlets per 10,000 persons, and city characteristics were obtained from 2000 U.S. Census data.ResultsUsing multilevel regression analyses and controlling for city characteristics, tobacco outlet density was positively associated with youth smoking. No significant main effects were found for the two tobacco policy types on any of the smoking outcomes after controlling for interactions and covariates. However, statistically significant interactions were found between local clean air policy and tobacco outlet density for ever smoked and past 12-month cigarette smoking. Comparisons of simple slopes indicated that the positive associations between tobacco outlet density and youth smoking behaviors were stronger at the lowest level of local clean air policy compared with the moderate and high levels.ConclusionsOur results suggest that tobacco outlet density is related to youth smoking. In addition, local clean air policy may act as a moderator of relationship between tobacco outlet density and youth smoking, such that density is less important at moderate and high levels of this tobacco policy.     

Youth tobacco access restrictions: Time to shift resources to other interventions?

There is limited data to guide policy makers as to whether youth tobacco access restriction is an effective strategy. Analysis of the limited data on youth access restriction suggests that (a) scalable models for access restriction are lacking, (b) enforcement of access restriction would be cost prohibitive, (c) the leaky commercial supply of cigarettes combined with the capacity of youth to tap into a "social supply" of cigarettes would hamper all but the most rigorously enforced efforts to restrict access to tobacco, and (d) access restriction may paradoxically increase allure of cigarettes for some youth. Although youth tobacco access restriction does not face strong political or industry opposition, the authors' analysis reveals that youth tobacco access restriction is likely to remain a failed strategy to control tobacco use in the United States.     

Peer influences and access to cigarettes as correlates of adolescent smoking: a cross-cultural comparison of Wuhan, China, and California

BACKGROUND: Few studies have assessed the effects of access to cigarettes and peer influences on adolescent smoking in non-Western countries. Using samples characterized by two distinct cultural, social, and economic systems, this study evaluated the associations of friends' smoking and perceived access to cigarettes with adolescent smoking behavior in California and Wuhan, China. METHODS: Survey data were obtained from 5870 eighth-grade students in the Independent Evaluation of the California Tobacco Control Program and 6992 seventh- to ninth-grade students in the Wuhan Smoking Prevention Trial. Odds ratios for lifetime and 30-day smoking, according to friends' smoking and perceived access to cigarettes, were calculated for boys and girls in both samples and compared. RESULTS: California students were more likely than Wuhan students to have friends who smoked and to perceive easy access to cigarettes. The smoking prevalence was lower in Wuhan than in California, mainly due to the low smoking prevalence among Wuhan girls. Friends' smoking was strongly associated with smoking in both samples, and the strength of this association did not differ between the two cultures. Access to cigarettes was associated with a higher risk of lifetime smoking in both cultures and a higher risk of past 30-day smoking in California only. CONCLUSIONS: Despite divergent tobacco control policy enforcement, social structures, and cultural contexts, similarities exist between Wuhan and California. The findings suggest support for adapting a social-influences-based smoking prevention program developed in the United States to the culturally specific needs of youth in Wuhan, China.     

Restricting minors' access to tobacco: a review of state legislation, 1991.

Currently, 46 states and the District of Columbia prohibit the sale of tobacco products to minors, and the minimum age requirement differs by state. In general, these laws are poorly enforced and inadequately prevent youth from obtaining tobacco. According to a four-part classification scheme used in this article, no states have comprehensive laws banning access to tobacco, four states have moderate laws, 37 states and the District of Columbia have basic laws, five states have nominal laws, and the remaining four states have no regulations. We recommend 11 important elements for laws that would adequately restrict minors' access to tobacco products.     

State-specific trends in lung cancer incidence and smoking--United States, 1999-2008

Lung cancer is the most commonly diagnosed cancer and the leading cause of cancer death in the United States. Most deaths from lung cancer are caused by cigarette smoking and exposure to secondhand smoke. Large variations in lung cancer, smoking behavior, and tobacco control programs and policies have been observed among states. Effective tobacco control policies can decrease smoking prevalence, ultimately leading to decreases in lung cancer. To assess lung cancer incidence by state, CDC analyzed data from the National Program of Cancer Registries (NPCR) and the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) program for the period 1999-2008. To assess smoking behavior by state, data from the Behavioral Risk Factor Surveillance System (BRFSS) for the period 1994-2009 were analyzed. This report summarizes the results of these analyses. From 1999 to 2008, decreases in lung cancer incidence were observed among men in 35 states and among women in six states. Regionally, the lowest rates and most rapid rate of decline in lung cancer were concentrated among states in the West, correlating with low smoking prevalence and high ratios of former smokers to ever smokers. Further reductions in smoking prevalence are critical to continue the decline in lung cancer incidence.