Claiming nearly half a million American lives annually, smоking is the leading cause of preventable death in the United States. Another 16 million Americans are living with a serious illness caused by smоking. Smоking 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.
Though the risks associated with smоking and tobacco use are well established and widely understood, 42.4 million American adults — or 16.6% of the adult population — regularly smоke сigarettes. In some parts of the country, smоking rates are far higher.
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 50 counties with the most smоkers. 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.
Smоking rates in the counties on this list range from 30.5% to nearly 45%. The majority of counties on this list are located in Southern states, including 11 in Kentucky alone.
Given the proven detrimental effects of smоking, it is perhaps not surprising that some important health outcome measures tend to be worse than average in metros with higher smоking rates. For example, in all 50 counties with the highest smоking rates, the share of adults who report being in fair or poor health is greater than the 16.5% share nationwide.
The correlation between smоking rates and life expectancy is also strong. In every metro area on this list with available data, average life expectancy at birth is below the 79.2 year national average.
Click here to see the counties with the most smоkers
Click here to read our detailed methodology
50. Elliott County, Kentucky
> Smoking rate: 30.5%
> Adults reporting poor or fair health: 30.6% — 88th highest of 3,106 counties
> Premature deaths per 100,000: 460.6 — 933rd highest of 3,081 counties
> Life expectancy at birth (years): 77.36 — 1,460th lowest of 3,073 counties
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49. Cocke County, Tennessee
> Smoking rate: 30.5%
> Adults reporting poor or fair health: 27.5% — 258th highest of 3,106 counties
> Premature deaths per 100,000: 640.1 — 103rd highest of 3,081 counties
> Life expectancy at birth (years): 71.50 — 73rd lowest of 3,073 counties
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48. Clay County, Tennessee
> Smoking rate: 30.6%
> Adults reporting poor or fair health: 28.5% — 181st highest of 3,106 counties
> Premature deaths per 100,000: 537.3 — 391st highest of 3,081 counties
> Life expectancy at birth (years): 74.55 — 455th lowest of 3,073 counties
47. Grundy County, Tennessee
> Smoking rate: 30.6%
> Adults reporting poor or fair health: 28.0% — 211th highest of 3,106 counties
> Premature deaths per 100,000: 611.7 — 135th highest of 3,081 counties
> Life expectancy at birth (years): 72.10 — 100th lowest of 3,073 counties
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46. Knox County, Kentucky
> Smoking rate: 30.7%
> Adults reporting poor or fair health: 32.7% — 49th highest of 3,106 counties
> Premature deaths per 100,000: 650.0 — 90th highest of 3,081 counties
> Life expectancy at birth (years): 72.41 — 125th lowest of 3,073 counties
45. Wayne County, Missouri
> Smoking rate: 30.7%
> Adults reporting poor or fair health: 26.9% — 319th highest of 3,106 counties
> Premature deaths per 100,000: 520.5 — 483rd highest of 3,081 counties
> Life expectancy at birth (years): 74.85 — 537th lowest of 3,073 counties
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44. Lincoln County, West Virginia
> Smoking rate: 30.7%
> Adults reporting poor or fair health: 29.7% — 121st highest of 3,106 counties
> Premature deaths per 100,000: 661.7 — 82nd highest of 3,081 counties
> Life expectancy at birth (years): 71.15 — 59th lowest of 3,073 counties
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43. Morgan County, Tennessee
> Smoking rate: 30.8%
> Adults reporting poor or fair health: 27.7% — 237th highest of 3,106 counties
> Premature deaths per 100,000: 532.2 — 421st highest of 3,081 counties
> Life expectancy at birth (years): 74.18 — 366th lowest of 3,073 counties
42. Hancock County, Tennessee
> Smoking rate: 30.8%
> Adults reporting poor or fair health: 27.7% — 233rd highest of 3,106 counties
> Premature deaths per 100,000: 682.1 — 66th highest of 3,081 counties
> Life expectancy at birth (years): 70.52 — 39th lowest of 3,073 counties
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41. Perry County, Tennessee
> Smoking rate: 30.8%
> Adults reporting poor or fair health: 28.9% — 159th highest of 3,106 counties
> Premature deaths per 100,000: 595.2 — 176th highest of 3,081 counties
> Life expectancy at birth (years): 73.32 — 214th lowest of 3,073 counties
40. Lake County, Tennessee
> Smoking rate: 30.9%
> Adults reporting poor or fair health: 30.4% — 97th highest of 3,106 counties
> Premature deaths per 100,000: 599.2 — 170th highest of 3,081 counties
> Life expectancy at birth (years): 72.39 — 124th lowest of 3,073 counties
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39. Dixie County, Florida
> Smoking rate: 30.9%
> Adults reporting poor or fair health: 27.4% — 271st highest of 3,106 counties
> Premature deaths per 100,000: 536.0 — 398th highest of 3,081 counties
> Life expectancy at birth (years): 75.36 — 707th lowest of 3,073 counties
38. Estill County, Kentucky
> Smoking rate: 30.9%
> Adults reporting poor or fair health: 30.7% — 86th highest of 3,106 counties
> Premature deaths per 100,000: 648.1 — 92nd highest of 3,081 counties
> Life expectancy at birth (years): 71.91 — 89th lowest of 3,073 counties
37. Webster County, West Virginia
> Smoking rate: 31.0%
> Adults reporting poor or fair health: 28.9% — 157th highest of 3,106 counties
> Premature deaths per 100,000: 547.5 — 344th highest of 3,081 counties
> Life expectancy at birth (years): 74.05 — 337th lowest of 3,073 counties
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36. Issaquena County, Mississippi
> Smoking rate: 31.1%
> Adults reporting poor or fair health: 37.4% — 8th highest of 3,106 counties
> Premature deaths per 100,000: 595.4 — 175th highest of 3,081 counties
> Life expectancy at birth (years): N/A
35. Vinton County, Ohio
> Smoking rate: 31.3%
> Adults reporting poor or fair health: 24.2% — 673rd highest of 3,106 counties
> Premature deaths per 100,000: 517.5 — 494th highest of 3,081 counties
> Life expectancy at birth (years): 74.53 — 450th lowest of 3,073 counties
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34. Roosevelt County, Montana
> Smoking rate: 31.3%
> Adults reporting poor or fair health: 25.4% — 510th highest of 3,106 counties
> Premature deaths per 100,000: 819.4 — 16th highest of 3,081 counties
> Life expectancy at birth (years): 67.67 — 10th lowest of 3,073 counties
33. Owsley County, Kentucky
> Smoking rate: 31.3%
> Adults reporting poor or fair health: 30.5% — 91st highest of 3,106 counties
> Premature deaths per 100,000: 806.6 — 18th highest of 3,081 counties
> Life expectancy at birth (years): 69.43 — 21st lowest of 3,073 counties
32. Jackson County, South Dakota
> Smoking rate: 31.3%
> Adults reporting poor or fair health: 28.5% — 178th highest of 3,106 counties
> Premature deaths per 100,000: 560.2 — 269th highest of 3,081 counties
> Life expectancy at birth (years): 73.26 — 206th lowest of 3,073 counties
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31. Breathitt County, Kentucky
> Smoking rate: 31.4%
> Adults reporting poor or fair health: 32.2% — 54th highest of 3,106 counties
> Premature deaths per 100,000: 760.8 — 23rd highest of 3,081 counties
> Life expectancy at birth (years): 69.62 — 23rd lowest of 3,073 counties
30. Clay County, West Virginia
> Smoking rate: 31.4%
> Adults reporting poor or fair health: 29.8% — 119th highest of 3,106 counties
> Premature deaths per 100,000: 572.4 — 232nd highest of 3,081 counties
> Life expectancy at birth (years): 72.73 — 148th lowest of 3,073 counties
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29. Dewey County, South Dakota
> Smoking rate: 31.8%
> Adults reporting poor or fair health: 27.3% — 280th highest of 3,106 counties
> Premature deaths per 100,000: 822.1 — 14th highest of 3,081 counties
> Life expectancy at birth (years): 68.09 — 12th lowest of 3,073 counties
28. Lee County, Kentucky
> Smoking rate: 31.8%
> Adults reporting poor or fair health: 33.4% — 41st highest of 3,106 counties
> Premature deaths per 100,000: 691.1 — 56th highest of 3,081 counties
> Life expectancy at birth (years): 71.27 — 61st lowest of 3,073 counties
27. Adair County, Oklahoma
> Smoking rate: 32.1%
> Adults reporting poor or fair health: 33.4% — 40th highest of 3,106 counties
> Premature deaths per 100,000: 600.7 — 166th highest of 3,081 counties
> Life expectancy at birth (years): 73.21 — 200th lowest of 3,073 counties
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26. Bennett County, South Dakota
> Smoking rate: 32.1%
> Adults reporting poor or fair health: 26.2% — 400th highest of 3,106 counties
> Premature deaths per 100,000: 755.6 — 27th highest of 3,081 counties
> Life expectancy at birth (years): 69.41 — 20th lowest of 3,073 counties
25. Harlan County, Kentucky
> Smoking rate: 32.3%
> Adults reporting poor or fair health: 34.6% — 32nd highest of 3,106 counties
> Premature deaths per 100,000: 732.3 — 33rd highest of 3,081 counties
> Life expectancy at birth (years): 70.47 — 37th lowest of 3,073 counties
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24. Tensas Parish, Louisiana
> Smoking rate: 32.4%
> Adults reporting poor or fair health: 36.0% — 18th highest of 3,106 counties
> Premature deaths per 100,000: 589.1 — 191st highest of 3,081 counties
> Life expectancy at birth (years): 75.69 — 818th lowest of 3,073 counties
23. Yukon-Koyukuk Census Area, Alaska
> Smoking rate: 32.5%
> Adults reporting poor or fair health: 27.5% — 255th highest of 3,106 counties
> Premature deaths per 100,000: 592.6 — 181st highest of 3,081 counties
> Life expectancy at birth (years): 71.98 — 92nd lowest of 3,073 counties
22. Benson County, North Dakota
> Smoking rate: 32.6%
> Adults reporting poor or fair health: 28.0% — 208th highest of 3,106 counties
> Premature deaths per 100,000: 660.2 — 83rd highest of 3,081 counties
> Life expectancy at birth (years): 72.23 — 112th lowest of 3,073 counties
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21. Bell County, Kentucky
> Smoking rate: 32.9%
> Adults reporting poor or fair health: 35.2% — 24th highest of 3,106 counties
> Premature deaths per 100,000: 695.1 — 53rd highest of 3,081 counties
> Life expectancy at birth (years): 71.50 — 74th lowest of 3,073 counties
20. Rolette County, North Dakota
> Smoking rate: 33.3%
> Adults reporting poor or fair health: 28.6% — 171st highest of 3,106 counties
> Premature deaths per 100,000: 608.3 — 149th highest of 3,081 counties
> Life expectancy at birth (years): 72.29 — 113th lowest of 3,073 counties
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19. McCreary County, Kentucky
> Smoking rate: 33.5%
> Adults reporting poor or fair health: 35.4% — 23rd highest of 3,106 counties
> Premature deaths per 100,000: 668.0 — 76th highest of 3,081 counties
> Life expectancy at birth (years): 71.87 — 83rd lowest of 3,073 counties
18. Mellette County, South Dakota
> Smoking rate: 33.5%
> Adults reporting poor or fair health: 29.8% — 118th highest of 3,106 counties
> Premature deaths per 100,000: 856.2 — 10th highest of 3,081 counties
> Life expectancy at birth (years): 66.97 — 4th lowest of 3,073 counties
17. Wolfe County, Kentucky
> Smoking rate: 33.6%
> Adults reporting poor or fair health: 34.6% — 30th highest of 3,106 counties
> Premature deaths per 100,000: 689.1 — 59th highest of 3,081 counties
> Life expectancy at birth (years): 70.30 — 34th lowest of 3,073 counties
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16. Clay County, Kentucky
> Smoking rate: 33.6%
> Adults reporting poor or fair health: 35.7% — 21st highest of 3,106 counties
> Premature deaths per 100,000: 697.8 — 51st highest of 3,081 counties
> Life expectancy at birth (years): 71.73 — 80th lowest of 3,073 counties
15. Menominee County, Wisconsin
> Smoking rate: 33.6%
> Adults reporting poor or fair health: 28.7% — 167th highest of 3,106 counties
> Premature deaths per 100,000: 732.7 — 32nd highest of 3,081 counties
> Life expectancy at birth (years): 71.55 — 76th lowest of 3,073 counties
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14. Glacier County, Montana
> Smoking rate: 33.6%
> Adults reporting poor or fair health: 27.2% — 297th highest of 3,106 counties
> Premature deaths per 100,000: 686.6 — 61st highest of 3,081 counties
> Life expectancy at birth (years): 70.94 — 52nd lowest of 3,073 counties
13. Ziebach County, South Dakota
> Smoking rate: 33.6%
> Adults reporting poor or fair health: 30.4% — 98th highest of 3,106 counties
> Premature deaths per 100,000: 449.0 — 1,043rd highest of 3,081 counties
> Life expectancy at birth (years): 76.90 — 1,281st lowest of 3,073 counties
12. Mingo County, West Virginia
> Smoking rate: 33.6%
> Adults reporting poor or fair health: 32.9% — 48th highest of 3,106 counties
> Premature deaths per 100,000: 720.3 — 36th highest of 3,081 counties
> Life expectancy at birth (years): 70.69 — 44th lowest of 3,073 counties
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11. Nome Census Area, Alaska
> Smoking rate: 33.8%
> Adults reporting poor or fair health: 28.0% — 210th highest of 3,106 counties
> Premature deaths per 100,000: 605.8 — 154th highest of 3,081 counties
> Life expectancy at birth (years): 70.49 — 38th lowest of 3,073 counties
10. Northwest Arctic Borough, Alaska
> Smoking rate: 34.2%
> Adults reporting poor or fair health: 29.6% — 124th highest of 3,106 counties
> Premature deaths per 100,000: 620.4 — 121st highest of 3,081 counties
> Life expectancy at birth (years): 71.11 — 56th lowest of 3,073 counties
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9. East Carroll Parish, Louisiana
> Smoking rate: 34.3%
> Adults reporting poor or fair health: 40.5% — 3rd highest of 3,106 counties
> Premature deaths per 100,000: 658.1 — 85th highest of 3,081 counties
> Life expectancy at birth (years): 72.08 — 98th lowest of 3,073 counties
8. McDowell County, West Virginia
> Smoking rate: 34.7%
> Adults reporting poor or fair health: 36.5% — 11th highest of 3,106 counties
> Premature deaths per 100,000: 841.4 — 12th highest of 3,081 counties
> Life expectancy at birth (years): 69.01 — 18th lowest of 3,073 counties
7. Corson County, South Dakota
> Smoking rate: 34.7%
> Adults reporting poor or fair health: 30.1% — 106th highest of 3,106 counties
> Premature deaths per 100,000: 945.4 — 4th highest of 3,081 counties
> Life expectancy at birth (years): 65.23 — 3rd lowest of 3,073 counties
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6. Bethel Census Area, Alaska
> Smoking rate: 35.0%
> Adults reporting poor or fair health: 32.3% — 53rd highest of 3,106 counties
> Premature deaths per 100,000: 556.8 — 288th highest of 3,081 counties
> Life expectancy at birth (years): 71.59 — 77th lowest of 3,073 counties
5. Sioux County, North Dakota
> Smoking rate: 36.2%
> Adults reporting poor or fair health: 33.9% — 38th highest of 3,106 counties
> Premature deaths per 100,000: 898.5 — 6th highest of 3,081 counties
> Life expectancy at birth (years): 68.46 — 15th lowest of 3,073 counties
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4. Buffalo County, South Dakota
> Smoking rate: 37.6%
> Adults reporting poor or fair health: 34.6% — 31st highest of 3,106 counties
> Premature deaths per 100,000: 963.5 — 3rd highest of 3,081 counties
> Life expectancy at birth (years): 64.54 — 2nd lowest of 3,073 counties
3. Todd County, South Dakota
> Smoking rate: 40.3%
> Adults reporting poor or fair health: 34.8% — 28th highest of 3,106 counties
> Premature deaths per 100,000: 813.8 — 17th highest of 3,081 counties
> Life expectancy at birth (years): 67.42 — 7th lowest of 3,073 counties
2. Oglala Lakota County, South Dakota
> Smoking rate: 40.9%
> Adults reporting poor or fair health: 34.9% — 26th highest of 3,106 counties
> Premature deaths per 100,000: 1,036.3 — 2nd highest of 3,081 counties
> Life expectancy at birth (years): 64.41 — the lowest of 3,073 counties
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1. Kusilvak Census Area, Alaska
> Smoking rate: 44.6%
> Adults reporting poor or fair health: 41.9% — the highest of 3,106 counties
> Premature deaths per 100,000: 678.7 — 68th highest of 3,081 counties
> Life expectancy at birth (years): 67.19 — 6th lowest of 3,073 counties
Methodology
To determine the counties with the most smokers, 24/7 Tempo reviewed the share of adults who are current smokers 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 smoking rates are from 2018.
Of the 3,220 counties or county equivalents, 3,142 had boundaries that fell within one of the 50 states or the District of Columbia. Counties with a 2019 five-year population estimate from the U.S. Census Bureau of less than 1,000 were excluded.
The remaining 3,106 places were ranked based on the adult smoking 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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