The tobacco industry spends $23 million a day advertising its products.

Tobacco now kills 480,000 Americans a year, with another 16 million living with diseases caused by tobacco.

Those numbers are no surprise to Thomas Carr, director of national policy for the American Lung Association (ALA).

Nor is the fact that a lot of that industry money pays for advertising to young people.

The ALA makes keeping children from using tobacco a top priority, but it’s an uphill battle.

It’s not just cigarettes.

The tobacco industry is creative in introducing new products like e-cigarettes.

That is the climate in which the ALA released the results of its 15th annual State of Tobacco Control report today.

The report evaluates key tobacco control policies at the federal and state levels. Grades are assigned based on how well laws and policies protect residents from death and disease caused by tobacco.

The report is not light reading.

It is lengthy and detailed, showing what the federal government, and each state and municipality is doing to eliminate or reduce tobacco use.

The report also covers trends, including which communities are doing better and which are falling behind.

Read more: Does plain packaging on tobacco products work? »

Keeping an eye on legislation

Carr keeps an eye on what is happening in the halls of Congress each year as well as the executive branch.

A program the association was backing may find more, or less, support depending on who chairs the relevant committee or how the rules of enforcement are written.

One of the issues closest to his heart is getting the legal age for smoking raised to 21, as was done last year in California.

“We’ve seen a lot of bills [on this issue] in state legislatures,” Carr told Healthline. “It’s an issue we’ve been pushing.”

He explains it as a simple matter of math. If you increase the age to 21, 223,000 premature deaths can be prevented.

The largest effect can be seen in the number of 15- to 17-year-olds taking up the habit. The reason, according to Carr, is that those teens usually get their cigarettes or other tobacco products from older teens, who would no longer have easy access themselves.

Marketing starts in childhood, he said.

“Cigarettes are as addictive as heroin,” he said.

In addition to a higher legal smoking age, Carr would like to see that basic services, such as counseling and workshops on quitting, are available to everyone.

Some health plans offer such coverage. Others don’t.

Looking ahead, Carr said, they don’t know what is going to happen with the change of administrations in Washington.

“We’re eager for housing rules preventing smoking in all public housing,” he said.

Carr noted that some places have implemented such a policy with voluntary compliance.

“Evictions are rare,” he said.

It’s an important policy to protect people exposed to secondhand smoke, especially children.

Carr said there are 760,000 children in public housing. Smoke seeping through the walls and outlets could make them sick.

“It’s a more popular policy than you would think,” Carr said. “It’s the number one complaint the lung association gets, about smoke in housing.”

Read more: No more smoking in public housing »

Grades and laws

California got mixed reviews in the report.

The state was graded as follows: smoke-free air, A; tobacco taxes, B; and access to cessation services, F.

Vanessa Marvin, vice president of public policy and advocacy for the ALA in California, emphasized the need for improvement at the local level.

“Last year a lot was accomplished in the [state] legislature,” she told Healthline.

California recaptured some of its national leadership in fighting tobacco use following the successful passage of laws and the approval of Proposition 56 in November. That measure will increase the state’s cigarette tax by $2 per pack as well as increase other tobacco product taxes.

In 2016, California also increased its minimum age of sale for tobacco products to 21 as well as passed a comprehensive quit-smoking benefit for Medicaid recipients.

The state also closed loopholes and added e-cigarettes to its smoke-free workplace law.

As a result of Prop. 56, the state will also significantly increase funding for its tobacco prevention and cessation program.

While pleased with this progress, Marvin noted that some communities were left behind.

“Big Tobacco gives a lot of money to legislators,” she said. “We have trouble getting bills through the legislature.”

This year she’s hoping for more action by local leadership. “More than 50 percent of the population doesn’t have protection from tobacco,” she said.

The picture is also mixed across the nation.

Raising the minimum age of sale for all tobacco products to 21 emerged in 2016 as an effective strategy to keep kids from using tobacco products.

In 2015, Hawaii became the first state in the nation to pass that law. Many other states considered Tobacco 21 laws in 2016. In addition to California, the District of Columbia also passed that law.

Taxes were another hot issue.

The year 2016 marked the return of states using the ballot to increase tobacco taxes. Not since 2006 had there been as many tobacco tax initiatives on the ballot. Only California’s was approved by voters, however.

Funding for state tobacco prevention and cessation, or quit-smoking programs for 2017 generally remained consistent with 2016.

There were notable exceptions.

Connecticut provided no new state funding for tobacco prevention and cessation programs for 2017. It joins New Jersey as one of only two states that provide no state funding to combat tobacco use.

Tennessee cut funding for tobacco prevention programs by several million dollars.

Louisiana, Pennsylvania, and West Virginia passed cigarette tax increases through their state legislatures in 2016, but only in Pennsylvania ($1 per pack increase) and West Virginia (65 cents per pack increase) were the increases significant enough to affect smoking rates.

Louisiana’s cigarette tax increased by 22 cents per pack.

In 2016, California joined Pennsylvania and West Virginia in establishing new taxes on e-cigarettes or the liquid used in them. Five other states and the District of Columbia already have established taxes on these products.

California, along with Maine, Missouri, North Dakota, and Ohio, has implemented policies to offer a comprehensive tobacco cessation benefit to all Medicaid enrollees. Missouri became the first state Medicaid program to have no barriers to accessing cessation coverage.

So far, no state has passed a comprehensive statewide smoke-free law, but some progress continued at the local level. California also became the first state to close loopholes in its existing smoke-free law and add e-cigarettes to the law.

Vermont and the District of Columbia passed legislation in 2016 adding e-cigarettes to their smoke-free laws. Nine states with comprehensive smoke-free laws as well as the District of Columbia now prohibit the use of e-cigarettes in all public places and workplaces.

Read more: What happens when you quit smoking? »