The highest cigarette smoking rates are found in a swath of states from the Midwest to the Deep South.

Average smoking rates in the United States have been dropping for decades — since the mid-1960s for adults and since the late 1990s for students.

But like many things related to health in the United States, efforts to reduce smoking rates have bypassed a large number of people.

In particular, adults in 12 contiguous states from the Midwest to the Deep South continue to smoke in large numbers — 22 percent on average compared to 15 percent in the rest of the country.

This high concentration of smokers is referred to as “Tobacco Nation” in a new report by the anti-smoking group Truth Initiative.

The tobacco states are Alabama, Arkansas, Indiana, Kentucky, Louisiana, Michigan, Mississippi, Missouri, Ohio, Oklahoma, Tennessee, and West Virginia.

The lack of progress in reducing smoking in the 12-state region is reflected in higher rates of lung and other cancers, as well as heart disease and chronic lower respiratory diseases.

Experts said that some of these states may have more people at risk for smoking.

But a lack of strong tobacco control laws and programs have also allowed smoking rates to remain high for decades.

Over the past few decades, public health efforts have had a dramatic effect on overall smoking rates in the country but not for all groups.

“Smoking is increasingly concentrated in individuals with lower income, with less education, or with higher rates of mental illness. So that could be, in part, the reason why we see the higher prevalence of smoking in [Tobacco Nation] states,” said Peter Hendricks, PhD, a clinical psychologist at the University of Alabama School of Public Health.

Truth Initiative reported that the average income for people living in the 12-state region is $45,133, compared to $56,852 for the rest of the country.

Also, only 22 percent of Tobacco Nation residents have at least a college degree, compared to 28 percent in the other 38 states.

The link to mental illness is a bit more complicated.

Several of the Tobacco Nation states — including Alabama, Arkansas, Indiana, Louisiana, Mississippi, and West Virginia — were ranked poorly for mental health by Mental Health America.

But several states outside this region also have poorer rankings, which is based on rates of mental illness and access to care.

Several of the Tobacco Nation states are also top tobacco growers, including Indiana, Kentucky, Ohio, and Tennessee, according to the Campaign for Tobacco-Free Kids.

This might have some influence on residents’ attitudes about tobacco.

But other major tobacco-growing states — such as North Carolina and Virginia — have lower rates of smoking.

In Ohio, which only grows a small amount of tobacco, smoking rates are high across the state, but it also has a problem with other types of tobacco.

“There are certainly parts of Ohio where smokeless tobacco use is a lot higher than it is in other parts of the state and in other parts of the country. Some of that is just because that’s been part of the culture there for a long time,” Micah Berman, JD, associate professor of health services management and policy at the Ohio State University College of Public Health and Moritz College of Law, told Healthline.

In many Tobacco Nation states, high smoking rates may go hand-in-hand with other health problems.

“Alabama and many states in the Deep South rank poorly in a number of public health indices,” Hendricks told Healthline. “Tobacco is not our only problem. We also struggle with obesity and childhood obesity.”

According to the CDC, Alabama, Arkansas, Louisiana, Mississippi, and West Virginia have adult obesity rates over 35 percent — the highest in the nation.

The Truth Initiative report also showed that the 12-state region spends less on public health — $81 per person on average, compared to $98 per person in the rest of the country.

Berman said that in Ohio, “Tobacco is one of several public health problems. It is a failure to invest not only in tobacco control but also in other public health and prevention issues.”

He added that the recent recession has made it more difficult.

Legislators faced with tight budgets are less likely to fund health initiatives that — although they’ll make people healthier — won’t save the state money for decades.

Experts say that in spite of these demographic factors, there are concrete steps that states can take to reduce smoking rates among adults and teens.

“In states with assertive smoking control policies, smoking rates are going to be lower,” said Hendricks. “Of course, that’s not the only factor, but I think it is a very strong one.”

Berman said that there’s a “pretty clear path” for states to follow, such as “adopting smoke-free laws, increasing the price of tobacco products, and providing adequate funding for tobacco control efforts.”

In Tobacco Nation states, a pack of cigarettes is 19 percent cheaper than in the rest of the country — $5.48 compared to $6.72.

The CDC reported that in Alabama, the tax on a pack of cigarettes is $0.675. In Ohio, it’s $1.60.

Compare this to New York, which has a tax of $4.35, or California, where the tax is $2.87.

California’s adult smoking rate is 11 percent and New York’s is 14 percent, according to the CDC.

Tobacco Nation states also have far less restrictive smoke-free laws than the rest of the country.

Only two of these states — Michigan and Ohio — have laws forbidding smoking in workplaces, restaurants, and bars.

But Ohio has seen some backsliding since the law was passed in 2006.

“A lot of legislators thought that passing the law meant they had taken care of the issue. After that, they pulled funding for Ohio’s tobacco control program, which had been one of the national leaders,” said Berman. “Since then, we’ve seen tobacco rates go back up.”

When asked if Alabama is heading in the right direction with its efforts to reduce smoking in the state, Hendricks said that “at the state government level, I don’t see any evidence. But there are some encouraging developments at the local level.”

He pointed to UAB Medicine’s tobacco-free hiring policy.

Potential employees are tested for nicotine use as part of their preemployment drug screening. If they test positive for nicotine, they won’t be hired.

While some people think this kind of testing is overly intrusive, current tobacco control policies are still falling short.

Even in Utah, which has the lowest smoking rate in the country, more than 8 percent of the population smokes cigarettes.

“We’re still losing half a million lives in this country to tobacco every year,” said Hendricks. “So at some point, you have to ratchet up your interventions — and sometimes that means moving toward interventions that might appear to be coercive.”

In Ohio, there’s good news from Columbus, which recently raised the legal age of buying tobacco products from 18 to 21 — part of a Tobacco 21 movement that is popping up around the country.

This is likely to have a big impact on the city, especially with tens of thousands of young people attending The Ohio State University.

“That just went into effect, so we will see how well it goes,” said Berman. “But I think that’s a promising development.”

While the Truth Initiative singled out 12 states for their high smoking rates, there are pockets of smoking around the country.

According to 24/7 Wall St., the smokiest cities include Fort Smith, Arkansas-Oklahoma; Lafayette, Louisiana; Erie, Pennsylvania; and Kingsport-Bristol-Bristol, Tennessee-Virginia — all with smoking rates higher than 28 percent.

But as Columbus shows, local efforts can move forward even while the state efforts continue to drag.