Rural Missouri has high smoking rates — and the health problems that follow

Families flock to McDonald County in southwest Missouri each summer to float down the Elk River, visit the caves where Jesse James took refuge and stay in a rustic cabin.

The county is a vestige of old, wild Missouri charm — and a place where restaurants and bars still ask, “Smoking or non?”

People in McDonald County, like those in other rural places across Missouri and the country, smoke more. The U.S. Centers for Disease Control and Prevention says smoking runs even higher in rural Missouri than in rural America as a whole.

Groups that research and advocate for decreasing tobacco consumption connect that to Missouri’s cigarette taxes, the lowest in the country, and relatively weak rules backing smoke-free public places.

Some rural communities across the state, including McDonald County, are enacting their own smoke-free ordinances and in-restaurant policies to improve health outcomes and fall in rhythm with their urban neighbors.

“We want more people staying here, living here, coming here (for) tourism –– we just want to keep people coming back to McDonald County,” said Kayla Langford, the assistant director at the health department.

Chronic lower respiratory diseases are the third highest cause of death in the state and run more than 20% higher in rural areas, according to data from Missouri Department of Health and Senior Services. The report attributes the deaths, in part, to high smoking rates.

Experts say some policies have strong records in lowering smoking rates.

“One of the exciting things about tobacco prevention is it’s actually a solvable problem,” said Nicole Sinderman, who leads the state’s Tobacco Prevention and Control Program. “There are evidence-based solutions that have been proven to work.”

The Missouri Department of Health and Senior Services, or DHSS, program works on four main platforms: media campaigns, creating smoke-free places, increasing access to cessation services and raising tobacco taxes.

Missouri taxes cigarettes at 17 cents a pack. Advocates for tobacco prevention want to add $1. Top tobacco-reduction organizations predict that would cut the number of people under 18 who smoke by almost 8% and trim the total number who smoke by at least 4%.

The same advocates also want to double the tax on other tobacco products like vapes, chew and dip.

The Missouri tobacco law’s preemption clause bars cities and counties from adding local surcharges.

Voters have rejected five different versions of tobacco tax increases since 2002. The issue is not on the November ballot, though several unsuccessful initiative petitions were circulated this year.

Tobacco sales make up a significant portion of business for convenience stores and grocery stores.

Ronald Leone, executive director of Missouri Petroleum & Convenience Association (MPCA), said Missouri’s low cigarette tax gives businesses a competitive advantage.

“It draws customers from our higher taxed border states who spend their money in Missouri on gasoline, tobacco, and other goods,” Leone said in an email statement.

MPCA sponsored a tobacco tax increase, Proposition A, in 2016 to counter a much higher tax increase proposal, Amendment 3. Ultimately, neither passed.

A U.S. Department of Health and Human Services study found that increasing tobacco prices by 20% would reduce consumption by 10% and reduce the number of young people who start smoking by 8%.

In the past two years, Missouri has significantly increased its allocation to tobacco prevention programs, though it still sits as one of 19 states that spend less than 10% of what the CDC recommends, according to Campaign for Tobacco-Free Kids.

Missouri DHSS runs several of these programs and partners with local health departments to give people the resources and incentives to quit.

Some programs offer counseling and nicotine replacement therapy. Others work with pregnant mothers and give them incentives for quitting, like gift cards for diapers and wipes. Missourians who want to quit can also call 1-800-QUIT-NOW (1-800-784-8669) or text the helpline (“start my quit” to 36072).

Langford and her co-coordinator Tina Hang started a tobacco cessation program at the McDonald County Health Department.

“We’re still adapting our policies to see what would work best for the health department,” Hang said. “But for the most part, it’s going pretty well.”

The program is free to McDonald County residents. When they come into the department, Hang assesses their willingness to quit and the best methods for them. Then she offers them counseling and nicotine lozenges, gum or patches. 

The county’s anti-smoking campaign sprang from a Building Communities for Better Health state grant to reduce preventable causes of chronic diseases.

Langford said her county ranks particularly high in physical inactivity and tobacco use, so they focused the grant money on building walking and biking trails and implementing smoke-free air policies.

“Biking and active transportation go hand in hand with tobacco, because most people who are wanting to use these facilities want it to be a clean environment,” Langford said.

The department started the initiative in the county seat, Pineville.

Melissa Ziemianin, Pineville’s city clerk, helped with the ordinance, which passed without pushback. It has been effective in reducing cigarette and vape use and the associated litter in city parks.

“We thought that if we could take out smoking in our parks and in our areas where kids were seeing it, … maybe then it would make that change where kids didn’t think it was OK,” Ziemianin said. “Maybe in the long run, we would see (children) not want to pick up cigarettes.”

Sinderman said smoke-free air policies are the basis of tobacco prevention, and rural communities across the state are taking similar actions.

“It’s not really a coincidence that in a lot of the counties where use is high, there are no smoke-free policies,” Sinderman said. “Smoking remains a social norm in rural communities, and I think part of it is the lack of smoke-free policies.”

Missouri laws currently prohibit smoking in child care facilities and require restrictions in schools, government buildings, health care facilities and restaurants, according to the American Lung Association.

Bars, private workplaces, bowling alleys and casinos have exemptions. Sinderman said that exposes more people to secondhand smoke.

All casino workers in Missouri live without smoke-free protection laws, according to a Bridging the Gapreport by American Nonsmokers’ Rights Foundation. The same report finds that over 70% of Missourians are not protected from exposure to secondhand smoke.

Sinderman said tobacco prevention isn’t just a presentation at school with a set of blackened lungs –– it’s about making community changes.

“It’s really changing the environment to make the healthy choice, the easy choice,” she said. “People don’t become addicted in the first place. … Those who are already addicted, you’re giving them a healthy environment where they can quit.”

McDonald County got another round of the same grant to make changes in Noel, a town of 2,100 people nestled between huge bluffs and the banks of the Elk River.

Noel is considering an ordinance that would bar smoking in city-owned parks. Meanwhile, Langford and Hang have worked with local businesses to establish their own no-smoking policies.

Many of the bars and restaurants in town don’t allow smoking, but Langford wants them to establish policies to point at if a customer were to challenge that request.

The bars that do allow smoking inside continue to do so for fear of alienating their clientele, especially during the colder months — when people are more annoyed at having to step outside for a smoke.

Local bar owner Robert Miller got involved with the process and has become an advocate for the active transportation and smoke-free efforts.

He bought his historic bar, Shadow Lake, in 2021 with his wife and added a VIP room with a no-smoking policy this year.

So far, he hasn’t had any pushback. He recently booked the VIP space to an older crowd for a high school reunion.

“That definitely wouldn’t have happened with that age group and crowd if we hadn’t had that space,” Miller said. “So even nonsmokers that typically won’t go to any establishment that has smoking don’t mind coming here.”

His bar thrives on river tourism, like most of the town. He sees the healthy-community initiatives as a way to expand the area and full-time population.

“The sidewalks and the tobacco policies, they really all work together,” Miller said. “If we can start offering some of these things, even just sidewalks, to make the city look nicer, it’ll start attracting those people.”

Beyond the potential economic benefit, Miller wants to see a healthier community.

“I stopped smoking before I bought the bar, and then being around it all the time made it so hard not to smoke,” Miller said. “Taking these steps has helped me take steps back too, in the right direction.”