More than one in five adults in Indiana smokes, and the state spends nearly $3 billion annually in tobacco-related health care costs, according to the American Lung Association's 2018 State of Tobacco Control report.
The annual report continues to give Indiana poor marks on its smoking laws, ranging from access to preventative services and quit assistance to laws that allow smoking in bars, taverns and casinos.
The report shows Indiana continues to have one of the country's higher adult smoking rates — 21.1 percent — and 23.7 percent overall tobacco use rate.
High school smoking rates are at 11.2 percent — but with a 32.4 percent overall tobacco use rate statewide, citing estimates from a 2015 Centers for Disease Control and Prevention behavioral survey.
The national average was 31.4 percent — of teens surveyed that used a tobacco product at least one day in the prior month, according to the CDC data.
Figures from the Indiana Department of Public Health estimated 26 percent of adults in Lake County smoked in 2017, compared to 19 percent in Porter County.
The American Lung Association's report gave the state a grade of "F" for tobacco taxes, tobacco prevention and control program funding, and minimum smoking age; a "D" for access to anti-smoking services; and a "C" for smoke-free air policies.
"We know how to reduce tobacco use in this country. 'State of Tobacco Control' looks at proven methods to save lives and protect the health of all Americans," American Lung Association Indiana Director of Tobacco Control & Advocacy Monique French said in a statement.
"Indiana elected officials must act to implement these proven policies, which will prevent tobacco-caused death and disease, and help keep our lungs healthy."
The study listed three recommendations for Indiana:
• Increase its cigarette excise tax by $1.50 per pack. Ithas remained at 99.5-cents per pack.
• Pass a comprehensive statewide smoking ban that includes bars, casinos and taverns.
• Raise the smoking age to 21.
French said via phone that her organization recommended increasing taxes on tobacco products as a barrier to teenagers.
"What we know is that the (tobacco) industry, it is a predatory industry. They continue to market to our youth," she said. "We know that (raising taxes) comes at a price point where high schoolers are not able to purchase those products."
The state passed a smoking ban, written by Rep. Charlie Brown, D-Gary, in 2012, but it exempted a variety of businesses, including casinos, bars, taverns and private clubs.
In November, a proposed Gary city ordinance to ban smoking at the Majestic Star Casino never made it to a vote after a city councilwoman withdrew her sponsorship over concerns it would lead to a loss of jobs.
"We know that secondhand smoke is a major killer," said Cynthia Sampson, tobacco prevention coordinator for the Northwest Indiana Health Department Cooperative. "With the casinos, bars and private clubs, there is a lot of people that work (there) that do not smoke."
Most employees "would tell you, they don't like it, but they need the work," she said.