Focus on 100% smokefree policies: Competing issues can distract and delay work on smokefree policies. Smokefree laws have immediate and long-term health and economic benefits, and they are worth the investment of time and effort to protect everyone from exposure to a known human carcinogen. (Source: USDHSS, 50 Year Surgeon General Report)
Gaps in protections leave some workers exposed to secondhand smoke and e-cigarette emissions
North Carolina is the 28th largest and 9th-most populous of the 50 United States, and home to 10,383,620 people. It is also home to Reynolds American tobacco company and the largest tobacco cultivation state. Raleigh is the state’s capital and Charlotte is its largest city.
- 62.3% of Americans enjoy comprehensive smokefree protections in all public places and workplaces, including restaurants and bars. In North Carolina, 100% of the state’s population is protected by smokefree restaurants and bars, but 0% are covered by laws for non-hospitality workplaces as a result of preemption.
- North Carolina partially preempts local smokefree air laws; only one North Carolina community, Beaufort County, has a 100% smokefree workplace, restaurant and bar law.
- North Carolina ranks 28th out of 50 states in overall health and 41st in Non-smoking Regulations according to America’s Health Rankings Annual Report [United Health Foundation. (2021).]
- At least 67 colleges in NC are smokefree/tobacco-free (45 community colleges and 22 private colleges.)
- Despite challenges, encouraging trends and developing strategies can help close the gaps in smokefree protections.
Preemption refers to situations in which a law passed by a higher level of government takes precedence over a law passed by a lower one. Preemption is a tobacco industry tactic that removes a community’s right to enact local smokefree air laws. North Carolina partially preempts local smokefree air laws, specifically in non-hospitality workplaces such as offices, factories, and retail stores.
The state recognizes eight sovereign Tribes: Eastern Band of Cherokee Indians, Coharie Tribe, Lumbee Tribe of North Carolina, Haliwa-Saponi Indian Tribe, Sappony Tribe, Meherrin Indian Tribe, Occaneechi Band of the Saponi Nation, and Waccamaw Siouan Tribe. Cotton and tobacco were important export crops in the 1800’s and tobacco’s legacy has lingered.
Preemption: The Tobacco industry's #1 opposition tactic against smokefree protections
Winston-Salem, AKA “Camel City”
Reynolds American’s hometown of Winston-Salem, North Carolina, has developed a relatively strict tobacco policy. The regulations are reflective of how cities have handled smoking in recent years. Even Reynolds employees who smoke must use smoking lounges away from their colleagues.
North Carolina has low taxes on cigarettes (ranks 48th) and is America’s dominant tobacco producing state receives $139m annually from such tobacco settlements. Initially, the state set up three trust funds to spend that money: one to prevent smoking, one to help rural communities hit by a decline in smoking and one to help tobacco farmers.
The fund to prevent smoking was dismantled in 2011 and all of the funds were redirected to the state’s general fund. However, lawmakers allowed the settlement to continue to fund tobacco growing efforts.
Between 2000 and 2004, another $41m of North Carolina’s tobacco settlement went to retrofit tobacco curing barns, a move that researchers called “arguably counter-productive to tobacco control,” and which some farmers believed was at the behest of tobacco manufacturers.
Those that work in hospitality venues like casinos and bars are most likely to be exposed to toxic secondhand smoke
Current Landscape of Smokefree Protections
The imprint of Big Tobacco looms large in North Carolina, despite an evolving agricultural market that no longer centers on growth of the product. In communities such as Raleigh-Durham, one is surrounded by the legacy of the tobacco industry including former tobacco warehouses and processing plants that have been repurposed into bars or other businesses as part of today’s more diversified economy.
In 2009 the Legislature enacted HB2, which required all restaurants and bars to be smokefree indoors. The law partially restored local control by permitting local governments to regulate smoking in local government buildings and vehicles, and in some specified public places such as outdoor areas. However, the state law did not extend smokefree protections to non-hospitality workplaces such as offices, factories, and retail stores. This gap in protection leaves thousands of workers at risk of working in smoke-filled environment. Preemption remains for a number of locations including places that are specifically exempted by HB2.
Additionally, the statewide law does not prohibit use of e-cigarettes in workplaces or public places.
The imprint of Big Tobacco looms large in North Carolina.
Other Tobacco Related Policy Progress
The health department has developed a Local Government SmokeFree Implementation Toolkit to help communities address local policies within the legal framework of the state law.
North Carolina was the first U.S. state to implement smokefree or tobacco-free policies at ALL acute care hospitals. (See ANR Foundation list of smokefree hospitals). Each hospital implemented its own policy but with the health of model language and tools to support it.
At least 51 colleges and universities in North Carolina have adopted a 100% smokefree or tobacco-free campus policy designed to protect public health and support as the norm of tobacco-free living.
The state has also made progress in smokefree housing, including innovative partnerships with multi-housing providers to implement voluntary policies for new construction and to encourage converting housing stock to non-smoking.
North Carolina has put significant effort into fighting the youth e-cigarette epidemic as well as support tobacco cessation as part of all its projects. This includes highlighting the quit line and other cessation resources.
Who is Left Behind?
North Carolina is failing to protect nonsmokers from secondhand smoke in public places and workplaces, especially vulnerable populations that face numerous social and economic challenges. The tobacco industry’s commitment to addicting citizens to its products has left a devastating result.
Smokefree laws help to reduce adult smoking prevalence and prevent youth and young adult smoking initiation. (Source: USDHSS)
North Carolina Tobacco Prevention and Control Branch has some data on tobacco control disparities. Those living in a rural area face unique demographic, economic, and health access challenges. To overcome this disparity and ensure protection from secondhand smoke no matter the zip code, a broad-based coalition of support will be necessary for supporting local efforts, closing gaps in the statewide law, and restoring local control. It is also critical for public health groups to acknowledge secondhand smoke exposure as a social determinant of health, in addition to tobacco use, and for all partners to recognize that exposure to secondhand smoke is a social justice issue, typically harming vulnerable groups like low income, rural populations.
Poor Health Outcomes and High Costs
Tobacco use is the leading preventable cause of death in the United States. More than 480,000 people die from smoking or exposure to secondhand smoke each year. 
North Carolina’s adult smoking rate is 16.5% (2020) (Source: NC Tobacco Prevention and Control Program). Youth tobacco use rates are also of utmost concern with a high school smoking rate of 8.3% compared to 6% nationally. The toll for tobacco related Medicaid expenditures is $931.4 million (Source: Centers for Disease Control and Prevention. (n.d.). State Highlights: North Carolina, from State Tobacco Activities Tracking and Evaluation System). Secondhand smoke exposure causes heart disease, stroke, and lung cancer among adults, as well as respiratory disease, ear infections, sudden infant death syndrome, more severe and frequent asthma attacks, and slowed lung growth in children. (Source: USDHSS).
Secondhand smoke exposure causes heart disease, stroke, and lung cancer among adults, as well as respiratory disease, ear infections, sudden infant death syndrome, more severe and frequent asthma attacks, and slowed lung growth in children. [7,9]
Beyond secondhand smoke exposure, nonsmokers exposed to thirdhand smoke in a casino are at an ever higher risk than those in a thirdhand smoke-polluted home.  Further, hospitality workers and children are susceptible to thirdhand smoke exposure, as the particles cling to hair, clothing, and cars. Young children are particularly vulnerable, because they can ingest tobacco residue by putting their hands in their mouths after touching contaminated surfaces. 
Smokefree laws help to reduce adult smoking prevalence and prevent youth and young adult smoking initiation. [7,9]
North Carolina is failing to protect nonsmokers from secondhand smoke in public places and workplaces.
Sovereign Tribal Policy Development and Gaming in North Carolina
Tribes are sovereign with their own government and policy-making authority. They are not subject to state or local smokefree guidelines. Because Tribes typically do not have local tax base, casino revenue is often the major source of revenue for everything from schools and healthcare. During the COVID-19 pandemic more than 200 U.S. gaming venues have implemented 100% smokefree policies including at least 160 sovereign Tribal gaming venues.
Harrah’s Cherokee Casino and Harrah’s Cherokee Valley River are 100% smokefree indoors as part of sovereign legislation enacted by Eastern Band of Cherokee Indians (EBCI). Catawba Two Kings Casino is also 100% smokefree indoors via the sovereign policy decision of Catawba Nation. There are a total of three gaming properties in North Carolina, all of which are smokefree.
First of its kind study demonstrates that casino visitors, even current smokers, desire smokefree spaces.
When smoking is allowed in indoor areas of casinos, millions of nonsmoking casino visitors and hundreds of thousands of employees can be involuntarily exposed to secondhand smoke and related toxicants. 
—Office on Smoking and Health, Centers for Disease Control and Prevention
A recent study found that 75% of U.S. adults who visit casinos favor smokefree casinos.
No prior studies have exclusively assessed adult attitudes toward smokefree casinos in the United States.
This study found very high favorability among those age >64 (81.6 %), college educated (81.7%), and higher income (79.1/80.8%). Smokers made up 13% of the sample, and, of those smokers, nearly half (45%) supported smokefree casinos. 
Potential Challenge: Secondhand Marijuana Smoke
Marijuana use is not legal in North Carolina. NC remains one of only 14 states that have not legalized medical or recreational marijuana use. Secondhand marijuana smoke is a health hazard for nonsmokers. Just like secondhand tobacco smoke, marijuana smoke is a potent source of PM 2.5 fine particulate matter. Marijuana secondhand smoke impacts cardiovascular function; it contains thousands of chemicals and at least 33 carcinogens.
COVID Reminds Us That Health Prevention Policies Matter
Smoking and vaping, along with exposure to secondhand smoke and aerosols, negatively impact the respiratory system and may cause a person’s immune system to not function properly, known as being immunocompromised. Research demonstrates that current and former smokers of any age are at higher risk of severe illness from coronavirus disease (COVID) in part due to compromised immune and/or respiratory systems. Smoking leads to cardiovascular disease, as well as respiratory illnesses including bronchitis, asthma, Chronic Obstructive Pulmonary Disease (COPD), and lung cancer as a result of exposure to particulate matter, toxins, and carcinogens into their lungs. Secondhand tobacco and marijuana smoke and aerosol contain many of the same toxins, carcinogens, and particulate matter that lead to respiratory and cardiovascular diseases.
Removing masks to smoke or vape indoors undermines the proven benefit of face coverings and increases the risk of transmitting or inhaling COVID via infectious respiratory droplets, uncovered coughs, and increased touching of faces. Preventing exposure to secondhand smoke and e-cigarette aerosol or vape by adopting a smokefree policy with no smoking or vaping indoors and moving smoking or vaping to socially distanced outdoor areas away from entrances, could help mitigate worker and public exposure to carcinogens and toxins, as well as COVID.
Just as social distancing and handwashing help prevent the spread of disease, eliminating secondhand smoke is critical to prevent acute and chronic diseases, and saves lives by reducing the risk of heart disease, stroke, respiratory diseases, and lung cancer by up to 30% at a population wide level.
Going smokefree prevents exposure to the carcinogens and toxins in secondhand tobacco and marijuana smoke as well as dramatically reduces the spread of respiratory droplets that could transmit flu and other viruses like COVID.
Strategies to Close Gaps & Increase Health Equity
Let local lead the way: Local control and increasing civic engagement is at the heart of our broader goal of educating the public about the health effects caused by secondhand smoke and changing attitudes regarding smoking in ways that harm other people. Smokefree laws should also prohibit the use of electronic cigarettes (e-cigarettes), marijuana, and hookah to prevent secondhand smoke exposure to the toxins, carcinogens, fine particles, and volatile organic compounds that have been found to compromise respiratory and cardiovascular health. (Source: Grana/Benowitz & Glantz, Villarreal)
Plan for closing gaps in the statewide smokefree law and restoring local control: Since a large portion of the state’s population resides in a rural area, a strong statewide law is the only way to ensure that every North Carolina citizen is equally protected from secondhand smoke exposure in workplaces and public places. Statewide campaigns are always a challenge. Given the influence of the tobacco industry, overcoming its interference with smokefree policy progress in North Carolina would be significant.
Invest in the future: In order to address gaps in smokefree coverage, a great deal of effort and financial resources will be required to explain the ongoing disparities in smokefree protections and the benefits of 100% smokefree environments, and to counter misinformation from the tobacco industry about the necessity of compromise in the appropriate role of government in providing smokefree workplaces to protect all employees and patrons. Collaborating with and mobilizing additional community-based partners who represent workers being left behind is critical to reach success.
Increase funding and resources: Tobacco prevention, education, training, and cessation funds are needed to better address disparities in smoking and exposure to secondhand smoke. In addition, funds to support the implementation of a statewide law are critical to increase community awareness of and compliance with the smokefree rules. The American Nonsmokers’ Rights Foundation is dedicated to improving community health and increasing health equity by ensuring that everyone is protected by a 100% smokefree law. We provide training, technical assistance, and tobacco policy surveillance data for civic engagement to improve community health
Workers in North Carolina Deserve Smokefree Air
Sources of Data:
- “U.S. Environmental Protection Agency, Respiratory Health Effects of Passive Smoking: Lung Cancer and Other Disorders,” EPA/600/6-90/006F, December 1992.
- American Nonsmokers’ Rights Foundation. (2021). U.S. Tobacco Control Laws Database. Berkeley, CA.
- Centers for Disease Control and Prevention. (n.d.). State Highlights: West Virginia [from State Tobacco Activities Tracking and Evaluation System].
- United Health Foundation. (2018). America’s Health Rankings Annual Report.
- U.S. Census Bureau Data (2018). West Virginia.
- West Virginia Lottery Commission Annual Report (2018).
- US Department of Health and Human Services. The health consequences of smoking: 50 years of progress. A report of the Surgeon General. Atlanta, GA: US Department of Health and Human Services, CDC; 2014.
- Truth Initiative, Tobacco Nation: The Deadly State of Smoking Disparity in the U.S. (2017).
- US Department of Health and Human Services. Preventing tobacco use among youth and young adults. A report of the Surgeon General. Atlanta, GA: US Department of Health and Human Services, CDC; 2012.
- Matt, Dr. Georg (2018). Smoking Bans May Not Rid Casinos of Smoke. US News and World Report.
- Matt, G E, Quintana PJ E, Hovell MF et. al. (2004). Households contaminated by environmental tobacco smoke: sources of infant exposures. British Medical Journal: Tobacco Control.
- Michael A. Tynan, BA1 ; Teresa W. Wang, PhD1; Kristy L. Marynak, MPP1; Pamela Lemos, MS1; and Stephen D. Babb, MPH1, Attitudes Toward Smoke-Free Casino Policies Among US Adults, Centers for Disease Control and Prevention Office on Smoking and Health, Public Health Reports, 2017 [accessed 2019 Mar 21].
- Grana, R; Benowitz, N; Glantz, S. “Background Paper on E-cigarettes,” Center for Tobacco Control Research and Education, University of California, San Francisco and WHO Collaborating Center on Tobacco Control. December 2013.
- Williams, M.; Villarreal, A.; Bozhilov, K.; Lin, S.; Talbot, P., “Metal and silicate particles including nanoparticles are present in electronic cigarette cartomizer fluid and aerosol,” PLoS ONE 8(3): e57987, March 20, 2013.
Huang, J., King, B.A., Babb, S.D., Xu, X., Hallett, C., Hopkins, M. (2015). Socio-demographic disparities in local smokefree law coverage in 10 states. American Journal of Public Health, 105(9), 1806–1813.
Tynan, M.A., Baker Holmes, C., Promoff, G., Hallett, C., Hopkins, M., & Frick, B. (2016). State and local comprehensive smoke-free laws for worksites, restaurants, and bars — United States, 2015. Morbidity and Mortality Weekly Report, 65(24), 623-626.
American Gaming Association. State of the States: The AGA Survey of the Casino Industry, September 2018.
Rhoades, R. and Beebe, L. Tobacco Control and Prevention in Oklahoma: Best Practices in a Preemptive State. American Journal of Preventive Medicine. (January, 2015)
[n.a.], “Tobacco industry interference with tobacco control,” Geneva: World Health Organization (WHO), 2008.
NCI Monograph 17: Evaluating ASSIST – A Blueprint for Understanding State-level Tobacco Control Evaluation of American Stop Smoking Intervention Study for Cancer Prevention Chapter 8, Evaluating Tobacco Industry Tactics as a Counterforce to ASSIST (October 2006).