GREENSBORO, N.C. (WGHP) — North Carolina’s heritage as a tobacco state is lingering as a problem for its public health.

The American Lung Association, in its annual report for the State of Tobacco Control, gives North Carolina a grade of F in all five categories in which it evaluates the state’s response to the public health threat that tobacco continues to pose.

Those evaluations include how much the state is spending on prevention and cessation programs and access to those services, how much air is smoke-free, how much the state is taxing tobacco and access to the flavored tobacco products that are known to lure young smokers.

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The lung association wants state officials to spend $21 million for tobacco control programs, including prevention, education and cessation, in alignment with the Centers for Disease Control and Prevention’s Best Practices for Comprehensive Tobacco Control Programs; to support licensing for all tobacco retailers, including e-cigarette retailers; and to support a tobacco tax increase for cigarettes of $1.46 to the current average cigarette tax and to equalize taxes for all tobacco products, including e-cigarettes.

The report on North Carolina cites the state’s $13,399,600 allocation for 2022 on tobacco control programs, and its total percentage against CDC levels is rated at 15.9%.

The report also says the state has tobacco-related revenue of $458.1 million. The state’s cigarette tax is 45 cents per pack, a full dollar lower than the recommended level.

The overall smoking restrictions evaluation dings the state for not having restrictions related to stores, rec facilities and private businesses and for not including e-cigarettes.

The lack of Medicaid expansion is part of the problem with the state’s overall commitment to cessation. The report says the state is spending $1.75 per smoker on what it calls its “quitline.” The median is $2.41.

There is no state regulation on flavored tobacco products, which includes menthol brands. The Food and Drug Administration reports there are nearly 18.6 million menthol smokers, most of them African American and Hispanic, and almost half of smokers between the ages of 12 and 17 smoke menthol.

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The summary of the report on North Carolina says that the state budget passed last year was inadequate in meeting the requests of the North Carolina Alliance for Health to allocate $17 million in recurring funding for prevention programs and $3 million for QuitlineNC.

The report applauded the move in June by Attorney General Josh Stein to a settlement requiring e-cigarette maker JUUL Labs to pay $40 million over the next six years because of its influence on young smokers.

That agreement includes $11 million for this fiscal year and $8 million for 2022-2023 to be used for “tobacco and nicotine dependence prevention and cessation activities targeted at youth and young adults.”

The lung association also cited no funding for QuitlineNC and a 30-cent limit on cigar taxes that it had opposed.