Cigarettes have caused a health epidemic, one that disproportionately affects the rural poor.

Long gone are the days when cigarette smokers frequented restaurants and other public spaces; when people smoked freely undeterred by threats of cancer; when nearly everyone, regardless of income or geography, took part in the social ritual of lighting up. From 1965—when the Surgeon General first released its report on the negative effect smoking has on health—to 2017, the number of Americans who smoke declined from 41.9 percent to 15 percent. However, despite the relative progress over the fifty year fight against tobacco use, it is still affecting over 43.8 million people, many of whom are poor or live in rural areas.

Cigarettes still kill nearly half a million people in the United States each year, according to the Center for Disease Control and Prevention. That number is 15 times the number of deaths related to the opioid crisis.

While the rich have given up their cigarettes, among Americans without a highschool diploma the smoking rate remains more than 40 percent. 18 to 20 percent more people living in rural areas acquire lung cancer compared with their city-dwelling counterparts. And researchers agree that the economically disenfranchised die more from cigarettes than any other group of Americans.

Debbie Seals, a 60 year old grandmother who worked with Girl Scouts of the USA but now volunteers teaching classes for the American Lung Association, has had first hand experience with the way class influences smoking. In her hometown of Martinsville, VA cigarettes are everywhere—strip malls, gas stations, advertisements, convenience stores, in people’s cars, on the street—a stark difference, she notes, from the wealthier parts of the state.

Like much of Appalachia, Martinsville has suffered culturally and economically following the decline of the once booming textile mills and furniture factories. All children in elementary and middle school automatically qualify for free and reduced-price meals because so many families face extreme poverty.