A Patchwork of Protections Leaves Thousands Exposed
Barely more than 1/3 of Mississippians are protected by a smokefree law in workplaces, restaurants, and bars.
Mississippi is a largely rural state, with many of its residents living in unincorporated regions. The casino and gaming industry is the fastest growing industry. There is no statewide smokefree law to protect workers from secondhand smoke exposure. Although there are over 140 comprehensive smokefree ordinances throughout the state, no major gaming municipality has a smokefree law that includes protections for casino workers. Thousands of workers continue to be exposed to secondhand smoke in workplaces including restaurants, bars, private clubs, and casinos.
State law does not preempt local governments from adopting smokefree air laws. 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. In this case, preemptive state laws set a ceiling, rather than a floor, and do not allow local authorities to enact strong local laws.
• 62.3% of Americans enjoy comprehensive smokefree protections in all public places and workplaces, including restaurants and bars. In contrast, in Mississippi only 31.3% of the population is protected by this type of smokefree law. 
• Mississippi's Gulf Coast is the 5th largest gaming market in the US.
• Only two of the state's 30 state-regulated casinos are smokefree; nearly 20,000 casino employees are exposed to secondhand smoke in their workplace.
•Mississippi is 1 of 10 "Most Challenged" states based on health outcomes according to the United Health Foundation's "America's Health Rankings Annual Report," ranking 49th out of 50, and 34th in Non-smoking Regulations. 
•Despite challenges, encouraging trends and developing strategies can help close the gaps in protections.
Current Landscape of Smokefree Protections
Mississippi is in a unique position to be a leader in comprehensive smokefree protections in the southern states. Over 150 localities have adopted a smokefree workplace, restaurant, and bar law. A strong statewide law – one that includes all non-hospitality workplaces, restaurants, bars, and even casinos – would ensure that the state’s 3 million residents, and millions of annual tourists, are protected from exposure to a known carcinogen: secondhand smoke. A state law would also ensure protections for Mississippians in unincorporated regions of the state who reside outside of municipal jurisdictions.
*By law, some cities and counties do not have freestanding bars, but their law is written in such a way that if bars were allowed they would be covered; in these instances, we have put a 100 in the Bars column.
A total of 162 Mississippi communities have 100% smokefree workplaces, restaurant and/or bar laws. Of those, 142 cover all three provisions.
Who is Left Behind?
Communities of color in Mississippi are most at risk. Forty percent of the state’s population are marginalized, compared to the national average of twenty-one percent. African Americans comprise nearly 40% of the state’s racial demographic – the highest in the country.
Black Americans in Mississippi have the highest rate of poverty (34%), highest rate of persons with less than a high school education (29%), and one of the highest rates of persons without health insurance (13%). When considering that nearly two-thirds of Mississippians are still exposed to secondhand smoke in workplaces and public places, it is conceivable that the state’s most marginalized people are overburdened by mounting negative social determinants of health.
Despite steady success in the passage of local smokefree ordinances, no major gaming community has passed an ordinance to protect casino employees. In fact, approximately 20,000 employees in the state’s 30 casinos are still exposed to secondhand smoke in their workplaces. The major gaming communities include Biloxi, Gulfport, Tunica, Vicksburg, Natchez, and Greenville. 
Those most likely to be exposed to secondhand smoke work in the hospitality industry and are more likely to identify as a racial minority.
Poor Health Outcomes and High Costs
Mississippi continues to trail behind the rest of the nation in poor health outcomes, ranking in the bottom five in most health outcome indicators. Among the leading causes of death in Mississippi were cardiovascular-related diseases, cancer, and heart disease. The state also struggles to significantly curb the smoking rate. The smoking rate among adults is 20.1% and 6.6% for high school students, compared to national rates of 14% and 4.6%, respectively. 
Tobacco exacts a high toll in Mississippi, with annual health care costs directly caused by tobacco use at $1.23 billion ($319 million of which is Medicaid expenditures). Healthcare costs attributed to tobacco use in Mississippi amount to $1.23 billion annually. 
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. [6,7]
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. [6,7]
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. 
Gaming in Mississippi
Casinos, race tracks and other gaming establishments are workplaces as well as public places and should also be smokefree.There are at least 29 gaming establishments in Mississippi, and five are 100% smokefree. In response to the COVID-19 pandemic, the Mississippi Band of Choctaw Indians made the sovereign decision to implement smokefree policies for the Tribe’s gaming venues: Bok Homa Casino, Golden Moon Hotel and Casino, and Silver Star Hotel and Casino. Additionally, the Magnolia Bluffs Casino in Natchez went smokefree via its own business policy as a part of their COVID-19 reopening plans. See the ANR Foundation Smokefree Casinos and Gaming Property Directory for Mississippi.
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. 
COVID-19 reminds us that health prevention policies matter greatly.
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-19) 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 face coverings to smoke or vape indoors undermines the proven benefit of face coverings and increases the risk of transmitting or inhaling COVID-19 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-19.
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.
Strategies to Close Gaps & Increase Health Equity
Focus on Smokefree
Plan for a Statewide Smokefree Law
Include e-cigarettes in smokefree laws
Invest in the Future
Focus on 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. 
Let local lead the way: Since Mississippi municipalities have the authority to adopt local laws, communities should focus on passing strong laws covering all workplaces, including bars and casinos. 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.
Plan for a statewide smokefree law: Since a large portion of the state’s population resides in unincorporated regions, a strong statewide law is the only way to ensure that every Mississippian is equally protected from secondhand smoke exposure in workplaces and public places. 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. [11,12]
Statewide campaigns are always a challenge given the influence of the tobacco industry in state legislatures, and the casino industry in Mississippi. In addition, the state’s large geography and demography make statewide organizing a challenge and will require ample human and financial resources. To elevate a statewide campaign to the next level would require investing in a highly professional and strategic organizing and paid media campaign. The campaign should highlight worker health (particularly casino employees being left behind) and emphasize broad public support for the measure as well as the financial benefits of going smokefree.
Invest in the future: In order to address the 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 about the viability of ventilation systems to protect people from secondhand smoke exposure. Collaborating with and mobilizing additional community-based partners who represent those individuals or specific classes of 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.
Sources of Data:
1. “U.S. Environmental Protection Agency, Respiratory Health Effects of Passive Smoking: Lung Cancer and Other Disorders,” EPA/600/6-90/006F, December 1992.
2. American Nonsmokers’ Rights Foundation. U.S. Tobacco Control Laws Database. Berkeley, CA, 2021.
3. United Health Foundation. (2021). America’s Health Rankings Annual Report.
4. American Gaming Association. State of the States: The AGA Survey of the Casino Industry, September 2018.
5. Centers for Disease Control and Prevention. (n.d.). State Highlights: Mississippi [from State Tobacco Activities Tracking and Evaluation System].
6. 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.
7. 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.
8. Matt, Dr. Georg (2018). Smoking Bans May Not Rid Casinos of Smoke. US News and World Report
9. 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.
10. 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].
11. 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.
12. 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.
[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).