While people can develop chronic obstructive pulmonary disease (COPD) no matter where they live, the condition is more common — and has worse outcomes — in some regions of the country.

COPD refers to a group of progressive lung diseases, mainly chronic bronchitis and emphysema. Smoking is the biggest risk factor for developing COPD, but exposure to chemical fumes, vapors, dust, and air pollution can also play a role.

As of early 2024, the American Lung Association (ALA) estimates that 11.7 million adults in the United States are living with COPD. About 8% of people living in rural areas have COPD, compared with 5% in more urban areas.

According to the ALA’s “COPD in Your State,” updated in 2024, the following 11 states have the highest rates of COPD in the United States:

  • Alabama
  • Arkansas
  • Indiana
  • Kentucky
  • Louisiana
  • Maine
  • Mississippi
  • Ohio
  • Oklahoma
  • Tennessee
  • West Virginia

One reason for the difference in COPD rates is that smoking rates tend to be higher in rural areas versus urban areas. In a 2024 report, the ALA found that adults living in rural areas smoked at a rate of 15.4% compared with 10.1% in urban areas.

More specifically, adults in Midwestern and Southern states are more likely to smoke cigarettes than those in Northeastern and Western states.

The smoking prevalence among adults and young adults in the states known as “Tobacco Nation” is about 50% higher than in other states. On average, both adults and young adults in Tobacco Nation smoke 53 packs per year versus 29 packs in the rest of the country. This means that compared to the average smoker, a smoker in Tobacco Nation could smoke nearly 500 more cigarettes per year.

As of 2023, the following 12 states were included in the region known as Tobacco Nation:

  • Alabama
  • Arkansas
  • Indiana
  • Kentucky
  • Louisiana
  • Michigan
  • Mississippi
  • Missouri
  • Ohio
  • Oklahoma
  • Tennessee
  • West Virginia

The rise in smoking rates in the states known as Tobacco Nation, combined with a lack of healthcare access, contributes to worse COPD outcomes like hospitalizations and deaths in those regions.

A study from 2013 found that 3.7 million people with COPD didn’t have access to a pulmonologist (lung specialist) within 50 miles of their location. This included people across the United States, but more people in rural areas (2.2 million) lacked access compared with those in urban areas (1.5 million).

A 2024 review of 35 studies found that people with COPD living in rural areas have less access to healthcare, including respiratory specialists. The review also looked at health outcomes based on age, socioeconomic status, sex, and ethnicity or race.

Almost half of the studies in the review found big differences in access to care and health outcomes depending on where people lived.

To learn more about COPD in each state, click on this interactive map of the United States that shows the following statistics:

  • number of people living with COPD
  • number of hospitalizations from COPD
  • number of deaths from COPD
  • number of specialty physicians (e.g., pulmonologist or asthma or allergy specialist)