Tennessee:Lack of Local Control Takes its Toll
No one in Tennessee is covered by a smokefree Workplace, Restaurant, and Bar law.
Tennessee is home to more than 6 million residents. From the Smoky Mountains to the country music capital of the world, residents and visitors of the Volunteer state are not fully protected by strong smokefree laws. In 2007, a weak statewide smokefree law went into effect with exemptions including small workplaces with 4 or fewer employees as well as restaurants and bars prohibiting entry for those 21 and under. Both of these are tobacco industry-sponsored exemptions meant to limit smokefree protections. Millions of residents are left behind by a weak partial statewide law and remain exposed to secondhand smoke.
No Local Control
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. Since 1994, Tennessee state law has preempted local authority from adopting smokefree air and other tobacco control laws. Private businesses can adopt a policy making their business smokefree, but municipalities are not able to pass a city-wide law prohibiting smoking in workplaces, restaurants, and bars.
Entertainers are Exposed to Secondhand Smoke
• 61% of Americans enjoy comprehensive smokefree protections in all public places and workplaces, including restaurants and bars. In contrast, in Tennessee 0% of the population is protected by this type of smokefree law. 
• Tennessee 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 42nd out of 50. 
• Localities in Tennessee do not have the authority to pass smokefree laws due to preemption.
• 41 college campus sites in the state are 100% smokefree, of which 37 are tobacco-free. 
• 125,000 Tennesseans currently under the age of 18 will die prematurely from smoking. 
• Healthcare costs attributed to tobacco use in Tennessee amount to $2.67 billion annually. 
Current Landscape of smokefree protections
Preemption: Tobacco Control's #1 Enemy
No one in Tennessee is protected by a 100% workplace, restaurant, and bar law. Thousands of employees, patrons, and visitors are exposed to secondhand smoke in these venues. The current state law has problematic exemptions for small businesses, and in restaurants and bars that prohibit patrons under 21 from entering. The exemptions affect some of the nation’s most beloved performers who remain exposed to secondhand smoke when touring and sharing their art in Tennessee. Nashville and Memphis are very high-profile tourist destinations known for live performances and a rich history with the music industry. Local jurisdictions lack the authority to strengthen smokefree protections at the municipal level. Tennessee workers continue to be exposed to secondhand smoke in the many exempted venues including workplaces, restaurants, and bars.
Tennessee: A Blank Slate for Smokefree Local Laws
Tennessee is a blank slate when it comes to smokefree laws. Because state law preempts local governments from implementing smokefree laws in Tennessee municipalities, it has fallen behind the rest of the nation in protecting its citizens from secondhand smoke. Reversing preemption and restoring local control is the clear solution to improve health, save lives, attract and retain the best talent to the Volunteer State. The triangles on the map represent municipalities with laws requiring 100% smokefree workplaces, restaurants, and bars. At the state level, blue represents a statewide law requiring 100% smokefree workplaces, restaurants, and bars and turquoise represents state laws requiring one or two of those components; grey represents no 100% smokefree provisions. Note that the map does not reflect American Indian sovereign tribal policies.
Implications of Preemption
Because state law preempts local law in Tennessee, it has fallen behind the rest of the nation in health protections from secondhand smoke. Broad preemption measures prevent communities from enacting smokefree air laws for indoor workplaces and remove communities’ right to enact local smokefree air laws. Historically, local legislation led the way to stronger statewide laws by building a groundswell of support and providing successes for the state to replicate.
Workers in Tennessee are Suffering in Secondhand Smoke
Demand for smokefree workplaces has never been higher. Local control should be restored so municipalities can enact strong, simple and fair laws that protect all workers and patrons. To remain a travelers' and artists' hotspot, and compete with major destinations, the Volunteer state needs to focus on improving living standards to attract and retain the best talent. A crucial first step is for Tennessee to restore local control to improve health outcomes by passing strong workplace, restaurant, and bar policies.
All tobacco-related legislation is still required to be reviewed by the state’s agriculture committee, reflecting a history of tobacco-growing states and corresponding lack of progress on life-saving public health measures like smokefree laws.
Despite the barriers imposed by preemption, community coalitions have made significant progress in strengthening local policies where allowable; more than 40 college sites have adopted 100% smokefree campuses.
Who is Left Behind?
Tennessee lags behind the rest of the country when it comes to protecting nonsmokers from secondhand smoke in public places and workplaces. Allowing smoking in workplaces, restaurants, and bars is not only leaving thousands of people exposed to the hazardous chemicals in secondhand smoke, but it also normalizes the act of smoking in public. Outside of metro areas, rural Tennessee residents are also left vulnerable to secondhand smoke exposure.
Thousands of workers continue to be exposed to secondhand smoke in exempted venues including smoking areas of restaurants, bars, and private clubs. Those living in Tennessee rank their own and their children’s health status as worse than the rest of the country.  Various social determinants and behaviors continue to consistently land the state in the bottom 10 of health rankings lists. These are: economic disparity, lack of insurance, higher rates of smoking, and lower rates of physical activity, and they contribute to chronic conditions like heart disease, cancer, and stroke. There is a widening gap between rural and urban areas of the state, which is especially a concern, since 1.5 million people – 22% of the state’s population – reside in a rural area. Those living in a rural area face unique demographic, economic, and health access challenges. They are also more likely to be elderly, engage in unhealthy behaviors, and have lower incomes.  To overcome this disparity and ensure protection from secondhand smoke no matter your zip code, a broad-based coalition of support will be necessary.
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. 
Tennessee's smoking rate among adults is 22.6% and 9.4% for high school students, compared to national rates of 14% and 8%, respectively. Tobacco exacts a high toll, with 11,400 Tennessee residents dying each year of tobacco-related illness.  At current trends, 125,000 kids under the age of 18 in Tennessee are projected to die prematurely from tobacco-related illness. 
Annual health care costs in the state directly caused by tobacco use are $2.67 billion ($823.6 million of which is Medicaid expenditures). 
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. [5,8]
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. [5,8]
Strategies to Close Gaps & Increase Health Equity
Focus on Smokefree
Adopt a Statewide Law
Restore Local Control
Invest in the Future
Increase Funding and Resources
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: they are worth the investment of time and effort to protect everyone from exposure to a known human carcinogen. 
Adopt a statewide smokefree law: Since communities in Tennessee are preempted from adopting strong local smokefree laws, efforts should be focused on the legislature to adopt a comprehensive 100% smokefree workplace law that includes restaurants, bars, and casinos. 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, particularly in southern states like Tennessee. Due to a lack of investment in building a local infrastructure to support smokefree policy change, grassroots and policy champions need to be recruited to move forward. Legislators need to hear from constituents that there is demand for smokefree workplace protections for all at the local and the statewide level.
Alternatively, repeal preemption and restore local control: There have been several successful preemption repeal campaigns that have restored local authority to adopt smokefree laws at the municipal level. 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. Delaware was the first state to repeal preemption and simultaneously adopt a law that made all workplaces, including casinos, 100% smokefree in 2003. Other examples include Illinois, which repealed preemption in 2006. The following year, over 30 Illinois municipalities enacted local smokefree laws. The state then adopted a law that went into effect in 2008 making all workplaces, including casinos, 100% 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.
Tennessee has tremendous potential to close the gaps in smokefree protections. There is engagement by state and national partners to restore local control. They have engaged in a local resolution campaign to show strong support on the municipal level to take action on smokefree. With a spotlight on health disparities in this southern state, there is significant interest in improving the public health of the population.
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, 2019.
3. United Health Foundation. (2018). America’s Health Rankings Annual Report.
4. American Nonsmokers’ Rights Foundation. U.S. College Campus Tobacco Policies Database. Berkeley, CA, 2018.
5. 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.
6. Centers for Disease Control and Prevention. (n.d.). State Highlights: Tennessee [from State Tobacco Activities Tracking and Evaluation System].
7. The Sycamore Institute. Healthy Debate 2018: Health and Well Being in Tennessee.
8. 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.
9. Matt, Dr. Georg (2018). Smoking Bans May Not Rid Casinos of Smoke. US News and World Report.
10. 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.
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).