The legacy of the Marlboro Man has not been completely snuffed out in western South Dakota.
Although the percentage of daily smokers statewide declined to 15.6 percent in 2012, nine of its top 13 smoking counties are in the West River, according to a nationwide report released Monday by the University of Washington's Institute for Health Metrics and Evaluation.
Counties within reservations, specifically Shannon, Dewey and Todd, all shared smoking rates of 22 percent or more. Pennington County has a rate of 16.5 percent, which is above the state average.
While smoking rates have dropped nationally to 14 percent, the report said the pattern was uneven and governments can do more to encourage declines in areas like Western South Dakota where above-average rates are still prevalent.
"There really needs to be local-level solutions as much as possible," said William Heisel, the institute's communications director. "There's not really a mystery on what can work."
The Centers for Disease Control and Prevention recommends states increase cigarette excise taxes and spend adequate money on tobacco prevention and education.
South Dakota ranks 24th in the nation with a $1.53 tax per pack. New York state has the nation's highest excise tax at $4.35 per pack followed by Massachusetts, Rhode Island and Connecticut, each with taxes above $3.
Missouri has the nation's lowest excise tax at 17 cents per pack. North Dakota joins Louisiana, Georgia, Alabama with taxes less than 50 cents per pack.
A spokesman for Gov. Dennis Daugaard said in an email the state was doing enough to fund anti-tobacco programs and pointed out the state's cigarette tax is higher than many neighboring states.
While South Dakota did ban smoking in bars, casinos, restaurants and workplaces in 2010, the CDC report said its other efforts to curb tobacco use were not enough. Smoking is the number one cause of preventable deaths with 1,100 adults dying of smoking-related causes per year.
"It doesn't have to feel like the government coming into your house and directing how to live your life," Heisel said. "People can realize on their own not only is tobacco going to shorten your life, it's going to make the life you live very short and painful."
The CDC recommended South Dakota increase its nearly $5 million state and federal annual funding for anti-tobacco efforts to $11.7 million. It also recommends all states consider raising cigarette taxes by at least another $1.50 per pack by 2020 to deter more children from picking up the habit.
Many of the most persistent challenges remain for Native Americans living on and off the reservations. A 2010 CDC report estimated more than 46 percent of them smoke.
"One person said to me, 'It's basically my best friend,'" said Dr. Patricia Nez Henderson of the Black Hills Center for American Indian Health in Rapid City. "When you're living in poverty and there's all these other issues that you're dealing with, it makes it much more difficult to quit."
Cigarettes there are often taxed at a lower rates and more prominently displayed in stores. Tribes have to look at commercial tobacco in another way and re-examine the role it plays in its cultures, values and traditions.
"With the tribes, we are like 15 years behind," Henderson said. "The state got money from tobacco settlements (for prevention efforts). How much of that actually went back into Indian country, we don't know."