For more than a decade, Kristin Page-Nei begged Montana lawmakers to raise cigarette prices. As a health advocate for the American Cancer Society, she watched year after year as other states increased their cigarette taxes and lowered their smoking rates. “What they’re doing is saving lives,” she kept saying.

Finally, this spring, she helped convince state senators to raise cigarette taxes for the first time in 12 years. Then came the tobacco lobbyists.

Bankrolled by the country’s two biggest cigarette companies, they swarmed the halls of the state capitol, wined and dined Republican leaders, launched a sophisticated call-in campaign and coached witnesses for hearings. The tobacco companies poured more than $200,000 into Montana, a state with barely a million residents.

It took them just one week to kill the bill – from the time it passed the state Senate to its last gasps in a state House committee. The tobacco lobby was so effective that, in the end, eight of the bill’s original co-sponsors voted against it.

“It was incredible. Just brutal,” Page-Nei said. “I’d never seen this amount of money being poured into a session in my 17 years here.”

Health experts agree that raising taxes is the most effective way to reduce tobacco use. The U.S. surgeon general, the World Health Organization and the Centers for Disease Control and Prevention have all concluded that raising taxes helps large numbers of smokers to quit and have advocated loudly for it.

But many states – Missouri, Kentucky and Georgia among them – have not significantly increased their cigarette fees in decades, bowing to pressure from tobacco lobbyists and an ingrained antipathy among conservatives to raising taxes of any kind.

As a result, America’s smokers are increasingly concentrated in states where cigarettes are cheap. A pack of cigarettes will soon cost $13 in New York City, where a tax hike of $2.50 was recently passed. But in Kentucky – the state with the highest rate of smokers, at 25.9 percent, compared to the national rate of 15 percent – you can buy that same pack for $4.77 on average.

“People around here just don’t like the ‘tax’ word,” said Ellen Hahn, a tobacco control expert at the University of Kentucky who has struggled for years to raise Kentucky’s 60 cents per pack cigarette tax. “Between that and the grip of the tobacco industry on our legislature, it’s hard to convince anyone, especially politicians.”

The huge gap in prices is the result of a long-running war between tobacco companies and health advocates. It is also, experts say, one of the biggest reasons low-tax states now suffer from high rates of cancer, heart disease, diabetes and a multitude of other tobacco-related diseases.

“It’s incredibly frustrating because unlike so many other problems in the country, this is one case where we know the solution,” said Matthew Myers, president of the Campaign for Tobacco-Free Kids. “Not only that. It’s a solution that’s widely popular, doesn’t cost the government anything, yet these states refuse to do it.”

In the 1980s, some states started aggressively raising cigarette taxes to combat smoking. Over the years, overwhelming research has proved it works. But there’s one wrinkle: The tax increase has to be large, or else it has little effect on smokers.

As a result, the battle has increasingly focused on not just whether states should increase taxes, but by how much.

Health advocates regularly fight for $1 to $2 increases, while cigarette companies push to limit them to hikes of 25 to 50 cents. That has led, at times, to bizarre conflicts.

Last year, when Missouri considered raising its cigarette tax for the first time in more than two decades, tobacco companies actually supported the increase, while health groups such as the American Cancer Society strongly opposed it.

The reason? The proposed increase was so low – either a gradual 23-cent hike or a 60-cent increase over four years – that researchers concluded smokers would pay it and keep smoking.

The Missouri fight was particularly important because the state has the lowest cigarette tax in the country. These days, Missouri smokers pay only 17 cents per pack, plus the nationwide federal tax of $1.01 cents.

Health advocates accused tobacco companies of backing the small bump to avoid larger hikes in the future.

Tobacco giant R.J. Reynolds, which spent $12.5 million for the cause, denied that motive, saying it promoted the tax because it didn’t hurt consumers and retailers and because the money would go to a good cause – early-childhood education. “We thought it was a reasonable, common-sense proposal,” R.J. Reynolds spokesman David Howard said.

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