In Wareham, nearly 23 percent of adults smoke cigarettes, 45 percent higher than the national average.

In Massachusetts, 6.8 percent of women smoke during pregnancy. In Wareham, that number rises to 20 percent - 194 percent higher than statewide, according to the Massachusetts Department of Public Health.

At over 46 percent, the rate of illegal tobacco sales to minors is 244 percent higher in Wareham than the rest of the state. Mortality from lung cancer is 62 percent higher in Wareham compared to the rest of Massachusetts.

In a bid to combat those high rates, the Board of Health issued new tobacco regulations in 2016, increasing minimum prices for some products, heavily restricting the sale of flavored tobacco products and raising the minimum age to purchase from 18 to 21.

Over 150 towns in Massachusetts, including Wareham, have raised the age of sale of tobacco products to 21. Though the federal floor is 18 for purchasing these products, cities and towns can choose to go above that age requirement. State legislators are scheduled to consider raising the minimum age for purchasing tobacco products from 18 to 21 this year.

Why so many people in Wareham smoke

There may be several reasons for the high number of smokers in Wareham, according to Kathy Wilbur, the program manager at Southeast Tobacco-Free Community Partnership.

“There are subcategories that help us see where higher smoking rates lie,” Wilbur said.

For example, statewide, 30 percent of adults with poor mental health smoke cigarettes. Among MassHealth users, 24.5 percent smoke. Other subcategories of those more likely to smoke include people with a household income of less than $25,000, those who have a disability, a high school education or less or identify as LGBT, Wilbur said.

In fact, people with a low socioeconomic status, who are on MassHealth or who have poor mental health make up 70 percent of smokers in Massachusetts, Wilbur said. In Wareham around 21 percent of the population has a household income of less than $25,000 and 46 percent of adults have a high school education or less, according to Census Bureau data.

“A lot of it has to do with a lack of access to quality health care and health literacy, knowing how to advocate for yourself and lacking opportunities for good health care,” Wilbur said.

Low income areas are also associated with a higher tobacco retail density. An increased access to tobacco can especially encourage young people to take up smoking.

Bob Collett, the tobacco control division program director for the Barnstable County Department of Health, said Wareham historically has had the highest smoking rate within his region of 30 towns. Wareham’s rates are consistent with cities like New Bedford, Brockton and Cranston.

Wilbur said those who fit in the categories that make people more likely to smoke apply to pregnant women as well. There is a strong likelihood that women with lower income, disabilities or poor mental health are affected by daily stress and anxiety, causing them to reach for a pack of cigarettes despite the health risks, she said.

Combatting the problem

In addition to health-related resources and raising the age to buy tobacco products, many towns in the state, including Wareham, are making tobacco retail policies that discourage young people from starting to smoke.

Wareham has implemented a flavor restriction, which means only adults-only retailers can sell flavored tobacco products. Since young people can’t frequent adults-only shops, which card at the door, they are less prone to purchase products “blatantly targeted at youth,” Wilbur said.

“This is a super effective strategy in preventing people from starting smoking at all,” Wilbur said.

Last April, the Wareham Board of Health also voted to raise the price of tobacco products in smoke shops. The board raised the price of a cigar to a $2.50 minimum and $5 for a two-pack. In neighboring towns without these regulations, the same cigar might cost as low as 79 cents for a single cigar or 99 cents for two.

Wilbur said some tobacco shops have stopped selling single cigars altogether because of the price increase throughout the state.

The Wareham Board of Health has been tremendously influential in tobacco cessation in town, Collett said.

“The work of the Wareham Board of Health has absolutely been a leader in addressing the tobacco program in Wareham,” Collett said. “They are to be commended for the regulations they have passed with the intent of addressing this problem.”

Fed up with recently imposed tobacco regulations, a smoke shop owner spoke to the Board of Health earlier this summer, saying regulations have lost him a lot of business in his Wareham shop.

“We’re all adults. We have the right make our own decisions,” Louis Bourassa, the owner of New England Smoke Shop on Cranberry Highway, told the Board of Health in June. “If people are going to smoke, they’re going to do it.”

Wilbur said a minimum price requirement for tobacco products has been shown to have its health benefits. A higher price lowers the chance of purchasing cigars as an “impulse buy,” she said.

Though some business owners may suffer in the short-term, Collett said this is relatively insignificant in comparison to the health benefits of tobacco regulations.

“Health benefits outweigh any potential temporary business loss for one or two businesses,” Collett said. “All Americans, as a population, we pay $800 billion per year in Medicare costs to care for sick and dying smokers.”

Around 95 percent of adult smokers start smoking before age 21, according to Tobacco-Free Kids, so this measure, when paired with other tobacco regulations, can discourage young people from ever starting to smoke, Wilbur said.

“In Massachusetts, there has been a sweeping movement to change the age to 21,” Wilbur said. “Most of the major cities and half of the state has done this.”

When it's time to quit

Funding for tobacco cessation programs is shrinking, Collett said. Resources have been cut from the state budget. Collett said they currently operate at half of 1 percent of the funds that are supposed to be designated for tobacco control in Massachusetts. Though local group and one-on-one counseling used to be available for those trying to quit smoking, these programs are no longer available.

There are several cessation resources still available in Wareham. Wilbur recommended starting out with a telephone-based helpline. Calling 1800-QUIT-NOW directs interested parties to a counseling service available 24/7. A trained cessation counselor can talk people through quitting or cutting down on cigarettes. They will also mail those who are medically eligible four weeks of nicotine patches.

Most health insurance plans also offer tobacco cessation benefits. MassHealth gives access to a nicotine replacements, including a patch, lozenge, gum or inhaler, according to Wilbur, with a copay of a few dollars.

All insurance plans should cover at least one FDA approved tobacco cessation product, Wilbur said. She recommends people call their insurance company to find out what is offered so they can take full advantage.

See interactive visual data on Wareham's smoking population here.