Smoking vs Drinking in America: Why the Two Habits Rarely Overlap

By Tim Oshchepkov, CTO at Map AI. Updated November 3, 2026.

You might expect the places that drink the most to smoke the most too. Map AI’s data shows the opposite: across 3,143 US counties, a higher smoking rate goes with a lower binge drinking rate, not a higher one.

Smoking and binge drinking rates are self-reported shares of adults aged 18 and older, from 2020 CDC data, as shown on Map AI’s health pages. The correlation across all counties is r = −0.35.

Smoking and drinking states rarely overlap

Splitting the 50 states at the median for each habit (18.8% for smoking, 16.4% for binge drinking) puts 34 of them in the two “mixed” groups: high on one habit, low on the other. Only 8 are above the median on both.

The “more smoking, less drinking” group is the South and Appalachia: Kentucky, West Virginia, Tennessee, Mississippi. The “less smoking, more drinking” group runs from the upper Midwest to the Northeast and the West: Wisconsin, Minnesota, Iowa, Massachusetts, California. The two state rankings tell the same story: the 10 highest-smoking states include four of the 10 lowest-drinking states.

A closer look: counties at the four extremes

Among the 2,405 counties with at least 10,000 residents, the mixed groups are again twice as common as the matched ones. The table shows the most extreme counties in each group, and those extremes have recognizable profiles:

Split at the county medians: 20.3% smoking, 16.2% binge drinking. Linked counties open their full health page on Map AI.

• High on both: the most extreme cases are rural counties in Montana, Louisiana, Alaska and the Dakotas, several of them with large Native American populations.
• High smoking, low drinking: seven of the ten most extreme cases are in the coal country of southern West Virginia, with others in the Mississippi Delta and Oklahoma. In McDowell County, WV, 35.3% of adults smoke but only 10.3% binge drink.
• Low smoking, high drinking: the most extreme cases are in the prosperous upper Midwest and its college towns: Madison (Dane County), Ames (Story County) and the Milwaukee and Minneapolis suburbs.
• Low on both: the ten most extreme cases are all in Utah, led by Utah County, the lowest-smoking county in the US.

Why the two habits split: income

Income explains most of the pattern. Across counties, the smoking rate falls as median household income rises (r = −0.73), while the binge drinking rate rises with it (r = +0.43). Wealthier, more educated counties smoke less and binge drink more, poorer ones the reverse. Once income and education are held constant, the link between smoking and drinking almost disappears (r = −0.12 across counties, and essentially zero across states). The two habits do not push each other away. They follow different social gradients.

What these numbers do not show

These are area rates, not individual habits: a county with high smoking and low drinking may still have many people who do both. The rates are 2020 survey-based estimates, and binge drinking measures occasional heavy drinking, not total alcohol use. The income and education controls are a simple linear adjustment on county medians, not a full model; age structure, religion, rurality and local alcohol law are not included.

Conclusion: smoking and drinking split along income lines

Smoking and binge drinking do not move together in America. Smoking concentrates in poorer Southern and Appalachian counties, binge drinking in wealthier Midwestern and Northern ones, and only about one county in six is above the median on both. For anyone planning health programs, that means the two problems usually need different strategies in different places, and checking the local data beats assuming that one risk implies the other.