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In North Carolina, the adult tobacco use rate was 27.1% in 2019, as reported by the American Lung Association (2020) in the State of Tobacco Control. The state has struggled to reduce tobacco use, earning failing grades in efforts to prevent smoking and e-cigarette use

Acknowledgements The authors thank the Taiwan Health Promotion Administration for collecting the data and providing access to their database for this study Funding The work was supported by the Health Promotion Administration, Ministry of Health and Welfare, Taiwan (Grant Number: MOHW105-HPA-H-114-133708), from Taiwans Health and Welfare Surcharge on Tobacco ProductsGrant Number: 03724606Project Code: 1051218-107), and grants R01DA043950 from the US National Institute of Drug Abuse and P50CA180890 from the US National Cancer Institute, and the US Food and Drug Administration (FDA) Center for Tobacco Products

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On a busy parkway in Connecticut a prominent sign read