Melvin Stubbs knows smoking cigarettes could give him heart disease, lung cancer or kill him. He said his habit hurts his wife and parents, who often urge him to quit.
"That's one thing I struggle with on a daily basis," said Stubbs, 38, a smoker for almost two decades. "You know if you don't stop how many loved ones will be upset if something happened to you."
The retail manager from Memphis, Tennessee is among the estimated 38 million American adults who smoke cigarettes because they've tried to quit but couldn't, because they enjoy it or because they are trying it for the first time.
While the U.S. cigarette smoking rate has declined dramatically since it its peak in the mid 1960s, rates remain high among some groups.
Native American and Alaska Native adults, African-American men, lesbian, gay and bisexual adults have the highest smoking rates, according to a recent CDC report. Rates also are high among the poor and those who have low educational attainment.
The consequences of cigarette smoking can be deadly.
About 480,000 Americans die every year due to cigarette smoking and secondhand smoke, according to the Centers for Disease Control and Prevention. Smoking also is linked to high blood pressure and diabetes, two conditions that can cause heart disease, the No. 1 killer of Americans. About one-quarter of heart disease and stroke deaths are related to cigarette smoking, according to federal data.
"This is a very severe addiction, it's almost as being addicted to cocaine," said Aruni Bhatnagar, a co-director of the American Heart Association's Tobacco Regulation and Addiction Center. "Nicotine is not an easy substance to get rid of."
Although prevention and cessation initiatives and regulations have helped people quit, he said, "We now need to focus our prevention efforts into targeting these subcultures [with high smoking rates]."
Radeanna Comb, a health educator in the Navajo Nation, nurtures relationships in tribal communities where cessation programs are scarce. For prevention to succeed, she said, "It's important to plan programs that are culturally relevant."
For instance, there are materials that may challenge sacred tribal customs that include tobacco use. She's mindful of that when sharing information about the harmful effects of nicotine, the powerful and addictive stimulant found in tobacco plants.
While the statistics by race and ethnicity offer a glimpse of who smokes in America, heart disease and stroke researchers say social and emotional issues underly cigarette consumption.
Studies have shown, for instance, that people who are under persistent stress, have suffered discrimination or live with anxiety and depression are more likely to find it harder to quit smoking.
Income level and educational attainment also play a role. Federal data shows people who earn less than the poverty guidelines and attended high school without completing, or who completed high school level studies only, are much more likely to smoke than peers who earn more and have more schooling.
In a recent report addressing these social factors, CDC researchers argued smoke-free regulations and cigarette taxes would help curb smoking rates among American adults who have low educational attainment and earn low incomes. They said that was true in part because they were more likely to be targeted by tobacco advertising and less likely to be exposed to health information.
"From a policy perspective, the most powerful action we could take is to raise price," said Dr. Michael Fiore, a physician and researcher for over 30 years and founder of the Center for Tobacco Research and Intervention at the University of Wisconsin.
But Fiore also said policymakers should make cessation programs more affordable - or free - for those who need them most.
Amanda L. Graham, a cessation expert, said access to programs is critical. A cancer and tobacco-use researcher for over 20 years, Graham has focused her work on how digital interventions and online social networks have helped people quit cigarettes and other tobacco products.
"When we think about the biggest drivers of health-care costs, if there's an investment that employers and health plans need to be making it's tobacco cessation," said Graham, head of digital cessation programs at Truth Initiative in Washington, D.C.
Stubbs, the man from Tennessee, said he'll continue to smoke for the foreseeable future. He's never sought help from a cessation program and said it could take a serious health problem to make him quit.
He wants his family to continue to urge him to quit because some of what they say sinks in. But he wants them to stop giving him the saddened looks he gets when he pulls out a pack of cigarettes.
"I feel that when they see me smoking, they see a dead body."