Alesa Ryals would spend close to $120 every month on her four-pack-a-day cigarette habit.

That is 80 cigarettes per day, and if she slept about seven hours every night, she smoked one cigarette on average every 15 minutes she was awake. That is one after another after another.

This was in the late 1970s, when she said cigarettes were about $1 per pack.

"I didn't do it like every day," she said of her habit. "I had gotten up to where I was smoking one after another."

While many think the tobacco epidemic in the U.S. is solved, the truth is that 37 million Americans still smoke -- including 21 percent of adults in Alabama -- and a new report from Truth Initiative reveals rates of smoking found in a region dubbed "Tobacco Nation."

Alabama is in that nation, along with Arkansas, Indiana, Kentucky, Louisiana, Michigan, Mississippi, Missouri, Ohio, Oklahoma, Tennessee and West Virginia.

What's worse, is if placed alongside the most tobacco-affected countries in the world, "Tobacco Nation" would rank fourth in the Bloomberg Initiative list of countries most impacted by tobacco globally, with youth smoking rates falling only below Indonesia, Ukraine and Mexico, according to the report.

With more than 66 million residents, these 12 states include roughly 20 percent of the U.S. population and more than 20 percent of its residents are young people aged 10-24. And that's not blowing smoke.

Tobacco use is still the leading cause of preventable death in the United States and in Alabama, according to the American Lung Association. There are more than 8,600 smoking-related deaths each year in the Yellowhammer State, costing more than $4 billion in health care costs and lost productivity.

The high smoking rates, compounded with relative poor health outcomes, low cigarette taxes and lax regulations make Tobacco Nation a disadvantaged country within a country.

Alabama has the 11th highest smoking rate in the nation, and each year, about 8,200 of Alabama's youth become smokers, according to the state's 2015-2020 Alabama State Plan for Tobacco Prevention and Control.

About 50 percent of those smokers will eventually die of smoking-related diseases.

"We cannot afford to let tobacco continue to addict our youth, damage the health of our citizens, and harm those who breathe secondhand smoke," stated then-acting state health officer Tom Miller in November 2015.

Ryals, formerly of Montgomery and who now lives in Fort Deposit, started smoking in her teens in the late 1960s. She stubbed her last cigarette on Dec. 31, 1981.

"I needed to change my lifestyle," she said. "One day, I got to where I was huffing and puffing when I got up my steps (to her house). I realized then that I had to do something."

This year, the American Lung Association in Alabama will continue to educate state legislators about the benefits of tobacco control policies and programs, including a statewide smoke-free law and increased funding for the tobacco control program.

The association will continue to work with partners in the Coalition for a Tobacco Free Alabama to ensure successful passage and preservation of comprehensive local smoke free ordinances.

"Over the past seven years, we've really seen a shift in the work that has been happening in Alabama that relates to prevention and control," said Ashley Lyerly, regional director of Public Policy with the American Lung Association, and chair of the Coalition for a Tobacco Free Alabama.

"A lot is focused on smoke-free environments, and where we can eliminate exposure to second-hand smoke," she said. "We want to start to change the norm around smoking so it becomes less of a norm."