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Many states received failing grades on the latest American Lung Association report card rating tobacco control efforts. Forty-three states and the District of Columbia earned an “F” for funding smoking-prevention programs at less than half the levels recommended by the Centers for Disease Control and Prevention (CDC).

Alaska was the only state that funded tobacco programs at the CDC’s recommended levels, Bloomberg Businessweek reports. Overall, states’ collective spending on anti-smoking programs dropped 11 percent last year, and only Vermont and Connecticut raised cigarette taxes. Eight states rejected cigarette tax proposals, while New Hampshire decreased its cigarette tax 10 cents per pack, according to the report, the State of Tobacco Control.

“At a time when our country is trying to get a handle on health-care spending, this is an enormous expense that could be avoided by investing in effective tobacco-prevention and cessation programs and policies,” said American Lung Association President and Chief Executive Officer, Charles Connor.

The report covered four policy areas: cigarette taxes, smoking bans, tobacco-prevention spending and cessation coverage. Four states—Delaware, Hawaii, Maine and Oklahoma—received passing grades in all four areas, while six states—Alabama, Mississippi, Missouri, South Carolina, Virginia and West Virginia—failed in all four categories.

The federal government made some progress in tobacco control, by beginning to offer comprehensive smoking cessation benefits to millions of federal employees and their families, the report noted. The federal government also announced it will give states partial reimbursement for smoking cessation counseling services for Medicaid enrollees through state toll-free phone quitlines.

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