The reduction in the rate of tobacco use in the USA has been dramatic. Having fallen from 42% of the adult population in 1964 to 18% by 20142 and down to 14% in 20173 it is one of the most significant public health achievements since population-wide vaccination programs. However, due to population growth, there are as many Americans dying from tobacco now as in 1964. Currently more than 540,000 US citizens die from tobacco related causes a year.4 In 2010, when the tobacco mortality estimate was 435,000 it was estimated that roughly 200,0005 suffered from other substance use and mental disorders6, a conservative number today considering the increased number of annual deaths.