A new report from the U.S. surgeon general finds there are gaps in smoking rates on racial, ethnic, gender and class lines. Cigarette smoking rates have been trending downward in recent years but the report found racial and ethnic communities, members of the LGBTQ+ community and lower-income people smoke at higher rates.

The report found that people in poverty are more than twice as likely to smoke as those with income above the poverty line.

Native Americans and Alaska Native people have higher rates of smoking than other racial and ethnic groups. Americans identifying as lesbian, gay or bisexual had higher rates of smoking than heterosexual adults.

“Tobacco use imposes a heavy toll on families across generations. Now is the time to accelerate our efforts to create a world in which zero lives are harmed by or lost to tobacco,” Surgeon General Vivek Murthy said in a statement alongside the report.

The report also found that 1 in 5 U.S. deaths tie to cigarette smoking and exposure to secondhand smoke. In total, smoking and secondhand smoke are responsible for roughly 500,000 deaths per year.

The report suggested a series of policy recommendations, including improving health care equity, enacting policies to protect people from secondhand smoke exposure, setting limits on how much nicotine can be in tobacco products and a ban on menthol cigarettes.

The U.S. Food and Drug Administration had been working on a rule to ban menthol cigarettes but the Biden administration held off on finalizing the rule after tobacco industry pressure.

The surgeon general’s report mentioned that inequality also persists in advocacy spending. The report says that for every $1 spent by tobacco control groups, there are more than $12 spent on tobacco industry marketing.