FRANKFORT, Ky. (AP) -- When Dr. Ralph Alvarado was elected to the Kentucky state Senate in 2014, he found his new colleagues had something in common with most of his patients: They knew smoking was bad, they just couldn't quit.
For more than two years, Alvarado has led the effort to restrict smoking in a state with the highest smoking rate in the country. He keeps a white lab coat in his Senate office, giving him a little more authority with lawmakers and lobbyists. But his efforts have so far been thwarted by the cultural legacy of tobacco, which along with coal has declined sharply because of a mix of market and political forces while still maintaining its grip on public policy in Kentucky.
Banning smoking in public places is still a politically perilous position for most of the state's Republican lawmakers, whose constituents view it as an attack on their personal freedoms. Alvarado - also a Republican - is insulated from this, even though his district includes parts of rural Montgomery and Clark counties where he says smoking bans are met with scowls.
"The comments from people (are), 'Well what do you expect, he's a doctor.' And so I'm almost excused," he said. "It takes off the shackles for me a little bit to be able to talk about this issue."
State lawmakers have focused most of their attention to the state's rising death toll from drug overdoses, including opioids, which killed more than 1,200 people last year. During that same time period, more than 8,800 Kentuckians died from tobacco-related illnesses, according to Shawn Jones, past president of the Kentucky Medical Association.
Kentucky had more tobacco-related cancer cases per 100,000 people than any other state, according to a study from 2009-13 by Centers for Disease Control and Prevention.
"If you're going to use the word crisis with respect to the opioid epidemic in Kentucky - and I think we should - then we must do the same with regard to smoking," he said.
Alvarado's first attempts to ban smoking failed. In 2015, he angered his Republican colleagues when he joined Democrats in an attempt to force a vote on a statewide workplace smoking ban. Last year, Alvarado sponsored a similar bill that had the support of at least one major tobacco company and the promised indifference from other tobacco interests. But he could not convince a majority of Republican senators to bring the bill to the Senate floor for a vote.
Alvarado has since narrowed the legislation and is trying again. This week, he convinced the Senate to approve a ban on all tobacco products from public schools and school-sponsored events, something only 36 percent of Kentucky's 173 school districts had done. The bill still drew opposition from some rural Republicans and Democrats, but it prompted a reluctant "yes" vote from Sen. Damon Thayer, the No. 2 Republican in the Senate who has long opposed other statewide smoking bans.
"The people at a school have no choice to be there," Thayer said.
While the Senate vote gives anti-smoking advocates hope that they have momentum, they still have hurdles to overcome. Since 2011, the tobacco industry has spent more than $4.5 million lobbying the state legislature, among the most of any industry.
And most lawmakers have steered the debate away from health risks and toward the philosophy of personal choices.
"You hear the statement that this could save lives. There's a lot of things we could do to save lives," Republican Sen. John Schickel said. "For me the question is who should be making the decision? Clearly, we shouldn't be making it."
A spokesman for Altria, which owns Phillip Morris USA and is consistently one of the top lobbying spenders in Kentucky, said the company did not lobby Alvarado's 2016 smoking ban bill. But they do support his tobacco ban in public schools.
Alvarado says his primary motivation comes on Friday afternoons, when he exchanges his suit jacket for a white lab coat and visits patients.
"I'm watching them kill themselves and I see them die with their last dying breath with a cigarette in their mouth," he said. "You get frustrated for those people probably more so than trying to pass a law.