PURPOSE: Tobacco smoking remains a leading cause of morbidity and mortality throughout Mexico. This study analyzes changes in smoking-attributable disease burden across Mexico’s 32 states from 1990 to 2017 using results from the Global Burden of Disease (GBD) 2017 study. METHODS: We obtained estimates of age-standardized mortality rates and disability adjusted life years (DALYs) attributable to smoking for commonly associated cardiovascular and chronic respiratory diseases. We then analyzed trends over time using time series data from 1990 to 2017. RESULTS: Smoking-attributable mortality rates decreased in Mexico from 1990 to 2017 for both cardiovascular (34.4 deaths per 100,000 persons to 15.4 deaths) and chronic respiratory diseases (16.8 deaths per 100,000 to 10.3 deaths). Magnitude of decline varied across states with the largest decreases observed in Aguascalientes and Coahuila. DALY rates also declined over this time period, with the largest declines observed in Nuevo Leon and Coahuila. The absolute number of smoking-attributable deaths increased by 17.8% (10.8%–24.3%) for cardiovascular causes and 68.8% (68.0%-71.5%) for chronic respiratory diseases over our study period. CONCLUSIONS: Although smoking-attributable morbidity and mortality have both decreased across Mexico over the last several decades, adverse health outcomes persist at unacceptably high levels. Variations in progress observed across states may provide an opportunity for local ministries of health to tailor tobacco control policies with greater precision. CLINICAL IMPLICATIONS: These findings reflect the enduring importance of tobacco control strategies in reducing smoking- attributable health burden across Mexico and the importance of strategies such as strengthening cessation services broadly.