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As a physician, former member of Congress, and former secretary of the U.S. Department of Health and Human Services, I have spent much of my career focused on policies that improve health outcomes. I have also seen the toll of smoking up close. I lost my father to what I often call “Lucky Strike lungs.” That experience has stayed with me — and it underscores a simple fact: smoking remains one of the nation’s most serious and persistent public health challenges.
Yet in Washington, there is a growing habit of talking about smoking as if it were yesterday’s problem. It is not. Roughly 25 million American adults still smoke cigarettes, and far too many have been left out of the public health conversation. That is the central message of “The Forgotten Smoker,” a new white paper from Philip Morris International U.S. (PMI U.S.) that urges policymakers to confront a reality they too often overlook: progress has stalled for millions of Americans still at greatest risk.
From a physician’s perspective, these Americans are not abstractions. They are patients, parents, workers, veterans and neighbors. Many have tried to quit more than once. Many know the risks all too well. But understanding the danger and overcoming addiction are not the same thing. If we are serious about reducing smoking-related disease, our policies must reflect the lived reality of adults who continue to smoke instead of assuming the problem will solve itself.
A more effective approach starts with a straightforward public health principle: the greatest harm comes from combustion. The FDA has recognized that tobacco and nicotine products exist on a continuum of risk, with cigarettes at the most dangerous end and smoke-free alternatives generally posing lower health risks than continued smoking. That matters. For adults who do not quit nicotine entirely, moving away from cigarettes can still be a meaningful health intervention.
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Unfortunately, that message is still not reaching the people who need it most. The FDA can make real progress by authorizing smoke-free products through its rigorous scientific review process, but that progress means little if patients never hear about it — or if their clinicians do not feel prepared to discuss it accurately. As a physician, I find that especially troubling. Regulatory action matters, but communication is what turns regulatory action into public health impact.
We can see the consequences in the data. A national survey of 1,565 U.S. healthcare practitioners commissioned by PMI U.S. and fielded by Povaddo LLC found that 47% mistakenly believe nicotine is a carcinogen, while another 19% are unsure. The fact is, nicotine itself does not directly cause cancer.
The same survey found that 69% want the FDA to share clinical evidence on the role smoke-free products can play in harm reduction, 68% want clear guidance on counseling patients who want to move away from cigarettes, and 95% say they would share FDA-provided information with patients. That is not a marginal finding. It is a clear signal that clinicians want credible, practical tools — and that the FDA is uniquely positioned to provide them.
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That confusion does not stop at the clinic door. “The Forgotten Smoker” research found that misinformation about nicotine and relative risk is widespread: 52% of Americans incorrectly believe nicotine itself causes cancer, and 73% mistakenly believe all tobacco and nicotine products are equally harmful.
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Yet the public also understands there is unfinished work. When presented with the scale of continued smoking, 79% say more should be done to reduce smoking-related harm. In Washington, that should be seen for what it is: both a warning and an opening to act.
What should happen next is fairly straightforward. The FDA should equip clinicians with practical, plain-language guidance they can use now — materials developed with input from practicing physicians that explain what the agency has authorized, what that authorization does and does not mean, and how to have evidence-based conversations with adult smokers trying to move away from cigarettes.
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It should say plainly and repeatedly what drives the greatest health risk: smoke, not nicotine. It should make authorization decisions understandable to non-experts and bring that science into exam rooms, where patient decisions are often shaped. And it should speak directly to adult smokers in ways that meet them where they are, especially populations that remain overrepresented among those who continue to smoke, including older Americans and veterans.
Good public health policy meets people where they are, uses the best available evidence, and gives both patients and clinicians the tools to act. The forgotten smoker has been overlooked for too long. Washington should stop looking away.
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