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As a physician, former member of Congress, and former secretary of the US Department of Health and Human Services, I have spent much of my career focusing on policies that improve health outcomes. I also saw a number of people smoking nearby. I lost my father to what I often call “Lucky Strike lungs.” That experience doesn’t stay with me – and it underscores a simple fact: smoking remains one of the most serious and persistent public health challenges.
Yet in Washington, there is a growing tendency to talk about smoking as if it were yesterday’s problem. It is not. About 25 million American adults still smoke, and far too many have been left out of the public health debate. That is the central message of “The Forgotten Smoker,” A new white paper from Philip Morris International US (PMI US) urges policymakers to face a reality they often ignore: progress has stalled for millions of Americans who are still at high risk.
From a doctor’s point of view, these Americans are not abstracts. Patients, parents, staff, veterans and neighbors. Many have tried to quit more than once. Many are well aware of the dangers. But understanding 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 older adults who continue to smoke instead of assuming that the problem will resolve itself.
An effective approach starts with a clear public health goal: the greatest harm comes from burning. The FDA has recognized that tobacco and nicotine products present a continuum of risk, with cigarettes being the most dangerous and other forms of smoking cessation that generally pose lower health risks than continuing to smoke. That is important. For adults who are not completely quitting nicotine, quitting smoking can still be a meaningful health intervention.
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There are 25 million Americans who still smoke, but are ignored by the public health conversation. (Stock)
Unfortunately, that message has not reached the people who need it most. The FDA can make real progress by approving smoke-free products through its rigorous scientific review process, but that progress means little if patients never hear about it — or if their doctors don’t feel ready to discuss it accurately. As a doctor, that worries me a lot. Regulatory action is important, but communication is what turns regulatory action into public health impact.
We can see the results in the data. A national survey of 1,565 US health professionals commissioned by PMI US and commissioned by Povaddo LLC found that 47% mistakenly believe nicotine causes cancer, while another 19% are unsure. The truth is, nicotine itself does not directly cause cancer.
The same survey found that 69% want the FDA to share clinical evidence about the role that smoke-free products can play in reducing harm, 68% want clear guidance on counseling patients who want to quit smoking, and 95% say they will share information provided by the FDA with patients. That is no small discovery. It’s a clear sign that doctors want reliable, effective tools — and that the FDA is uniquely positioned to provide them.
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That confusion does not stop at the door of the clinic. “The Forgotten Smoker” The survey found that misinformation about nicotine and its associated dangers is widespread: 52% of Americans incorrectly believe that nicotine itself causes cancer, and 73% mistakenly believe that all tobacco products and nicotine are equally dangerous.
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However, the community also understands that there is unfinished business. When presented with the prevalence of smoking, 79% say more needs to 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 straightforward. The FDA should equip doctors with practical, plain-language guidance they can use now – materials enhanced with input from practicing doctors that explain what the agency has approved, what that approval does and doesn’t mean, and how to have evidence-based conversations with adult smokers who are trying to quit smoking.
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It should clearly and repeatedly state what causes the greatest danger to health: smoking, not nicotine. It should make prescribing decisions understandable to non-specialists and bring that science into the exam room, where patient decisions are often shaped. And it should speak directly to older smokers in ways that meet them where they are, especially communities that are often overrepresented in 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 provides both patients and clinicians with tools for action. A forgotten smoker goes unnoticed for a very long time. Washington should stop looking away.
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