I lay out why millions of Americans who still smoke are being overlooked, what the evidence says about relative risk, how clinicians and regulators are misaligned, why communication matters as much as authorization, and what practical steps could help adults move away from the deadliest products.
I’ve practiced medicine and served in public office, and those two perspectives shape how I see tobacco policy. I also lost my father to what I often call “Lucky Strike lungs.” That loss is why I keep returning to one stubborn truth: smoking is not a solved problem.
More than two dozen million adults in this country still light up, and progress has slowed for many who face the toughest barriers to quitting. A recent white paper titled “The Forgotten Smoker,” draws attention to the fact that large swaths of the population remain at high risk and often fall outside the reach of current public health efforts.
These people are not statistics. They are patients, parents, coworkers and veterans who have tried to quit more than once and know the risks, yet keep struggling. Addiction and life circumstances complicate behavior, so policy that assumes people will simply stop smoking ignores lived reality.
From a health standpoint, there is a simple principle that should guide choices: combustion causes the most harm. Regulatory science now treats tobacco and nicotine products as a continuum of risk, with combustible cigarettes at the far end of danger and smoke-free options generally carrying lower risks for those who will not fully quit nicotine.
Authorization of less harmful, smoke-free products by regulators matters, but it is only one part of the equation. If clinicians and patients never get clear, evidence-based guidance, authorization stays inside government documents instead of reaching exam rooms and kitchen tables where decisions are actually made.
“The Forgotten Smoker” research found that confusion about nicotine and relative harm is widespread: 52% of Americans incorrectly think nicotine itself causes cancer, and 73% believe all tobacco and nicotine products carry the same risk. A separate survey of U.S. healthcare practitioners showed similar gaps in understanding, with 47% mistakenly identifying nicotine as a carcinogen and another 19% unsure.
Those same clinicians want tools. The survey found 69% want the FDA to share clinical evidence about the role smoke-free products can play in harm reduction, 68% want clear counseling guidance for patients looking to move away from cigarettes, and 95% say they would pass FDA-provided information along to their patients. That is a clear signal: healthcare professionals will use credible, practical resources if those resources exist.
Practical next steps are straightforward and actionable. Regulators should pair rigorous authorization with plain-language materials developed with input from practicing physicians that explain what authorizations mean and what they do not mean. Communications should emphasize the key driver of health risk — smoke, not nicotine — and present the science in terms that patients and non-experts can grasp.
Messages must meet people where they are, especially those overrepresented among current smokers, including older adults and veterans. Public health policy that rests on the best evidence and hands clinicians usable tools can turn regulatory wins into real reductions in disease and death. The forgotten smoker deserves to be part of that work, not left behind.
