Jeffrey Willett: If we want to end smoking, harm reduction must be part of the plan

By Jeffrey Willett

Cigarette smoking remains Washington’s most persistent and costly public health problem. Each year, cigarette use kills more than 8,000 residents and drives 1 in 4 cancer deaths statewide. Smoking costs Washington’s Medicaid program roughly $850 million – an especially daunting amount given the projected $3 billion in annual cuts to the program following federal legislation passed in July 2025.

Despite decades of progress, smoking is increasingly concentrated among people who already face the greatest health burdens, including military veterans, people with mental health or substance use disorders, LGBTQ adults and seniors. We need to focus on newer strategies that can quickly improve public health outcomes; strategies that help people who smoke switch to far less harmful alternatives offer one of the most promising paths forward.

Most people who smoke want to quit. About half try each year. Yet fewer than 1 in 10 succeed using traditional cessation tools alone, such as counseling or medicinal nicotine replacement therapies.

For many adults, those methods simply don’t work, which is why millions are turning to lower-risk, noncombustible nicotine products such as e-cigarettes and nicotine pouches, and why many report greater success leaving cigarettes altogether.

This matters because it’s the burning of tobacco, not nicotine itself, that causes most smoking-related diseases. That distinction is not controversial. For years, independent scientists and the Food and Drug Administration have recognized a “continuum of risk” for tobacco products, with combustible cigarettes posing the greatest harm and noncombustible products presenting substantially lower risk.

Since 2009, the FDA has regulated tobacco products and evaluated whether new products can be legally sold. Recently, the agency authorized several e-cigarette and nicotine pouch products after determining that they are likely to provide greater public health benefits for adults who switch from cigarettes. FDA sets a high bar for any new tobacco products, and these authorizations reflect a careful, often years-long scientific review.

Yet despite strong science regarding the continuum of risk, many policymakers and health professionals continue to treat all nicotine products as equally harmful. Proposals to ban flavors or impose high taxes on FDA-authorized, lower-risk products ignore the basic reality: People who smoke are highly sensitive to product price and access.

When less harmful alternatives become harder to obtain or more expensive than cigarettes, fewer adults switch and more keep smoking. Yet, as of Jan. 1, thanks to the tax increase passed by the Legislature in 2025, a nicotine pouch costs more in Washington than a pack of cigarettes.

Current legislative proposals threaten to widen this disparity by adjusting the Modified Risk Tobacco Product discount – a policy designed to lower the cost of products with proven harm-reduction benefits – in the wrong direction.

Two bills currently under consideration in the Washington Legislature illustrate this counterproductive trend. HB 2382 would cut the MRTP tax discount in half, significantly diminishing the financial incentive for smokers to switch to better alternatives. Meanwhile, SB 6129 would remove the MRTP discount entirely and increase the tax rate for nicotine pouches from 95% to 100%.

Opponents of tobacco harm reduction raise an important concern: youth nicotine use. That concern must be taken seriously. No one wants kids using nicotine, but protecting youths and helping adults move away from smoking are not mutually exclusive goals.

Thanks to Tobacco 21 laws, improved age-verification, and sustained education efforts, youth nicotine use in the United States has fallen to the lowest levels in decades. Those gains show that it’s possible to reduce youth access without denying adults effective alternatives to smoking. Policies that blur this distinction risk sacrificing adult lives without delivering meaningful additional protection for youth.

Public health has long embraced harm reduction in other areas, from condoms and clean syringes to safer medications and overdose prevention. Tobacco should be no different.

Washington can lead by aligning its tobacco policies with science. That means ensuring FDA-authorized, lower-risk nicotine products remain available and affordable, especially in comparison to cigarettes, for adults who want to transition away from smoking.

It also means encouraging health care providers to talk openly with patients who smoke about all evidence-based options, including lower-risk alternatives, rather than limiting conversations to approaches that have already failed them.

For decades, policymakers have focused on making cigarettes more expensive and more inconvenient to use. That effort should continue, but if we truly want to accelerate the end of smoking, we must also make less harmful options more affordable and accessible.

Harm reduction is not a retreat from public health; it is a practical strategy for finally ending the extraordinary harm caused by cigarettes.

Jeffrey Willett, a tobacco and nicotine policy expert, formerly served as the senior vice president of health strategies at the American Heart Association and as vice president of the Truth Initiative. He is an adviser on tobacco harm reduction to PMI US Services Inc. He lives in Andover, Kansas.