Wednesday, February 25, 2026
Senate Committee on Agriculture and Revenue
Assembly Committee on State Affairs
2 East Main Street
Madison, Wisconsin 53707
Chairman Testin, Chairman Swearingen, Members of the Committees, thank you for the opportunity to testify today.
As many of you know, I’m Leah Vukmir, Senior Vice President of State Affairs at the National Taxpayers Union, a former Wisconsin state legislator, and a certified pediatric nurse practitioner. I come before you as a nurse, as a policy professional, and as a former legislator who understands firsthand how tax policy shapes behavior. Many of you and I served together in this building. We debated difficult issues, but we always shared the same goal—better outcomes for Wisconsin families.
As I consider tobacco harm reduction from the different perspectives I’ve held throughout my career, I arrive at a simple conclusion: tobacco harm reduction, supported by rational tax policy, can improve public health and reduce costs for Wisconsin taxpayers.
As a nurse practitioner, I have seen firsthand what years of combustible cigarette smoking can do to the human body. Smoking remains the leading cause of preventable disease and death in America. It is the burning—the combustion—that causes the overwhelming majority of harm. Despite decades of public health efforts, millions of adults still smoke. Quitting is difficult. While cessation is the ideal, many adults need practical tools to move away from combustible cigarettes. That is where harm reduction matters.
Not all tobacco and nicotine products carry the same level of risk. Non-combustible alternatives—including nicotine pouches, e-cigarettes, heated tobacco products, snus, and traditional smokeless tobacco—eliminate combustion. These smoke-free alternatives are increasingly used by adults seeking options beyond cigarettes, and innovation continues to expand the range of non-combustible products available.
Despite the addition of these products to the marketplace, the American medical and policy communities have been frustratingly slow to embrace their use as lower-risk options. No, these products are not risk-free. However, for many lifelong smokers, they may be the most realistic way to quit cigarettes.
As a clinician, I have also seen how widespread misunderstanding about nicotine itself discourages harm reduction. Many people mistakenly believe nicotine is the primary cause of cancer, heart disease, and lung disease. A global survey of more than 15,000 physicians found that 74–78% wrongly believed nicotine causes lung cancer, COPD, or atherosclerosis; 70–86% of U.S. doctors hold the same misconception [1].
In reality, it is combustion—not nicotine itself—that drives the overwhelming majority of smoking-related disease. When smokers believe all nicotine products are equally dangerous, they are less likely to switch—and more likely to continue using combustible cigarettes.
As a policy professional and former legislator, I believe tax policy should reflect differences in risk. Tax policy is not just about generating revenue—it also creates incentives and shapes behavior. Wisconsin has an opportunity to shape both public policy and individual choices by developing a tax code that reflects the relative health risks of products currently on the market, as well as innovative, lower-risk alternatives entering the marketplace. These less harmful innovations should certainly be taxed at a lower rate than combustible cigarettes, which pose the greatest danger. When tax policy treats products with materially different health profiles the same, it undermines the incentive structure that makes harm reduction possible.
The fiscal implications of smoking-related illness are substantial, both here in Wisconsin and nationally. According to the Wisconsin Department of Health Services, smoking-related care in Medicaid alone is estimated to cost close to $700 million each year. Smoking drives an estimated $3 billion in annual health care expenses, along with $5.6 billion in lost worker productivity [2].
Nationwide, smoking drives approximately $240 billion annually in Medicaid and state health plan costs [3]. Even a modest 1% reduction among Medicaid patients could save $2.6 billion—roughly $25 million per state [4].
When smokers transition away from combustible cigarettes to lower-risk, non-combustible products, exposure to toxicants falls, leading to fewer cases of cancer, heart disease, COPD, and pregnancy complications. These improvements translate into lower healthcare costs, fewer hospitalizations, and meaningful relief for state health budgets, easing the financial strain on taxpayers while improving public health outcomes.
Modernizing Wisconsin’s tobacco and nicotine tax structure to reflect relative risk would align public health goals with fiscal responsibility and ensure that our policies keep pace with innovation and emerging smoke-free alternatives.
This is not about encouraging use. It is about ensuring that tax policy reflects differences in risk and supports harm reduction for adults who would otherwise continue smoking combustible cigarettes.
As a nurse, my priority is patient health. As a policy professional, my priority is evidence-based outcomes. As a former legislator, my priority is ensuring that our laws align with our public health and fiscal goals.
If we want fewer smokers and lower Medicaid costs, our tax code should make that outcome easier—not harder.
Every smoker who transitions away from combustible cigarettes represents a public health victory—and a taxpayer victory.
Less harm. More health. Lower costs. That’s the outcome Wisconsin should incentivize.
Thank you for your time and consideration.
Sincerely,
Leah Vukmir
Senior Vice President of State Affairs
National Taxpayers Union
References
[1] Steinberg MB, Bover Manderski MT, Wackowski OA, Singh B, Strasser AA, Delnevo CD. Nicotine risk misperception among US physicians. Journal of General Internal Medicine. 2021;36(12):3888–3890. doi:10.1007/s11606-020-06172-8.
[2] Wisconsin Department of Health Services Tobacco Use Cessation Report (2024). Tobacco Use Cessation: 2024 Annual Report to the Governor and the Legislature. Wisconsin Department of Health Services. Published June 9, 2025. Accessed February 24, 2026.
[3] Centers for Disease Control and Prevention. Economic Trends in Tobacco. National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health. Published September 17, 2024. Accessed February 24, 2026.
[4] Glantz SA. Estimation of 1-Year Changes in Medicaid Expenditures Associated With Reducing Cigarette Smoking Prevalence by 1%. JAMA Network Open. 2019;2(4):e192307. doi:10.1001/jamanetworkopen.2019.2307