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Abstract Purpose of Review Increasing wildfire size and severity across the western United States has created an environmental and social crisis that must be approached from a transdisciplinary perspective. Climate change and more than a century of fire exclusion and wildfire suppression have led to contemporary wildfires with more severe environmental impacts and human smoke exposure. Wildfires increase smoke exposure for broad swaths of the US population, though outdoor workers and socially disadvantaged groups with limited adaptive capacity can be disproportionally exposed. Exposure to wildfire smoke is associated with a range of health impacts in children and adults, including exacerbation of existing respiratory diseases such as asthma and chronic obstructive pulmonary disease, worse birth outcomes, and cardiovascular events. Seasonally dry forests in Washington, Oregon, and California can benefit from ecological restoration as a way to adapt forests to climate change and reduce smoke impacts on affected communities. Recent Findings Each wildfire season, large smoke events, and their adverse impacts on human health receive considerable attention from both the public and policymakers. The severity of recent wildfire seasons has state and federal governments outlining budgets and prioritizing policies to combat the worsening crisis. This surging attention provides an opportunity to outline the actions needed now to advance research and practice on conservation, economic, environmental justice, and public health interests, as well as the trade-offs that must be considered. Summary Scientists, planners, foresters and fire managers, fire safety, air quality, and public health practitioners must collaboratively work together. This article is the result of a series of transdisciplinary conversations to find common ground and subsequently provide a holistic view of how forest and fire management intersect with human health through the impacts of smoke and articulate the need for an integrated approach to both planning and practice. 

We review science-based adaptation strategies for western North American (wNA) forests that include restoring active fire regimes and fostering resilient structure and composition of forested landscapes. As part of the review, we address common questions associated with climate adaptation and realignment treatments that run counter to a broad consensus in the literature. These include: (1) Are the effects of fire exclusion overstated? If so, are treatments unwarranted and even counterproductive? (2) Is forest thinning alone sufficient to mitigate wildfire hazard? (3) Can forest thinning and prescribed burning solve the problem? (4) Should active forest management, including forest thinning, be concentrated in the wildland urban interface (WUI)? (5) Can wildfires on their own do the work of fuel treatments? (6) Is the primary objective of fuel reduction treatments to assist in future firefighting response and containment? (7) Do fuel treatments work under extreme fire weather? (8) Is the scale of the problem too great – can we ever catch up? (9) Will planting more trees mitigate climate change in wNA forests? and (10) Is post-fire management needed or even ecologically justified? Based on our review of the scientific evidence, a range of proactive management actions are justified and necessary to keep pace with changing climatic and wildfire regimes and declining forest successional heterogeneity after severe wildfires. Science-based adaptation options include the use of managed wildfire, prescribed burning, and coupled mechanical thinning and prescribed burning as is consistent with land management allocations and forest conditions. Although some current models of fire management in wNA are averse to short-term risks and uncertainties, the long-term environmental, social, and cultural consequences of wildfire management primarily grounded in fire suppression are well documented, highlighting an urgency to invest in intentional forest management and restoration of active fire regimes.