publication date: Sep. 18, 2020

Alan Blum, MD

Professor and Endowed Chair in Family Medicine,

Director, The Center for the Study of Tobacco and Society,

University of Alabama School of Medicine, Tuscaloosa

Eric Solberg, MS

Vice president, academic & research affairs,

University of Texas Health Science Center at Houston;

Faculty associate, McGovern Center for Humanities and Ethics,

McGovern School of Medicine, Houston

This story is part of The Cancer Letters ongoing coverage of COVID-19s impact on oncology. A full list of our coverage is availablehere.

The unprecedented COVID-19 pandemic makes it possible to compare and contrast the public health and political responses to previous health crises.

The most obvious comparison is to the influenza epidemic of 1918-19, which took the lives of 675,000 Americans in less than two years.

Yet a comparison with cigarette smoking, which has killed untold millions of Americans in the 20th century and continues to take the lives of 500,000 a year, is arguably more illuminating. At first glance, comparing COVID-19 to cigarettes seems illogical. Yes, people who take up smoking do so willingly, although most do so before they reach adulthood. And yes, those who contract COVID-19 do not willingly seek out the virus.

Disease and death from smoking take years, even decades to occur. Deaths from COVID-19 can occur within days or weeks, albeit in less than 2.9% of victims, most of whom have comorbid conditions such as hypertension, obesity, and emphysema.

As we assess the 50-year War on Cancer that was declared when President Richard M. Nixon signed the National Cancer Act of 1971, some parallels and lessons from the past that can be gleaned from anti-smoking campaigns and applied to the efforts against COVID-19.

As defiant and skeptical as President Trump may be of the preventive behavioral measures that all health agencies agree are the first step to contain the spread of the virus, his magical-thinking approach mirrors the playbook of previous presidents to ending the cigarette pandemic, even decades after it was recognized as the nations leading avoidable cause of death and disease.

Should anyone really be surprised that when it comes to public health and health care, money and politics take precedence over science?

In early April, no sooner had Anthony Fauci, of the White House COVID-19 Task Force, come to the conclusion that all Americans, not just front-line health workers and patients, needed to wear face masks, practice social distancing, and wash their hands to prevent the spread of COVID-19, President Trump began subverting this message by retweeting Faucis original assertion in March that mask-wearing by the general public was not yet necessary.

By mid-summer, Trump had rejected the recommendations by the Centers for Disease Control and Prevention on protecting meat processing plant workers, teachers, other school personnel, and children from COVID-19. Trump not only muted, muzzled, and marginalized the CDC, he had also become its de facto spokesperson.

Even as he has publicly played down the ease of spread and the adverse health consequences of COVID-19, last week we listened to the recording of his February interview by reporter Bob Woodward, in which Trump acknowledged the ferocity of the new virus.

This called to mind the response by another president to the efforts by the top health official in his administration to launch the federal governments first anti-smoking campaign. In January 1978, U.S. Secretary of Health Education and Welfare Joseph A. Califano, Jr., announced that HEW would place the weight of its scientific authority behind programs to inform the publicespecially the youngabout why they should not smoke and how they can quit if they wish. As the chief health officer of government, I have the duty to see that we do just that.

Within weeks, Califanos efforts were being undermined by President Jimmy Carter, who traveled to North Carolina to assure tobacco famers that the government would make cigarette smoking even safer than it is today. As Califanos campaign continued to gain momentum, and after HEW published the most comprehensive indictment yet of cigarette smoking in its 1979 Surgeon Generals Report, Carter fired Califano. There was little doubt that the main reason was his fervent anti-smoking stance.

The present-day Republican-led opposition to state and local ordinances mandating the wearing of face masks in public places is akin to the vocal opposition in 1964 to federal legislation to require an understated warning on the side of cigarette packs (Caution: Cigarette Smoking May Be Hazardous to Your Health).

The staunchest opponents of the warning were not just the cigarette manufacturers and tobacco state congressmen, but also the American Medical Association, which claimed that the public was already well informed about the dangers of smoking.

In those days, Republican Sen. Jesse Helms were beating back anti-smoking bills introduced by Democratic Sens. Ted Kennedy and Dick Durbin and Reps. Henry Waxman and Ron Wyden. Today, we can take in the spectacle of Republican Sen. Rand Paul (a physician) and Republican House Members Matt Goetz, Luis Gohmert, and Mark Meadows deriding the recommendation to wear face masks.

All four contracted COVID-19, with Gohmert blaming his infection on having to wear a mask.

At his nationally televised town meeting on Sept. 15, in which he claimed that herd mentality could make the virus disappear, Trump also claimed that the repeated putting on and taking off a mask could increase the chances of becoming infected with COVID-19.

The other two physicians in the Senate, Republicans John Barrasso and Bill Cassidy, have stood behind Trump every step of the pandemic. In May, Barrasso, an orthopedic surgeon until he was appointed to the Senate in 2007, cited his medical background to support Trumps call to end COVID-19 containment shutdowns and echoed Trumps comment that we cannot allow the cure to be worse than the disease.

Granted, oversimplifying the comparison between the response to COVID-19 and the fight against smoking risks reducing it to a body count competition. Yet, that is just what Stanford historian Robert Proctor did in a book review in the July 7 issue of JAMA:

It all seems so February. Cigarettes remain the leading preventable cause of death, but that morbid fact is easily lost in more pressing pandemics. It is worth keeping in mind that even if the novel coronavirus 2019 (COVID-19) ends up killing 200,000 people in the U.S., that number will not be even half the annual toll from cigarettes, which still kill half a million Americans every year.

Such a comment is as simplistic and cold-hearted as any of Trumps unempathetic pronouncements downplaying the catastrophic impact of COVID-19. One hears echoes of the claim that the virus will just disappear, but smoking will remain.

Sadly, this is the same narrative that all too many individuals who work in the field of tobacco control have used for other emerging health crises such as the rapid rise in obesity, namely that smoking is always the bigger killer.

They seem to see other health issues as a threat to their turf. Proctor calls the assertion that his smoking dog is bigger than your COVID dog an enduring constancy and insists that scholars need to pay more attention to cigarettes, even in these distressing days of plague.

Any focus on disease that ignores the cigarette or the cigarette industry is like pretending to have an interest in malaria while paying no attention to mosquitoes or swamps. Nicotine addiction is likely to outlive coronavirus, shackling millions in chains that lead to suffering and death. The havoc wreaked on human health is worse than any virus.

Nathan Schachtman, an attorney and lecturer at Columbia Law School who has written on tobacco litigation, is appalled by Proctors claim. This type of comparison between COVID-19 and smoking is inapposite, he says. COVID puts me at risk from even a brief encounter with an infected person. I have no control as an individual over the risk of this infectious disease; it absolutely requires coordinated action by government. We can all agree that both smoking and COVID are public health problems, while refraining from making inane comparisons. The thing about COVID-19 is that a pandemic ensures that there will be innocent victimspeople who did not assume the risk, but had the risk of death and disability foisted upon them by fellow citizens.

Two hundred thousand deathsin addition to hundreds of thousands of potential long-haulers suffering from crushing fatigue, lung and heart damage, and other problemscaused by a single pathogen in just six months extrapolates to 300,000 deaths this year, plus a lingering morbidity comparable to that caused by cigarette smoking. And there is no cure in sight, but rather false promises by the president of a breakthrough vaccine just around the corner before Election Day.

Instead of trying to make the case that smoking is worse than COVID-19, we should instead be applying the lessons weve learned from anti-smoking efforts to reduce the toll of COVID-19, argues Michael Siegel, professor of community health sciences at Boston University School of Public Health. Most obviously, the chronic conditions of emphysema and cardiovascular disease that help COVID take hold are frequently due to smoking. The successes and failures of the past five decades of anti-smoking actions are playing out now in the daily COVID-19 death tallies.

Writing in Financial Times on Aug. 4, Sir Richard Feachem, who served as under-secretary-general of the United Nations and founding executive director of the Global Fund to Fight AIDS, Tuberculosis, and Malaria, warns that counting on a COVID-19 vaccine to come to our rescue soon is not only unlikely but is a dangerous assumption on which to plan the overall response to the pandemic.

Politicians and vaccine developers have incentives to reinforce this assumption, he notes, in spite of the long odds against a vaccine with high efficacy, a protracted duration of protection, a convenient dosing schedule, and the ability to administer billions of doses.

Is this not reminiscent of the never-ending quest for the Holy Grail of the safe cigarette? Can anyone doubt that the biggest failure in the history of the National Cancer Institute is not to have dispelled the myth that filtered cigarettes can prevent lung cancer?

The tobacco industrys view, as reflected in the Tobacco Observer, a publication of the Tobacco Institute, April 1982.

Following the release of the 1964 Surgeon Generals Report, there was a dramatic increase in advertising claims by the tobacco companies implying that filtered cigarettes were safer than non-filtered ones.

This campaign extended to Hollywood, where TV and movie heroes and heroines smoked filtered brands while the crooks and tramps smoked non-filters. Alas, the history of the filter is at the heart of why the reduction in smoking has been so slow.

Beginning in the early-1950s, when the devastating reports of the impact of smoking on health were making front-page news and beginning to drive down cigarette sales, the tobacco industry took the upper hand by proclaiming in full-page newspaper advertisements across the U.S. that it would fund research to identify and remove any harmful ingredients from cigarette smoke.

By the late 1960s and throughout the 1970s, the National Cancer Institutes research efforts on smoking were almost entirely directed toward finding a safer cigarette. This dead-end research didnt get the ax until 1980, when Vincent DeVita became director of NCI and began shifting the focus of smoking research to getting heavy smokers to quit.

Even then, a far more heavily funded NCI research project in the 1980s was chemoprevention, which aimed to reduce lung cancer in smokers with large doses of vitamin A. The highly promoted study was halted when it was found that this caused an increase in lung cancer.

The unequivocal conclusion of the landmark 1964 U.S. Surgeon Generals report on smoking and health that cigarettes cause lung cancer and other diseases was to have ended a debate that had raged for decades.

Instead, the tobacco industry made a preemptive strike by funneling a total of $18 million over 14 years to the American Medical Associationthe only major health organization to withhold its endorsement of the reportin a research program to identify and remove any possible harmful components of cigarette smoke.

Why did the AMA choose not to campaign against smoking, but rather to conduct the same kind of research that the report had already found sufficient for its indictment of smoking?

It did so in order to remain in the good graces of tobacco state senators, whom it counted on to help prevent the creation of Medicare by Congress. This, in turn, leads to another villain that has gone unnoticed: the insurance industry, which never lifted a finger to fight smoking, even long after a small Massachusetts insurer, State Mutual Life Assurance Company, offered the first non-smoker discount after the SG report came out in 1964.

Because the anti-smoking narrative has been revised as a great victory instead of an abject failure, the rogues gallery is endless. One of the genuine leaders was the fearless Sen. Maureen Neuberger, who castigated not just the tobacco companies but also the see-no-evil, hear-no-evil, speak-no-evil AMA in her 1964 book Smoke Screen: Tobacco and the Public Welfare.

The AMA/tobacco industry collaboration distributed research funds to dozens of universities to keep scientists in their laboratories and not out testifying to the need to end smoking now. Columbia University, although not a participant as an institution with the AMA program, went so far as to market a patented super-filter that it claimed would remove the cancer-causing tar and prevent lung cancer. It didnt.

The filter con endures to the present day. Ninety-nine percent of cigarettes sold are filtered brands, in spite of the fact that filters likely increase the risk of death and disease from smoking by virtue of the smoker needing to inhale more deeplyand by fostering complacency about the dangers of smoking.

Essentially the same kind of players that fought efforts to pass clean indoor air legislation or bills to ban or restrict cigarette advertising and promotion are at it again with COVID-19. The cigarette companies filter and low-tar hucksterism is not unlike the touting by Trump of oleander, hydroxychloroquine, zinc, bleach, Lysol, and UV light for the prevention of COVID infections.

Meanwhile, Trumps COVID-19 advisers include individuals untrained in infectious disease, notably retired Stanford radiologist Scott Atlas. In a scathing op-ed in the Los Angeles Times on Sept. 10 by Stanford epidemiologists Steven Goodman and Melissa Bondy, co-signed by all of their epidemiology colleagues at the university, the authors castigate Atlas for recommending less COVID-19 testing and less mask-wearing in indoor public spaces, as well as for downplaying the nonfatal health risks of the virus and its transmissibility by children.

The Washington Post and The New York Times were criticized by an editorialist at The Wall Street Journal for questioning Atlas fitness and credentials, even though Atlas got the job after espousing his unconventional views on Fox News. Both the Journal and Fox News are controlled by the pro-Trump Murdoch family, whose patriarch Rupert Murdoch served on the board of Philip Morris from 1989 to 1998; Philip Morris executives in turn have served on the board of Murdochs News Corp.

To think that in 1854, fully 40 years before Robert Koch discovered the bacterium that causes cholera, a lone London obstetrician named John Snow identified the source of a cholera outbreak with pencil, paper, and shoe leather.

By interviewing surviving family members of many of the more than 500 victims, he realized that the fatalities were clustered around a single water pump in Broad Street, from which most of the victims had obtained their household supply.

Countless lives were saved when the pump was ordered shut, over the objections of the water companies, which blamed the cholera epidemic on bad air, or miasma. Religious zealots blamed divine intervention.

Ironically, it was a minister, Rev. Henry Whitehead, who at first contended that the outbreak was not caused by tainted water but by Gods will, who surprised himself to discover that the cause was a soiled diaper emptied into a leaky cesspool near the pump.

More than half a century after the causes of the epidemic of lung cancer and emphysema became known through epidemiologic studies, the tobacco industry, like the water companies of Snows London, insisted that their product was not to blame. They were backed up by administration after administration as the cigaretteand its tax revenuesbecame a mainstay of the economy.

Arguably the best single summary of government policy on smoking came from the United Kingdoms Royal College of Physicians in the 1971 sequel Smoking and Health Now to its pioneering report on smoking and health in 1962: Castigating the government for spending little to educate the public about the dangers of smokinga tenth of the amount spent on traffic safety.

The report dryly observes, It seems that Ministers, while accepting the evidence that cigarette smoking is dangerous to health, are guided in their actions by the view that the risks are regrettable but inevitable consequences of a habit which they believe to be an essential source of revenue.

The economy-over-lives approach to COVID-19 by the current president is reminiscent of other administrations approach to curbing smoking.

College football, get out there and play football, Trump said on Aug. 11, when the only major universities left whose officials had given the season a green lightin the Atlantic Coast and Southeastern conferencesare located in the very region with the least adherence to personal COVID-19 health precautions and a steady rise in the number of cases.

By his masks-be-damned rallies and his tweets to Liberate Michigan! and other battleground states with Democratic governors from the inconvenience of wearing a mask and washing hands, Trump has become a 21st century Typhoid Mary, a super-spreader of COVID-19 through his crowded campaign rallies.

By stoking the embers of anti-scientific thinking for years in regard to the safest and most effective vaccines, by mocking the wearing of masks and social distancing, and by claiming that there is a COVID-19 vaccine just around the corner, Trump has undermined confidence in the safety and efficacy of any such rushed-out vaccine by those who would normally support vaccination.

In addition, HHS and FDA have been corrupted by political pressure to approve hydroxychloroquine and convalescent plasma as treatments for COVID-19 in spite of the absence of safety data. Fauci has been told to refrain from stating that children can transmit COVID-19. And CDC has been forced to walk back recommendations on school reopening and contact tracing, and its venerable publication, MMWR has been censored by the administration.

On June 23, Financial Times published the marvelously understated headline, Resistance is low at U.S. disease-control body. This week we finally learned that the source of this chaos and the sharp decline in the publics and health professionals confidence in the CDC has been a troubled Trump appointee, Michael Caputo, a far-right conspiracy-monger and protg of convicted felon Roger Stone.

It is dj vu all over again. In 1987, one of us (AB) would be told upon assuming a faculty position at Baylor College of Medicine that he could not use his academic affiliation when speaking publicly on smoking and that he should consider getting into something more socially acceptable, like cocaine.

This meant, of course, that studying illicit drugsnot cigaretteswas where the grant funding wasand dont you keep messing with the folks at the tobacco companies who have influence over Capitol Hill and the NIH!

One year later, he would be offered the editorship of the journal of the American Academy of Family Physicians, American Family Physiciancontingent on his not speaking publicly on the subject of smoking.

The AAFP was a recipient of advertising revenue from food subsidiaries of RJ Reynolds and Philip Morris. AB turned down the job.

What is the fairest way to compare strategies to contain the virus with the efforts to reduce cigarette smoking? Why not begin with those who are made ill by a known agent through no fault of their own, as well as through willfully misleading directives by elected officials?

The turning point in the effort to reduce cigarette smoking came in the early 1980s, when studies in Japan and Greece found that long-term exposure to cigarette smoke could cause lung cancer in a person who did not smoke.

Certainly, those individuals who were involuntarily exposed to cigarette smoke over many years at the workplace and who developed terminal lung cancer or emphysema would be unequivocal innocent victims of smoking.

What about those who contract COVID-19?

The only ones in this population who arent unequivocally innocent victims are those who refuse to wear masks, practice physical distancing, wash hands frequently, and refrain from participating in social gatherings, political rallies, or protest demonstrations.

Another way to look at smoking-related deaths is through the number of those who had chosen to continue to smoke in spite of knowing that it could kill them.

One could argue that nicotine addiction is too powerful to overcome, and that, therefore, all of the blame must be laid at the feet of tobacco industry executives and the leaders of allied businesses that have engaged in the promotion of cigarettes in spite of the dangers.

But what about the accountability of public health agencies, which are tasked both with curbing infectious outbreaks and improving the health of the entire population? If a commissioner of health were found to have failed to allocate funds to mosquito control after an outbreak of West Nile, dengue, St. Louis encephalitis, or zika, then that individual would be held partially responsible for the cases that resultedand criminally negligent if the funds were deliberately withheld because the commissioner didnt believe that mosquitoes were the vector, or if he or she pocketed the money.

Analogously, why shouldnt a health commissioner or health agency that chooses not to allocate funding to discourage smoking be held accountable for a failure to reduce tobacco-related deaths and diseases and/or cigarette consumption? Fanciful? But if the number one avoidable cause of death and disease in the health district doesnt receive sufficient funding, then why shouldnt there be accountability?

Although Surgeon General Luther Terry called for appropriate remedial action on smoking in 1964, it would be fully 25 years before every state had even a single individual assigned to reduce smoking.

Nor were health department commissioners permitted to endorse efforts to pass clean indoor air regulations to protect nonsmokers.

And what about academia, organized medicine, and the voluntary health organizations, such as the American Cancer Society? What did they do as the battles over restrictions on cigarette advertising heated up in the 1980s? Most were nowhere to be found.

Individual tobacco product liability lawsuits brought against the tobacco industry beginning in 1983 by New Jersey attorney Mark Edell (Cipollone v Liggett Tobacco Group Inc.), followed by class action suits brought by several state attorneys general in the mid-1990s, began to expose the myth of organized medicine as an enemy of Big Tobacco.

In a TV interview in 1996, the president of the American Medical Association, Lonnie Bristow, famously claimed, We were duped.

This is in spite of the AMA having accepted cigarette ads in its journal from the early-1930s to the mid-1950s, the same time period when the epidemiological and pathological research showing the association between smoking and disease was being published.

This was also in spite of the publication of the Surgeon Generals Report in 1964, following which the AMA, as noted here, spent 14 years conducting research funded by the tobacco industry in lieu of taking action or even calling for action against smoking, apart from advising the public not to smoke in bed.

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Seeing COVID-19 through a cloud of cigarette smoke The Cancer Letter - The Cancer Letter