Lessons from the Tobacco Wars for the Vaccination Wars

Covid-19 has caused many deaths since it began affecting the whole world in 2019. As of April 19, 2022, the disease caused by the novel SARS-CoV-2 virus had officially claimed 6.2 million lives worldwide; however, the figure would have been much higher without effective vaccines being introduced.

In late 2020, when the first vaccines began to emerge, research showed that approximately 1 in 3 US adults wanted to be vaccinated, 15% (a fairly stable proportion) were strongly resistant to vaccination, and the remainder had no strong ideological opposition. Currently, approximately 27% of US adults remain unvaccinated. A major challenge for future pandemics and all vaccines is hesitancy and individuals not receiving booster doses.

Amid the confusing, entirely political noise, much of it full of hatred and lies, the voice of the public health system must not be lost. These rates are similar in many Western societies with developed healthcare systems.

A Similar Struggle: The Tobacco Wars

Lessons from the tobacco wars can provide perspective on the current pandemic. In the case of tobacco, the cigarette industry unfortunately fueled “preventable deaths” by influencing millions of people with messages portraying use of its products as glamorous and normal.

In the 1960s, nearly half of US adults smoked. Today's rate of approximately 12.5% is the result of decades of multifaceted public health efforts that made tobacco use less attractive, less normal, and less socially acceptable.

Scientific research on tobacco harms was first summarized in the first US Surgeon General's report on smoking and health in 1964; the tobacco industry attacked these data. Unfortunately, the report had little impact. C. Everett Koop's 1986 report, a major compilation of epidemiological and biological data, pointed to tobacco use as a major preventable cause of cancer and death in a way that overcame the challenges and, most importantly, also highlighted the harms of exposure to tobacco smoke.

Resistance from the Tobacco Industry

Koop and similar researchers were defamed by the tobacco industry, which launched and sustained campaigns aggressively casting doubt on the scientific evidence linking smoking and health, spreading misinformation about smoking, emphasizing tobacco's economic importance, and issuing supposed warnings about restrictions on individual freedom. Industry leaders lied to the US Congress, a government body, and the public, contrary to longstanding knowledge that nicotine is addictive and tobacco use can be fatal.

Smoking Does Not Harm Only You! Just as Not Being Vaccinated Does Not Harm Only You

Although early debates on tobacco control focused on personal choices, two studies in 1981 reported that nonsmoking spouses of smokers had a greater risk of lung cancer than nonsmoking spouses of nonsmokers, shifting the discussion away from individual choice. Over the next few years, at least a dozen further studies demonstrated the dangers of secondhand smoke. What initially concerned smokers became an issue for everyone when it became clear how one person's actions endangered other people's lives.

Congress never imposed a federal smoking ban. Efforts by former FDA (US Food and Drug Administration) Commissioner David Kessler and other officials to have the FDA restrict nicotine and tobacco products were rejected by the Supreme Court in 2000.

• Related topic: Beyond Secondhand Smoke: What Is Thirdhand Smoke?

The War Against Tobacco Began

Fortunately, in 2009, Congress gave the FDA limited authority to regulate tobacco to restrict marketing and sales to young people and require warning labels on tobacco products. Healthcare professionals' smoking-cessation messages thus reached every level of society. Policies were also introduced to restrict smoking in public places, workplaces, schools, restaurants, bars, and aircraft. As part of the message behind the goal of broadening the social norm, these efforts not only reduced smoking but also highlighted the importance of clean air.

In addition to public information messages from athletes, artists, and actors, advertisements featured people debilitated by tobacco use who expressed regret about smoking and warned others not to start. The US Centers for Disease Control and Prevention (US-CDC) Tips From Former Smokers campaign, launched in 2012 and still running on television, encouraged more calls to quitlines and increased smoking cessation rates.

Taxing tobacco products, restricting promotional advertising, and taking important steps against tobacco industries recruiting more young people to use their products also helped reduce the number of smokers. Legal battles were launched to hold tobacco companies accountable and allow states to recover insurance costs for people harmed by smoking. These battles culminated in the 1998 Master Settlement Agreement, the largest liability settlement in US history.

The Battle Against Resistance to Covid-19 Vaccination

The efforts of antivaccination movements, which are not particularly new but grew during the Covid-19 pandemic, show many similarities to strategies used during the tobacco wars. Although not funded by a single industry, these movements are well supported by certain political figures, some doctors, and media companies. Unfortunately, these opposing views create doubt and distrust toward science and government. A large amount of misinformation about vaccine safety and effectiveness can easily reach everyone through the internet and similar channels.

Initially, the tobacco wars involved large advertisements and public relations campaigns, but antivaccine social media and reactionary media channels now produce and support absurd conspiracy theories claiming that vaccines contain microchips to control human behavior, cause infertility, or harm fetuses. Smearing scientific leaders such as Anthony Fauci, Chief Medical Adviser to the US President, is a sad repetition of the attacks on Koop and others. Once again, important decisions affecting public health are being made by courts—including the Supreme Court—rather than public health experts.

Vaccination Reduces the Outbreak

Of course, important differences exist between tobacco control and vaccination. For example, interventions to prevent smoking initiation and chronic disease take decades to have an effect, while vaccination can reduce hospitalizations and acute viral illness within days or weeks. CDC data have shown that the number of people receiving approved Covid-19 vaccines reduced hospitalizations and Covid-related deaths in the United States. Studies of household transmission have also shown that vaccination programs reduce SARS-CoV-2 transmission. Vaccination also prevents indirect damage to the healthcare system.

A Campaign for Accurate Information

We believe persuasive public information campaigns modeled on the successes of the tobacco wars—such as a poster showing the harm caused by Covid-19 and the power of vaccines—are necessary to counter vaccine misinformation. Receiving vaccines and booster doses should be an accepted social norm during any pandemic. Adaptations of campaigns such as Tips for Vaccination could include expressions of regret from the many people who had not been vaccinated just before being intubated. Only then do these patients say they need the vaccine, adding that it is now too late.

Get Vaccinated and Reduce the Burden on Healthcare Workers!

Unvaccinated people often assume doctors and hospitals will always be available when they become ill. Informational messages could therefore also feature healthcare workers demonstrating the burden Covid-19 places on doctors and patients who need treatment for any condition.

Mandatory Vaccination Cards

Vaccination requirements, like seat belts and airport security checks, have helped increase vaccination rates in some places. Local and community-level regulations, such as requiring proof of vaccination (a vaccination card, for example) to enter public spaces and maintain local business functions, may be even more effective than federal mandates.

The Most Trusted Source: Doctors

Trusted doctors remain the best source for communicating health information most effectively. However, despite the extraordinary efforts of many doctors during the pandemic, not every doctor provides accurate information. Governments are also invalidating, or should invalidate, the professional licenses of healthcare workers spreading harmful misinformation.

Not Being Vaccinated Harms the Whole Community, Not Just You

Public health experts have known for years that tobacco use causes cancer, but unfortunately scientific knowledge alone has little effect on smoking behavior. Just as recognizing that smokers endanger others was a turning point for tobacco control, it is clear that unvaccinated people also endanger their family members, surroundings, community, and healthcare system. Messages containing this information and these warnings may be effective in encouraging vaccination. However, a well-funded, multifaceted communication effort will be needed to change the behavior of people who remain hesitant.

People are still free to choose and will remain free: smoking or not being vaccinated is still a choice. But the roadmap laid out by tobacco-control efforts has shown that public thinking can turn toward public health and social benefit. With vaccination, this may take decades, so it would be best to start as soon as possible.