The John Snow Project has set out some of the growing body of evidence that suggests COVID-19 is having serious adverse long-term impacts on human health. This evidence is, however, being subjected to the same ‘doubt as product’ approach that was successfully deployed by the tobacco lobby to slow the introduction of public health measures to protect people from the harms of smoking, and the underlying economic incentive is similar to the rationale of the cigarette companies. While attendees at the World Economic Forum in Davos had to be vaccinated, wear masks, undergo regular COVID-19 tests, and used advanced air ventilation, filtration and treatment to reduce their risk of infection, the costs of such protocols to protect the general public are widely viewed as prohibitively expensive. 

Instead, those who would like to see clean air and protective measures implemented everywhere, from hospitals to schools, are presented as fearmongers, who are recklessly advocating investment in public health without precisely quantifying the benefit, and doubt is cast over the validity of any evidence that suggests COVID-19 may cause long-term or serious harm. We’ve seen this approach before, with merchants of doubt peddling uncertainty in order to undermine solid scientific evidence and dissipate the political impetus for action.

In August 1969, J W Burgard, an executive at Brown & Williamson Tobacco Corporation, sent an internal memo1 setting out six objectives for a campaign that would educate the public on the tobacco industry’s response to the health controversy surrounding smoking. Burgard wanted to:

  1. Attack science as a question of perspective and personality to dispel the ‘false belief’ smoking is associated with lung cancer and other diseases, casting such views as unscientific conjecture made by publicity-seeking opportunists.
  2. Associate smoking with freedom by restoring the cigarette to its proper place of dignity in the marketplace of American free enterprise.
  3. Suggest ill intent by setting out to expose the greatest criminal libel and slander ever perpetrated against any product in the history of free enterprise.
  4. Associate smoking with stability by linking the attack on cigarettes to a pattern of attack on the American free enterprise system.
  5. Dismiss those concerned with public health as fearmongers, by proving the attack on cigarettes is trial by lynch law engineered by uninformed, irresponsible people to induce fear.
  6. Undermine faith in the scientific process in order to establish once and for all that there is no scientific evidence that cigarettes cause cancer.

Burgard went on to say he viewed “our product as doubt, our message as truth—well stated” and viewed the competition as “the body of anti-cigarette fact that exists in the public mind.”

Burgard’s audacious memo was written more than 40 years after the first published evidence of a link between smoking and cancer. In 1925, Fritz Lickint authored a report showing that smoking led to an increased incidence of gastric ulcers and stomach cancer and in 1929 he published the first formal statistical evidence linking tobacco smoking with lung cancer, in which he showed that patients with lung cancer were especially likely to be heavy smokers2.

In 1931, Frederick Hoffman published Cancer and Smoking Habits in the Annals of Surgery3 in which he produced evidence showing a higher general rate of cancer and of lung cancer in particular in smokers when compared to non-smokers, enabling him to conclude, “smoking habits unquestionably increase the liability to cancer of the mouth, throat, esophagus, larynx and lungs.”

1950 saw the publication of three case control studies that demonstrated a link between lung cancer and smoking4-6. In what became a commonplace method of ad hominem attack, doubt was cast on the strength of one of those studies with the suggestion that one of the principal researchers, Ernest Wynder, was motivated by puritanical fervor. Neville Goodman, a civil servant at the British Ministry of Health, said of Wynder:

“He is a young man ‘far gone in enthusiasm’ for the causal relationship between tobacco smoking and lung cancer. (I had been told when I was in New York this spring that he was the son of a revivalist preacher and had inherited his father’s antipathy to tobacco and alcohol). The American Cancer Society was very suspicious of his early work for this reason.”7

1954 saw the publication of the cohort studies that conclusively demonstrated the causal relationship between smoking and lung cancer8,9, which helped pave the way for the first report of the Surgeon General’s Advisory Committee on Smoking and Health in 196410,11. The report concluded smoking was a cause of lung cancer and laryngeal cancer in men, a probable cause of lung cancer in women and the most important cause of chronic bronchitis and prompted health warnings on cigarette packages and a ban on cigarette advertising in broadcasting media.

Anyone who grew up in the 1980s and 1990s, when governments around the world finally acted to ban smoking in public places and restrict tobacco sales, might be surprised that the evidence of the harms caused by smoking had been around for so long. The public would be forgiven for assuming governments would act, and act quickly, once causation was proved.

This was not the case. For instance, the British government accepted the causal link between smoking and cancer in the early 1950s. In 1954, as pressure was mounting on the British government to publicise the links, the Health Minister Iain Macleod, who once chain-smoked through a press conference on the dangers of smoking, wrote to John Boyd-Carpenter, the Financial Secretary to the Treasury:

“I needn’t say anything about the financial implications of any ill-considered statement in this field for we all know that the Welfare State and much else is based on tobacco smoking…My only anxiety is to make whatever statement should be made as quietly as is possible but I feel that we must move soon if events are not to overtake us.”12

As this excerpt from Denial & Delay by David Pollock makes clear, the government of the day suspected the public would not take scientific evidence seriously unless it was endorsed by the government itself:

“Lord Salisbury’s brief for the Home Affairs Committee…recognised that an announcement ‘may well be unavoidable before long . . . But the possible effect of an announcement on the Revenue clearly cannot be ignored. The yield of the tobacco tax is about £600 millions a year – i.e., considerably more than the cost of the Health Service. The television programme [from] about two years ago…seems to have had little effect on smoking. But it may well be that people paid little attention to that programme, thinking that if the matter was really as serious as was suggested, the Government would have made an announcement. If this were so, the effect of the Minister of Health’s announcement might be to bring about a serious reduction in revenue, which it would be very difficult to replace by any tax as little objected to or as easily collected as the tobacco tax.’”12

In the end, the Ministry of Health issued a three-page briefing paper which subtly emphasised the doubts and uncertainties of the link between smoking and cancer. At the same time, the Health Minister accepted an offer from the tobacco industry of £250,000 to fund further study of the issue by the Medical Research Council.12

In 1956, the British Cabinet considered the issue of smoking as a cause of cancer. In response to the then Health Minister, Robert Turton, who suggested warning the public, the Chancellor of the Exchequer Harold Macmillan said that this was a “very serious issue. Revenue was equivalent to 3/6d on income tax: not easy to see how to replace it.” He added: “Expectation of life is 73 for smoker and 74 for non-smoker. Treasury think revenue interest outweighs this. Negligible compared with risk of crossing a street.”13

Burgard’s ‘doubt as product’ memo was written a full 5 years after the US Surgeon General presented unequivocal evidence that smoking caused lung cancer, more than 15 years after the British government had been forced to publicise the link as quietly as possible. Even in the face of compelling evidence and official government statements about the danger and public health advice to avoid smoking, Burgard’s approach worked, partly because there were credible clinicians and scientists who refused to accept the weight of scientific evidence of the harms and helped sustain the false dichotomy by maintaining the fiction of doubt14. It took decades for public health restrictions to finally be imposed, demonstrating to people that governments acknowledged the causal link between smoking, cancer, heart disease and other conditions. Millions of people’s lives ruined or lost, some of them likely thinking to the very end that, “if smoking was really bad, the government would take steps to protect people”.

But with the benefit of hindsight and access to official records, we can see governments didn’t take steps to protect people in the face of a proven public health risk, and consistently prioritised economic interests. Even in healthcare settings where people might be more vulnerable to the impact of secondary smoke, smoking was not discouraged until the late 1980s and wasn’t banned in hospitals and other healthcare settings until the late 1990s and early 2000s15-17. Despite extensive scientific evidence of harm, hospitals and healthcare settings allowed people to engage in a physiologically damaging activity because it was socially and politically acceptable. To admit harm in a healthcare setting would have implied harm in other settings, which might have undermined the economic contribution being made by the tobacco industry.

Whatever one’s understanding of the harms of COVID-19, it would be a mistake to assume governments would automatically protect people from a public health threat in the face of more immediate economic considerations. In fact, history tells us there would be resistance to change that might be costly until the evidence to justify it was overwhelming, a process we’ve already seen played out during the COVID-19 pandemic.

From asymptomatic and airborne transmission to the risk of breakthrough infections and reinfections, from organ, immune system and neurological damage to the impact of Long Covid, every single serious harm of SARS-CoV-2 has been minimized by influential commentators, including experts on some public health committees, whose words seem to carry more weight with policymakers than the carefully designed studies evidencing these harms. Each of these harms increases the rationale for a change of approach - and each will be resisted by those keen to defend the status quo.

J W Burgard would be proud of his contemporary disciples who have taken on his mantle as merchants of doubt, but the public should be under no illusions about what is happening. While national and international health agencies around the world advise against infection or reinfection by SARS-CoV-2, industry lobbies and many politicians are enthusiastically promoting a return to pre-2020 social and economic practices without any mitigations against the novel virus that has transformed the risks we all face as we go about our daily lives. For while smokers choose to accept the risks inherent in satisfying their tobacco addiction, none of us can opt out of breathing.

It is important to note that no government has said COVID-19 has gone away and that we can resume unmitigated social interactions facing the same risks we did in 2019. Instead, official messaging has centered around the idea of individual responsibility, that we should each engage in our own assessment of the risks of SARS-CoV-2 infection. This feels a little like government smoking policy in the 1950s; the scientific evidence of cumulative harm is mounting, some national and international public health agencies are warning of the danger, merchants of doubt are making appeals to uncertainty in the name of individual freedom, and governments are unconcerned or worried about the costs of implementing the changes necessary to help keep people safe.

While we wait for public health policy to catch up with the scientific evidence, here are some steps we can take to reduce our risk.