2022.02.17 COVID不会像流感那样结束。它将像吸烟一样。

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COVID Won’t End Up Like the Flu. It Will Be Like Smoking.
Hundreds of thousands of deaths, from either tobacco or the pandemic, could be prevented with a single behavioral change.

By Benjamin Mazer
Eight cigarettes arranged in the shape of a coronavirus
Getty; The Atlantic
FEBRUARY 17, 2022
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It’s suddenly become acceptable to say that COVID is—or will soon be—like the flu. Such analogies have long been the preserve of pandemic minimizers, but lately they’ve been creeping into more enlightened circles. Last month the dean of a medical school wrote an open letter to his students suggesting that for a vaccinated person, the risk of death from COVID-19 is “in the same realm, or even lower, as the average American’s risk from flu.” A few days later, David Leonhardt said as much to his millions of readers in the The New York Times’ morning newsletter. And three prominent public-health experts have called for the government to recognize a “new normal” in which the SARS-CoV-2 coronavirus “is but one of several circulating respiratory viruses that include influenza, respiratory syncytial virus (RSV), and more.”


The end state of this pandemic may indeed be one where COVID comes to look something like the flu. Both diseases, after all, are caused by a dangerous respiratory virus that ebbs and flows in seasonal cycles. But I’d propose a different metaphor to help us think about our tenuous moment: The “new normal” will arrive when we acknowledge that COVID’s risks have become more in line with those of smoking cigarettes—and that many COVID deaths, like many smoking-related deaths, could be prevented with a single intervention.

Read: Endemicity is meaningless

The pandemic’s greatest source of danger has transformed from a pathogen into a behavior. Choosing not to get vaccinated against COVID is, right now, a modifiable health risk on par with smoking, which kills more than 400,000 people each year in the United States. Andrew Noymer, a public-health professor at UC Irvine, told me that if COVID continues to account for a few hundred thousand American deaths every year—“a realistic worst-case scenario,” he calls it—that would wipe out all of the life-expectancy gains we’ve accrued from the past two decades’ worth of smoking-prevention efforts.

The COVID vaccines are, without exaggeration, among the safest and most effective therapies in all of modern medicine. An unvaccinated adult is an astonishing 68 times more likely to die from COVID than a boosted one. Yet widespread vaccine hesitancy in the United States has caused more than 163,000 preventable deaths and counting. Because too few people are vaccinated, COVID surges still overwhelm hospitals—interfering with routine medical services and leading to thousands of lives lost from other conditions. If everyone who is eligible were triply vaccinated, our health-care system would be functioning normally again. (We do have other methods of protection—antiviral pills and monoclonal antibodies—but these remain in short supply and often fail to make their way to the highest-risk patients.) Countries such as Denmark and Sweden have already declared themselves broken up with COVID. They are confidently doing so not because the virus is no longer circulating or because they’ve achieved mythical herd immunity from natural infection; they’ve simply inoculated enough people.

President Joe Biden said in January that “this continues to be a pandemic of the unvaccinated,” and vaccine holdouts are indeed prolonging our crisis. The data suggest that most of the unvaccinated hold that status voluntarily at this point. Last month, only 1 percent of adults told the Kaiser Family Foundation that they wanted to get vaccinated soon, and just 4 percent suggested that they were taking a “wait-and-see” approach. Seventeen percent of respondents, however, said they definitely don’t want to get vaccinated or would do so only if required (and 41 percent of vaccinated adults say the same thing about boosters). Among the vaccine-hesitant, a mere 2 percent say it would be hard for them to access the shots if they wanted them. We can acknowledge that some people have faced structural barriers to getting immunized while also listening to the many others who have simply told us how they feel, sometimes from the very beginning.

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The same arguments apply to tobacco: Smokers are 15 to 30 times more likely to develop lung cancer. Quitting the habit is akin to receiving a staggeringly powerful medicine, one that wipes out most of this excess risk. Yet smokers, like those who now refuse vaccines, often continue their dangerous lifestyle in the face of aggressive attempts to persuade them otherwise. Even in absolute numbers, America’s unvaccinated and current-smoker populations seem to match up rather well: Right now, the CDC pegs them at 13 percent and 14 percent of all U.S. adults, respectively, and both groups are likely to be poorer and less educated.

Read: It’s a terrible idea to deny medical care to unvaccinated people

In either context, public-health campaigns must reckon with the very difficult task of changing people’s behavior. Anti-smoking efforts, for example, have tried to incentivize good health choices and disincentivize bad ones, whether through cash payments to people who quit, gruesome visual warnings on cigarette packs, taxes, smoke-free zones, or employer smoking bans. Over the past 50 years, this crusade has very slowly but consistently driven change: Nearly half of Americans used to smoke; now only about one in seven does. Hundreds of thousands of lung-cancer deaths have been averted in the process.

With COVID, too, we’ve haphazardly pursued behavioral nudges to turn the hesitant into the inoculated. Governments and businesses have given lotteries and free beers a chance. Some corporations, universities, health-care systems, and local jurisdictions implemented mandates. But many good ideas have turned out to be of little benefit: A randomized trial in nursing homes published in January, for example, found that an intensive information-and-persuasion campaign from community leaders had failed to budge vaccination rates among the predominantly disadvantaged and low-income staff. Despite the altruistic efforts of public-health professionals and physicians, it’s becoming harder by the day to reach immunological holdouts. Booster uptake is also lagging far behind.

This is where the “new normal” of COVID might come to resemble our decades-long battle with tobacco. We should neither expect that every stubbornly unvaccinated person will get jabbed before next winter nor despair that none of them will ever change their mind. Let’s accept instead that we may make headway slowly, and with considerable effort. This plausible outcome has important, if uncomfortable, policy implications. With a vaccination timeline that stretches over years, our patience for restrictions, especially on the already vaccinated, will be very limited. But there is middle ground. We haven’t banned tobacco outright—in fact, most states protect smokers from job discrimination—but we have embarked on a permanent, society-wide campaign of disincentivizing its use. Long-term actions for COVID might include charging the unvaccinated a premium on their health insurance, just as we do for smokers, or distributing frightening health warnings about the perils of remaining uninoculated. And once the political furor dies down, COVID shots will probably be added to the lists of required vaccinations for many more schools and workplaces.


To compare vaccine resistance and smoking seems to overlook an obvious and important difference: COVID is an infectious disease and tobacco use isn’t. (Tobacco is also addictive in a physiological sense, while vaccine resistance isn’t.) Many pandemic restrictions are based on the idea that any individual’s behavior may pose a direct health risk to everyone else. People who get vaccinated don’t just protect themselves from COVID; they reduce their risk of passing on the disease to those around them, at least for some limited period of time. Even during the Omicron wave, that protective effect has appeared significant: A person who has received a booster is 67 percent less likely to test positive for the virus than an unvaccinated person.

But the harms of tobacco can also be passed along from smokers to their peers. Secondhand-smoke inhalation causes more than 41,000 deaths annually in the U.S. (a higher mortality rate than some flu seasons’). Yet despite smoking’s well-known risks, many states don’t completely ban the practice in public venues; secondhand-smoke exposure in private homes and cars—affecting 25 percent of U.S. middle- and high-school children—remains largely unregulated. The general acceptance of these bleak outcomes, for smokers and nonsmokers alike, may hint at another aspect of where we’re headed with COVID. Tobacco is lethal enough that we are willing to restrict smokers’ personal freedoms—but only to a degree. As deadly as COVID is, some people won’t get vaccinated, no matter what, and both the vaccinated and unvaccinated will spread disease to others. A large number of excess deaths could end up being tolerated or even explicitly permitted. Noel Brewer, a public-health professor at the University of North Carolina, told me that anti-COVID actions, much like anti-smoking policies, will be limited not by their effectiveness but by the degree to which they are politically palatable.


Without greater vaccination, living with COVID could mean enduring a yearly death toll that is an order of magnitude higher than the one from flu. And yet this, too, might come to feel like its own sort of ending. Endemic tobacco use causes hundreds of thousands of casualties, year after year after year, while fierce public-health efforts to reduce its toll continue in the background. Yet tobacco doesn’t really feel like a catastrophe for the average person. Noymer, of UC Irvine, said that the effects of endemic COVID, even in the context of persistent gaps in vaccination, would hardly be noticeable. Losing a year or two from average life expectancy only bumps us back to where we were in … 2000.

Chronic problems eventually yield to acclimation, rendering them relatively imperceptible. We still care for smokers when they get sick, of course, and we reduce harm whenever possible. The health-care system makes $225 billion every year for doing so—paid out of all of our tax dollars and insurance premiums. I have no doubt that the system will adapt in this way, too, if the coronavirus continues to devastate the unvaccinated. Hospitals have a well-honed talent for transforming any terrible situation into a marketable “center of excellence.”

COVID is likely to remain a leading killer for a while, and some academics have suggested that pandemics end only when the public stops caring. But we shouldn’t forget the most important reason that the coronavirus isn’t like the flu: We’ve never had vaccines this effective in the midst of prior influenza outbreaks, which means we didn’t have a simple, clear approach to saving quite so many lives. Compassionate conversations, community outreach, insurance surcharges, even mandates—I’ll take them all. Now is not the time to quit.

Benjamin Mazer is a physician specializing in laboratory medicine.



COVID不会像流感那样结束。它将像吸烟一样。
数十万人死于烟草或大流行病，只需一个行为改变就可以避免。

作者：本杰明-马泽尔
八支香烟排列成冠状病毒的形状
Getty; The Atlantic
2022年2月17日

说COVID就像或者很快就会像流感一样，突然变得可以接受。长期以来，这样的比喻一直是大流行病最小化者的专利，但最近它们已经悄悄进入了更开明的圈子。上个月，一所医学院的院长给他的学生写了一封公开信，建议对于接种疫苗的人来说，COVID-19的死亡风险 "与普通美国人的流感风险相同，甚至更低"。几天后，大卫-莱昂哈特在《纽约时报》的晨报上对他的数百万读者说了同样的话。三位著名的公共卫生专家呼吁政府承认一种 "新常态"，即SARS-CoV-2冠状病毒 "只是包括流感、呼吸道合胞病毒（RSV）等在内的几种流通的呼吸道病毒之一"。


这种大流行病的最终状态可能确实是COVID看起来像流感一样。毕竟，这两种疾病都是由一种危险的呼吸道病毒引起的，在季节性周期中起伏不定。但我想提出一个不同的比喻来帮助我们思考我们脆弱的时刻。当我们承认COVID的风险已经与吸烟的风险更加一致时，"新常态 "就会到来--许多COVID的死亡，就像许多与吸烟有关的死亡一样，可以通过单一的干预措施来预防。

阅读。地方性是没有意义的

这场大流行的最大危险源已经从一种病原体转变为一种行为。现在，选择不接种COVID疫苗是一种可改变的健康风险，与吸烟相当，在美国每年有40多万人死于吸烟。加州大学欧文分校的公共卫生教授安德鲁-诺伊默告诉我，如果COVID每年继续造成几十万美国人死亡--他称之为 "现实的最坏情况"--这将使我们在过去20年的吸烟预防工作中积累的所有生命预期收益化为泡影。

毫不夸张地说，COVID疫苗是所有现代医学中最安全、最有效的疗法之一。一个未接种疫苗的成年人死于COVID的可能性是接种疫苗者的68倍，这是令人吃惊的。然而，在美国，普遍的疫苗犹豫不决已经造成了超过16.3万例可预防的死亡，而且还在不断增加。由于接种疫苗的人太少，COVID的激增仍然使医院不堪重负--干扰了常规医疗服务，导致成千上万的人因其他疾病而丧生。如果每个符合条件的人都接种了三联疫苗，我们的卫生保健系统将重新正常运作。(我们确实有其他的保护方法--抗病毒药和单克隆抗体--但这些方法仍然供不应求，而且往往不能让最高风险的病人得到保护。） 丹麦和瑞典等国家已经宣布与COVID断绝关系。他们自信地这样做并不是因为病毒不再流通，也不是因为他们已经从自然感染中获得了神话般的群体免疫力；他们只是接种了足够多的人。

乔-拜登总统在一月份说，"这仍然是一场未接种疫苗者的大流行，"而疫苗持有者确实延长了我们的危机。数据表明，目前大多数未接种疫苗的人都是自愿保持这种状态的。上个月，只有1%的成年人告诉凯撒家庭基金会，他们想尽快接种疫苗，只有4%的人表示他们正在采取 "等待和观察 "的方法。然而，17%的受访者表示，他们肯定不想接种疫苗，或者只有在需要的情况下才会接种（41%的接种过疫苗的成年人对加强剂也有同样的说法）。在对疫苗犹豫不决的人中，只有2%的人说，如果他们想打疫苗，会很难获得。我们可以承认，一些人在接受免疫接种时面临着结构性障碍，同时也可以听取其他许多人的意见，他们只是告诉我们他们的感受，有时从一开始就这样。

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同样的论点也适用于烟草：吸烟者患肺癌的几率要高15到30倍。戒掉这个习惯就相当于接受了一种强大得惊人的药物，这种药物可以消除大部分的多余风险。然而，吸烟者，就像那些现在拒绝接种疫苗的人一样，面对劝说他们的积极尝试，往往继续他们危险的生活方式。即使从绝对数字来看，美国未接种疫苗的人口和目前吸烟的人口似乎也相当匹配。现在，CDC认为他们分别占所有美国成年人的13%和14%，而且这两个群体都可能比较贫穷，受教育程度较低。

阅读：拒绝为未接种疫苗的人提供医疗服务是一个可怕的想法。

无论在哪种情况下，公共卫生运动都必须考虑到改变人们的行为这一非常困难的任务。例如，反吸烟工作试图激励良好的健康选择，抑制不良选择，无论是通过向戒烟者支付现金、在烟盒上的可怕视觉警告、税收、无烟区，还是雇主吸烟禁令。在过去的50年里，这场斗争非常缓慢但持续地推动了变革。近一半的美国人曾经吸烟；现在只有大约七分之一的人吸烟。在这一过程中，成千上万的肺癌患者得以避免。

在COVID方面，我们也草率地追求行为上的引导，把犹豫不决的人变成了接种者。政府和企业已经给了抽奖和免费啤酒一个机会。一些公司、大学、卫生保健系统和地方司法机构实施了强制措施。但是，许多好的想法被证明是没有什么好处的：例如，1月份发表的一项在养老院进行的随机试验发现，来自社区领导人的密集信息和劝说活动未能提高以弱势群体和低收入员工为主的疫苗接种率。尽管公共卫生专业人员和医生做出了无私的努力，但要接触到免疫学上的顽固分子却变得越来越难。增强剂的吸收也远远落后。

这就是COVID的 "新常态 "可能与我们几十年来与烟草的斗争相似的地方。我们既不应该期望每一个顽固不化的人在明年冬天之前都会接种疫苗，也不应该绝望地认为他们都不会改变主意。相反，让我们接受这样的事实：我们可能会慢慢取得进展，而且要付出相当大的努力。这种看似合理的结果具有重要的政策含义，即使是令人不舒服的。由于接种疫苗的时间长达数年，我们对限制的耐心将非常有限，特别是对已经接种的人。但也有中间地带。我们没有彻底禁止烟草--事实上，大多数州都保护吸烟者不受工作歧视--但我们已经开始了一场永久性的、全社会范围的不鼓励使用烟草的运动。COVID的长期行动可能包括向未接种疫苗的人收取健康保险费，就像我们对吸烟者所做的那样，或者分发有关未接种疫苗的危险的可怕的健康警告。一旦政治风波平息，COVID疫苗可能会被添加到更多学校和工作场所的必要疫苗接种清单中。


将抵制疫苗与吸烟相提并论，似乎忽略了一个明显而重要的区别。COVID是一种传染病，而烟草使用不是。(烟草在生理意义上也是会上瘾的，而疫苗抵抗力则不是）。许多大流行病的限制是基于这样的想法：任何个人的行为都可能对其他所有人构成直接的健康风险。接种疫苗的人不只是保护自己不受COVID的影响；他们还减少了将疾病传给周围人的风险，至少在某些有限的时间内是如此。即使在Omicron浪潮中，这种保护作用也显得非常明显。与未接种疫苗的人相比，接受过强化治疗的人检测出病毒阳性的可能性要低67%。

但是烟草的危害也可以从吸烟者身上传给他们的同伴。在美国，二手烟的吸入每年造成41,000多人死亡（比一些流感季节的死亡率还要高）。然而，尽管吸烟的风险众所周知，许多州并没有完全禁止公共场所的吸烟行为；私人住宅和汽车中的二手烟暴露--影响了25%的美国初中和高中儿童--在很大程度上仍然没有得到监管。对吸烟者和不吸烟者来说，普遍接受这些暗淡的结果，可能暗示了我们在COVID方面的另一个方向。烟草的致命性足以让我们愿意限制吸烟者的个人自由，但只是在一定程度上。尽管COVID是致命的，但有些人无论如何都不会接种疫苗，而接种疫苗和未接种疫苗的人都会将疾病传播给其他人。大量的超额死亡最终可能被容忍，甚至被明确允许。北卡罗来纳大学的公共卫生教授Noel Brewer告诉我，反COVID行动与反吸烟政策一样，将受到限制，不是因为其有效性，而是因为其在政治上的可接受程度。


如果没有更多的疫苗接种，患有COVID的人可能意味着每年要忍受比流感高一个数量级的死亡人数。然而，这也可能会让人觉得是它自己的一种结局。地方性的烟草使用造成数十万人死亡，年复一年，而为减少其损失而做出的激烈的公共卫生努力却在后台继续进行。然而，对于普通人来说，烟草并不像一场大灾难。加州大学欧文分校的诺伊默说，即使在疫苗接种持续存在差距的情况下，地方性COVID的影响也很难被察觉。平均预期寿命减少一两年，只是让我们回到了2000年时的状态。

慢性问题最终会屈服于适应性，使它们变得相对不易察觉。当然，当吸烟者生病时，我们仍然照顾他们，并尽可能地减少伤害。医疗保健系统每年为此赚取2,250亿美元--从我们所有的税款和保险费中支付。我毫不怀疑，如果冠状病毒继续对未接种疫苗的人造成破坏，该系统也将以这种方式进行调整。医院在将任何可怕的情况转化为可销售的 "卓越中心 "方面有着成熟的才能。

COVID可能在一段时间内仍然是一个主要的杀手，一些学者提出，只有当公众不再关心时，大流行病才会结束。但是我们不应该忘记冠状病毒不像流感那样的最重要原因。在以前的流感爆发中，我们从来没有过如此有效的疫苗，这意味着我们没有一个简单、明确的方法来拯救相当多的生命。富有同情心的谈话、社区宣传、保险附加费，甚至是强制规定，我都会接受。现在还不是放弃的时候。

本杰明-马泽尔是一名专门从事实验室医学的医生。