Other Views: Washington Smokers Now Get Vaccine Priority; Our Gut Doesn't Approve But Our Head Does

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As of last week, thousands of smokers of all ages, whether current or former, are automatically eligible for COVID-19 vaccinations in our state.

No proof of purchase or breath test required. No evidence that you've puffed at least 100 cigarettes in your lifetime, the US Centers for Disease Control's rather random threshold for whether someone is or was a smoker.

"We trust people in Washington to assess their eligibility honestly" when signing up for a vaccine as smokers, a Washington Department of Health spokesperson told us.

Just like they're now trusting the honor system for hundreds of thousands of other Washingtonians. DOH shut down its online phase finder tool last week as the three approved vaccines become more and more widely available.

Vaccinating smokers not only aligns with federal COVID-19 guidelines, it's also the general consensus among respiratory specialists. We recognize that it's a way to bolster the healthcare safety net. By reducing preventable virus hospitalizations, more beds are available for everyone from car accident survivors to cancer patients.

But we do have to plug our nose to accept it. These are the kinds of politically fraught, ethically messy criteria that a once-in-a-century pandemic has forced our country to reckon with.

It's not unreasonable to ask: Why should someone who won't kick a self-destructive habit have an edge over someone who makes good lifestyle decisions? Why should a 21-year-old who smokes be invited to roll up his sleeve before a 55-year-old who doesn't?

We'll be glad to see such questions fade into the background once all adults officially become eligible for vaccination this month.

"I completely get the gut feeling that it seems unfair," Dr. Mark Wurfel, a University of Washington professor and a pulmonologist at Seattle's Harborview Medical Center, said this week when we asked him about smoker eligibility.

Trying to predict who will be hit hardest by COVID-19 is a numbers game, Wurfel acknowledged, with some of the highest odds among people with metastatic cancer or severe kidney disease. But from his experience, there's also serious risk among smokers with lung disease. Many have additional morbidities such as obesity and diabetes — a "classic COVID case" that he provides care for.

A study published in January by JAMA Internal Medicine backs him up; it found that 125 percent of heavy smokers were more likely to be admitted to the hospital with COVID than nonsmokers, and 89 percent more likely to die.

"What public health officials are trying to do is prevent a surge into the hospital system that will affect everybody," Wurfel said.

Even so, smoking is arguably the most controversial vaccine qualification because it revolves around a bad choice. In most other cases, priority is based on non-discretionary factors like age or a specific medical diagnosis. Or on positive contributions to society, like serving as a frontline worker.

There also are eligibility questions that the guidelines don't answer with any great degree of satisfaction.

What about marijuana smokers or those with a vaping habit? And what of the thousands who've been subjected to secondhand smoke in their lifetimes, the cause of an estimated 50,000 lung cancer and heart disease deaths among American nonsmokers every year?

One wise provision that our state included is requiring smokers to have at least one underlying medical condition. This contrasts with states like Mississippi and New Jersey that made vaccines available to all smokers way back in January, ahead of thousands of nonsmoking essential workers, including teachers.

Another factor worth considering in this imperfect calculus: Smokers might not have as much choice as nonsmokers assume. "Tobacco dependence is kind of like alcohol dependence," Wurfel said. "Yes, there is a volitional component, but there is a very strong dependence that is like a disease."

All things considered, granting vaccine priority to smokers makes a fair amount of sense at the brain and chest level, if not the gut level.

Thank goodness a day is coming when the vaccination playing field is leveled and supply surpasses demand.

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