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Coughing into your elbow: a (new) old wives' tale

Coughing into your elbow: a (new) old wives' tale

There is little to no evidence to show that coughing into your elbow prevents the spread of disease.

Signage like this puts the onus on individuals to keep themselves safe, with an emphasis on questionable methods like elbow-coughing. Meanwhile, clean air and respirators are absent. (Photo:James Andrew Smith, 2022.)

Elbow-coughing has long struck me as a cop-out, but some posts on Twitter piqued my interest into digging around in the scientific literature. Thanks to Dr. Christine Peters and Dr. Lee Altenberg for the pointers to the 2013 paper and 2020 online post.

Throughout the COVID pandemic, public health officials have cast doubt on the value and practicality of respirators, citing the need for more studies, especially studies that demonstrate effectiveness of masking at scale. On the other hand, no such standard was required for these same officials to recommend elbow-coughing.

The elbow-cough approach was advocated by the WHO early on in the pandemic (Jan. 2020), possibly as a way to deal with a shortage of respirators. However, general "cough etiquette" predates that, as the WHO was recommending variations of it in the 2000/01 timeframe for use in prisons.

So why is elbow-coughing recommended? Well, intuitively, it seems to be better than simply not covering your mouth and nose when you cough. But that's it. It's simply a convenient, intuitive argument. It feels good. But that's it. On the other hand, masking, especially with respirators has more evidence to demonstrate it as an effective migitation measure.

The reasonable conclusion is that elbow-coughing appears to be the public health equivalent of an old wives' tale.

Unlike clean air infrastructure or respirators provided by employers or governments, cough etiquette does not appear to be grounded in scientific studies, nor is it part of occupational health and safety best practices.

So, until it can be shown otherwise, we should be applying best practices in our schools, hospitals, long term care homes and work places. To reduce the spread of disease, we need clean air infrastructure, employer- and government-provided respirators, as well as programs that allow sick people to remain home.


Zayas, Gustavo et al. “Effectiveness of cough etiquette maneuvers in disrupting the chain of transmission of infectious respiratory diseases.” BMC public health vol. 13 811. 8 Sep. 2013, doi:10.1186/1471-2458-13-811

Bailey, Claire, et al. "Simulating the environmental spread of SARS-CoV-2 via cough and the effect of personal mitigations." Microorganisms 10.11 (2022): 2241.

Liu, Haixia, Liang Gao, and Chenyu Sun. "Elbow instead of hand: is it more helpful or harmful?Journal of Public Health43.4 (2021): e656-e656.

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James Andrew Smith is a Professional Engineer and Associate Professor in the Electrical Engineering and Computer Science Department of York University's Lassonde School, with degrees in Electrical and Mechanical Engineering from the University of Alberta and McGill University.  Previously a program director in biomedical engineering, his research background spans robotics, locomotion, human birth and engineering education. While on sabbatical in 2018-19 with his wife and kids he lived in Strasbourg, France and he taught at the INSA Strasbourg and Hochschule Karlsruhe and wrote about his personal and professional perspectives.  James is a proponent of using social media to advocate for justice, equity, diversity and inclusion as well as evidence-based applications of research in the public sphere. You can find him on Twitter. Originally from Québec City, he now lives in Toronto, Canada.