"Why Do You Fund Biomedical Research" or "Why Don't You Fund Biomedical Research Anymore?" by Jeffrey Cheek

Depending on the inquisitor's point of view, the answer to one of these questions is obvious while the other may be inconceivable. TRDRP staff have heard both: some advocates and researchers committed to preventing youth from starting to smoke, or to encouraging smokers to kick the habit, want to know why resources are "wasted" on biomedical research instead of prevention and cessation efforts. Conversely, some biomedical researchers, particularly those who would like to return to the "good old days" of TRDRP when most funded grants were in the biomedical sciences, nowadays question if they need bother submitting an application, since "TRDRP is no longer supporting basic science." The reality is that while behavioral, policy and biomedical researchers all strive to reduce tobacco use and disease, they achieve those goals by following very different paths - and TRDRP supports all of these efforts. Since TRDRP's funding was restored in 1996, slightly less than half of new awards have focused on the biological basis, diagnosis or treatment of tobacco-related diseases, while the balance of funded projects have been in the nicotine dependence, behavioral and policy priority areas.

"Doesn't NIH provide enough support for biomedical research on tobacco-related diseases?"
There are two main differences influencing our research priority areas compared to those of the National Institutes of Health (NIH). First, in contrast to the multibillion dollar NIH budget and its broad mission to uncover new basic knowledge that will lead to better health for everyone, TRDRP's budget is much smaller (see Figure 1) with a much narrower focus. The specific issues shaping the emphasis of TRDRP funding are as follows: if people never smoke, they don't suffer from tobacco-related illnesses (prevention); if they start smoking but successfully quit, they are far less likely to suffer the associated morbidity and mortality (cessation). However, many smokers are unable to kick the habit, and even in the unlikely event that all smokers quit tomorrow, society will still need to treat tobacco-related illnesses (diagnosis and treatment). Indeed, while the Institute of Medicine's National Research Council has called for increased federal leadership in support of biomedical research on tobacco-related diseases,⁽¹⁾ Barbara Rimer of the National Cancer Institute's Division of Cancer Control and Population Science recognizes that "…there has been a slower pace in the last few years in reducing the burden of smoking." ⁽²⁾

Second, given that the TRDRP's resources and scope are limited, and that tobacco-related diseases are largely preventable, it makes for sound public health policy to emphasize the need for prevention and cessation research, and the development of policies that encourage such efforts. Nevertheless, the need for research to identify the biological mechanisms underlying the development of tobacco-related illnesses, which serves as the foundation for future research applied to the diagnosis and treatment of individuals suffering from disease, remains equally critical as long as individuals continue to smoke. The key is to find a balance in supporting biomedical, behavioral and policy research.

"How does biomedical research facilitate tobacco control efforts?"
While some supporters of behavioral research argue that biomedical research doesn't keep people from smoking, the fact is that studies on the health effects of both smoking and exposure to secondhand smoke have had a powerful influence on public opinion, as well as on judicial and legislative action. A case in point is the development of ordinances regulating secondhand smoke. The uproar over the recent ruling by a U.S. Appeals Court that invalidated the Environmental Protection Agency's (EPA) classification of secondhand tobacco smoke as a carcinogen centers on the fact that this classification served as the basis for many civic ordinances limiting public exposure to secondhand smoke. With regards to public policy, this judicial ruling (at least from the perspective of the tobacco industry) calls into question the justification of most, if not all, of the antismoking ordinances enacted in this decade. Unfortunately, this myopic emphasis on whether or not secondhand smoke is definitively proven to be a carcinogen, and thus represents a threat to public health per se, conveniently (for the industry) ignores the well-documented cardiovascular, pulmonary and myriad other health effects of secondhand smoke.⁽³⁾

Other public concerns that influence how monies for tobacco-related health research are spent are the relationship of behavior to health and the perception of relative risk. With regards to smoking, since the majority of the population does not partake, there is a not uncommon sentiment that those who choose to engage in this risky behavior deserve what they get. Indeed, lung cancer patients have justifiably complained that they are perceived as bringing about their own demise. Unfortunately, such a shortsighted, punitive attitude ultimately leads to public health policies that fall short of their goals. One example of how Federal public health policy was misguided by an emphasis on individual "choice" or "responsibility" was the delayed and deficient response of the Reagan administration in addressing the risk posed by the AIDS epidemic. Understanding the role of public opinion in shaping tobacco control policies will require increased interaction between biomedical, behavioral and policy advocates. For example, TRDRP recently funded a pulmonary physician-scientist to directly address how the perception of individual responsibility influences the availability of health care for smokers.(4)

In contrast to the health effects attributed to personal choices, the relative risks due to factors beyond our individual control (such as involuntary exposure to environmental pollutants, like secondhand smoke) rate much higher on public and policymakers agendas. It is obviously easier to achieve public support when it's other people's actions that affect your personal well-being, as opposed to motivating individuals to modify their own behavior in the interest of health. It follows that the public concern over the long-term effects of exposure to secondhand smoke, combined with the industry's challenge of the EPA ruling, further illustrate the need to support research that focuses both on assessing public health risks from involuntary exposure (i.e., biomedical research) and on reducing the number of people who choose to smoke (i.e., prevention and cessation projects).