New NIH "Addiction Institute" must not damage existing tobacco control research

The National Institutes of Health has announced that it is creating a new  "National Institute of Substance Use and Addiction Disorders" and invited public comment on this plan. If done well, this could be an improvement.  If done poorly -- particularly if all tobacco-related work was swept into the new institute -- this plan could do great harm to the tobacco research enterprise.  The public comment period is open until 11:59 PM on Friday May 11.  While the deadline is near, I urge everyone to put in comments on this proposal.

Details of the proposal are at http://grants.nih.gov/grants/guide/notice-files/NOT-OD-12-045.html, where you can post a comment.

Here is the public comment I submitted:

While it seems sensible to create a new institute to consolidate substance use, abuse, and addiction-related research in a single institute (a National Institute of Substance Use and Addiction Disorders), including “knowledge of tobacco use and addiction, including co-morbidity with other addiction and psychiatric disorders,” it is important that such a consolidation of tobacco addiction-related work not disrupt existing research programs on other aspects of tobacco use, including population-based tobacco control and tobacco treatment in the context of treating tobacco-induced disease (other than in the context of treating psychiatric disorders), currently under way in other Institutes, particularly the National Cancer Institute and the National Heart, Lung and Blood Institute.

While the fact that nicotine is addictive is the physiological reason that people continue smoking, it is important to recognize that development and treatment of this addiction is only one aspect of understanding and eventually eliminating tobacco-induced diseases.  As the Surgeon General has noted, tobacco affects virtually every organ system in the body and it is crucial that tobacco-related research be distributed to all relevant NIH Institutes. 

Most important, the policies and interventions that have driven most of this decline have been population-level interventions that have little to do with the fact that nicotine is addictive, the pharmacology of nicotine addiction, or the treatment of that addiction. Rather, this progress has been made under the broader agenda of cancer and heart and lung disease prevention and control by understanding the social determinants of smoking behavior, the effectiveness of population-based interventions (such as smokefree policies, tobacco taxation, media campaigns and smoking in the movies) as well as learning how to counter efforts by the tobacco industry to block implementation of effective interventions. These are all areas that the NCI Division of Cancer Control and Population Sciences, through its Tobacco Control Research Branch, have stimulated and supported for many years.

In addition, in recent years, the National Heart, Lung and Blood Institute has developed an interest in smoking treatment among hospitalized smokers and the effects of secondhand smoke on the cardiovascular system.  The location of this work in NHLBI has been important for engaging the cardiovascular community in issues of smoking and tobacco treatment and prevention, something that has been sorely needed for a long time.

The relative importance of addiction (and related) research to dealing with the overall tobacco problem is illustrated by the volume of publications in different areas.  Searching PubMed on 9 May 2012 yielded the following results:

(tobacco or smok*) and addiction                           5,390 papers
(tobacco or smok*) and cancer                             44,009 papers
(tobacco or smok*) and (heart or lung or blood)  84,991 papers

This broad distribution of work between relevant NIH Institutes should be maintained and encouraged.

It is also important to note that, while tobacco work is spread across NIH, there has been good cooperation between the existing institutes, particularly NCI and NIDA (where almost all addiction and nicotine treatment work is already located).  Rather than trying to consolidate all or most tobacco research in the new institute, the kind of cross-institute collaboration that has already been so successful should be continued and rewarded.

I am co-director of the UCSF Helen Diller Family Comprehensive Cancer Center’s Tobacco Program. It has been a long fight to integrate tobacco control into the cancer center’s basic biological and clinical programs, but we are now making progress. Shifting the tobacco control research portfolio out of NCI will create the appearance and reality of NCI walking away from tobacco. Worse, it will and send a strong message that NCI does not think that tobacco control research is a priority for cancer control.

This reorganization of NIH comes at a particularly sensitive time for tobacco control, given the release last year of Secretary Kathleen Sibelius’ “Ending the Tobacco Epidemic: A Tobacco Control Strategic Action Plan for the US Department of Health and Human Services.” Even a cursory review of this document will reveal that the work funded by and conducted at NCI provides much of the scientific foundation for this plan. NCI should be taking credit for this important contribution, not trying to move it to another institute.

I am particularly concerned that the proposed reorganization of tobacco control research will create heightened opportunities for the tobacco industry to shut down the kind of research and training that has made such a strong contribution to reducing smoking prevalence and consumption together with a wide range of cancers and other diseases. Even absent frank political interference, a major reorganization will almost certainly disrupt NIH’s tobacco control funding and activities at this crucial time.

Rather than concentrating all or most tobacco control research in the addictions institute, NIH should work to integrate tobacco into the full range of its programs. Tobacco kills more people through heart and vascular disease than cancer, yet NHLBI has had a very limited presence in tobacco control research.

I have also attached a letters on this subject that Dr. Frank McCormick, director of our Cancer Center, and I sent NIH Director Collins on this subject last year addressing these points.

In addition, I draw your attention to the editorial published in 2011 by leaders of the American Cancer Society, American Heart Association, American Lung Association, Campaign for Tobacco Free Kids, Legacy Foundation and Partnership for Prevention (Tobacco Control 2011;20:175e177, doi:10.1136/tc.2011.043968) that concluded, “As major organisations concerned with reducing the burden of tobacco-induced diseases we strongly advise the task force and Director Collins to leave existing tobacco research at NCI, NHLBI and the Fogarty  International Center, with some flexibility regarding the transfer of research that is wholly focused on the dependence-producing properties of tobacco. Indeed, rather than removing tobacco research from these (and other relevant) institutes, they should be encouraged to strengthen and expand their efforts to a level  commensurate with the risks tobacco imposes and the central contribution that reducing smoking and tobacco use has been demonstrated to have reducing the burden of cancer, heart, lung and other diseases.”

This is a sensible recommendation from organizations that represent an important element of NIH’s organized constituency in general and regarding tobacco in particular.  Please carefully consider the practical effect on the research community and the ability of NIH to make an ongoing contribution to implementing the Department’s new Strategic Plan and see that there are no disruptions to NIH’s contribution to reducing the burden of tobacco-caused cancer and other diseases.