Tobacco Documents Online

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F Table of Content~ Summary I. Introduction II. Establishing the Institute III. The Research Program IV. Priorities and Programs for the First Three Years Appendices Implementation B. Budget C. Key Personnel Schedule i I 16 25 35 A-I 8-I C-I .~ i~.~:¸ 0 j.i .i 0

<. F ¥ r SUMMARY OF THE PROPOSAL Of the many self destructive behaviors that threaten American children, cigarette smoking has the greatest impact on their llfe expectancy. Over half of the mere than three million teenage smoksr~ in the U,S. today will begln their adult lives addicted to ¢Igarsttes and will be faced with excessive risks of lung and other cancers, heart disease, emphysema end s variety of ether life threatening and debilitating diseases, Recent ~esearch has shown that, in addition to causing these long latency diseases, smoking can harm the very young smokem and that smoking during pregnancy can harm the fetus and the newborn. Research has also shown that children of smoking dements are twice as likely t@ smoke as childTen ~f nonsmoking Dements sn~ that teenage smoking is the most significant determinant of lifetime addiction to cigarettes. Smoking car clearly De seen as a lifelong liability. Since the release of the first Surgeon @eneral's reoorl in 196A, there has been a dramatic decline in the percentage of adults who smoke. Smoking among teenagers has also declined in recent years after • surge in the early 1970's. However. 94 million Americans over the age of 18 still smoke sno 340,000 smokers will die prematurely this year. ~.w The reasons for the dramatic changes in smoking in America a~e not clear, n@c are the reasons why SO many millions of young people still take up smoking knowing of tne ~isks i ~r they face. ~

answers to these questions are essential to the formulation of policies and programs to help prevent adolescents from starting to smoke and encourage smokers to stop. Unfortunately, our knowledge of smoking behavior is too limited to give the answers needed to design new and better prevention programs. This lack of knowledge about smoking behavior can be attributed to three factors: the low priority assigned to behavioral research on smoking until recently; the lag between biomedical science and the sciences dealing with behavlor; and a lack of direction, coorqlnation and leadership in addressing smoking behavior research. To capitalize on improvements in the status of the first two factors and to help correct the third, the John F. Kennedy School of Government of Harvard University is establishing an Institute for the Study of Smoking Behavior and Policy. This new research resource will have as its primary goal the development of new knowledge about smoking behavior and the j~ translation of that knowledge into pollcles and programs for smoking prevention. Within tnls goal, the Institute will conduct research on smoking behavior, stimulate others to conduct research, and provide lnformatlon and coordination services to other researchers and research institutions. The Institute's highest priority in carrying out these functions will be conducting and fostering research that contributes to the prevention of smoking by children and adolescents. The Institute will be s permanent and integral part of Harvard University and will = , draw on the many resources available ii

@ ,, fzom within that community. Derek Bok, President of the University, Graham Afllson, Dean of the Kennedy School of Government and Julius B. Richmond, M.D., Director of the University's Division of Health Policy Research and Education are lending their full support to this endeavor. The University will assist in the identification of long term funding support and the Kennedy School end the Division have already committed over $30,000 to planning and development. This proposal requests a total of $658,000 from the Carnegie COEporatlon over three years to help the Institute become operational and to launch its basic research efforts. This represents approximately one half of the $1.35 million being sought for programs and projects in this three year development phase, The funds sought f~om the Carnegie Corporation ~iiI support: o The creation of a Research Advisory Committee to assist the Institute in defining the most promising areas of research on smoking behavior among chlldren and adolescents. The Committee will meet twice a year during the three year development phase; o The inltlatiom of an ongoing process to assess research on smoking behavior and policy; an analytical framework that will form the basis for better information and coordination of research on smoking by young Deople; J ..... iii , ........

+ ~ o The production of position @aper5 discussing the st@re Of research on $moklng behavior with partlcular emphBsls on children and adolescents; o The Identlficatlon of key data sources capable of provldlng new or more complete knowledge about @dolescent smoking behavior; o The ldentificatlon and ~ataloguln9 of ongoing research on smoking behavior; o The c~e~tion of more permanent lln~$ Of communication and ~nfo~m~tlon exchange between ~esea~chers @no inst~tutlon~ conducting research on aaolescen~ smoking behBvior; o The examination of method@logicBl probl~ms ~na~ may be h~nderlng the success of research proposals deallng with smoking among young people. o The identlficatlon and catal~gulng of information on fundlng sources for reseazch on adolescent smoking behavior~ o The development of new channels for the ~issemlnatlor of r~se~rch ~esults and I$$u~$; 0 The creation of central resource capable of assisting t~ose interested in or engageo in smoking behavior research in developlng research Ideas and projects; iv

e The identification end recruitment of new researchers 1rite research on smoking behavior; o The ¢reatlon of a framework for a more efficient and effective national and international effort to generate the knowledge necessary to prevent end control cigarette smoking. k

INTRODUCTION I

INTROOU~TI~N Every child born in America today will be raised in a society in which he or she will face powerful environmental inducements to take up self destructive behaviors. Among all of these behaviors, cigarette smoking has the greatest impact on llfe expectancy, an impact directly related to the age at which a person first takes up the habit and the number of cigarettes smoked. This Is especially significant in light of the fact that In 1979, an estimated 100,000 12 year old children were regular cigarette smokers. Over }.5 million teenagers in the United States today are regular smokers. Of thls number, over half will begin their young adult lives addicted to cigarette smoking and by the time these young smokers reach age 24, over a third of them wlll have tried seriously to quit smoking three or more times. Smoking is an addiction of the most pernicious sort. First, it will lead over time to poorer health and earlier death, and In the short term, damage to the young smoker. Second, smoking addlction represents a severe loss of control, a debilitating obsession with a behavior that is no longer unlversally sccepteP or deemed attractive by the majority of Americans. Unfortunately, despite a marked decline in the social acceptability of smoking, the inducements to take up the habit remain strong. Among the strongest Is smoking by parents and peers. These and other powerful pressures put young people at great lisk of beginning whet must be considered a lifelong liability. t~

$~cki~a in Contemnorarv Society The medical llterature on the consequences of cigarette smoking is one of the most complete collections of scientific data ever accumulated. Since the release of the first Surgeon General's Report in 1964, thousands of studies have indicted smoking ss a leading cause of lung and other ca~ce~s, cardiovascular disease, emphysema, chronic bronchitis and other llfe threatening and disabling diseases. In the two decades following that Report, remarkable changes took place in the smoking patterns of Americans. Nilllons of smokers qult, and millions of peDDle never started -- there are 33 million former smokers In the United States today and the percentage of adult current smokers has dropped from 42 percent to ~3 percent. Attitudes and awareness about smoking changed as dramatically as smoking rates. Over 80 percent of current smokers now say they ~ould like to quit and 40 percent report at least three unsuccessful quit attempts each year. Smoking among adolescents also underwent dramatic changes. After surging In the early 1970,s, teenage smoking rates have shown a steady decline• The vast majority of teenagers are aware of the risks posed by cigarettes. Despite these dramatic changes and encouraging statistics there is another side to the picture. In 1982, 54 million CD Americans smoked 620 billion cigarettes. An estimated 340,000 of ~ those smokers wlll die prematurely this year. In addition, the ~ most recent survey of smoking by high school seniors raises ~4~:ii~i

questions about whether adolescent smoklng rates will continue downward. Other countries have experienced similar successes and problems. In Western Europe large numbers of smokers have Quit end teenage rates have declined. However, the number of current smokers and the rates of related disease in these countries remain high. Smoking rates and cigarette consumption are on the rise in developing nations, thanks in part to intensive marketing efforts. These countries can ill afford smoking related diseases while still struggling to eliminate the ravages of communicable disease. The i982 Surgeon General's Report puts the smoking problem in an appropriately broad and serious perspective: ~Cigarette smoking• is the chlef, single avoidable cause of death in our society and the most important public health issue of our time." ~oki~9 is s fa~ more complex and Inaldi~ua public health problem then many Americans realize. Many, especially smokers, ere unaware that in addition to lung cancer and emphysema, smokin9 m~uaes heart disease ~nd e ~sriety of other c~ncers. Also, Surveys show an alarming perception of the risks of lower tar and nicotine cigarettes -- }6 percent of smokers believe these cigarettes pose no risk at all. And although over 80 percent of Americans are aware that smoking is dangerous, they consistently rank it far below other health risks whose contributions to death and disability pale by Comparison.

"r Smoking is having a particularly insidious impact on developing countries where tobacco is grown° Worldwide as well es domestic demand has greatly i~reaaed tobacco acreage, ks a ~eault, more land has been cleared and more wood cut to oure the tobacco, creating serious problems of deforestation, soil erosion, air pollution and the diversion of agricultural ~esourcea f~om food production. 5moktno ~mouno Youno Peoole The most serious problems posed by smoking are among children and adolescents. Early ~esearch findings on the hazards of smoking focused on adulta and the long-latency ~iseases such as cancer. Nowever, since 1964, an increasing body of knowledge has aocumuIated on the effects of smoking on young people. Perhaps most important is the finding that teenage smoking habits are the major determinants of lifelong smoking dependence~ Very few smokers begin their habit after the age of twenty. In addition, there is overwhelming evidence that smoking during pregnancy has a serious impact on the welibeing of the fetus and the health of the newborn. Other effects on the y~ung include: o Maternal smoking retards fetal growth and increases the risk of spontaneous abortion, fetal death and neonatal death; o Children of smoking mothers may have deficiencies in physical growth, intellectual and emotional development;

$ + o Young cigarette smokers have evidence of irreversible small airway dysfunction; o Teenage and young adult smokers have a higher prevalence of respiratory symptoms than nonamokers~ o There is a significant relation between children's respiratory illness and parental smoking; c Children ~hose parents smoke ere twice as likely to become smokers than children from nonsmoking families. These disquieting facts about the effects of smoking or children Illustrate the significant interrelationship of adult and childhood smoking at all stages of development: maternal smoking oan affect fetal and neonatal health and overall development; parental smoking can affect childhood health end can determine teenage smoking habits; teenage smoking can determine , lifelong smoking habits with both short and long term health effects, It is clear from these interrelationships that programs aimed at preventing children from smoking or encouraging them to ~ • quit must consider the full spectrum of smoking behavior. They ~, '~ii~:~ adolescent behavior, in must focus on pregnant women, young children, young adult role models and peers, parents and other adult exemplars. And they must be based on a thorough understanding of smoking behavior and the broader context of adolescent

or "4 rlsk-taklng and experimentation with alcohol and other drugs. However, the strong llnk between childhood smoking and adult dependence argues that regardless of the specific policy or point of intervention, the elimination of smoking in our aoclety will ultimately depend on the elimination of smoking among young people. Understandlno Smokino Behavior The reasons for the dramatic changes in American smoking ~attarne are not nearly es apparent as the changes themselvesp nor are the reaso~a ~hy so aany young Amerlca~e continue to take up smoking and why so many adults smoke, despite widespread knowledge of the risks. The public health efforts launched In the sixties must have played a major role. The information, education and regulatory programs implemented by the federal govelnmant~ voluntary ~@encies an~ state and local governments have somehow had a measurable impact on smoking behavior, public knowledge end awareness and even on the social status of smoking. What Is not known is how these efforts worked and why they succeeded with some smokers an~ not with others. It is also not understood what other verlables have played independent or dependent roles in changing smoking behavior. While the health consequences of smoking are well documented, the bahavioriel aspects are not -- what makes young people start smoking, why it is so hard to quit, who sueceeos ano how, why relapse is so frequent, even after long periods of abstinence. C~ W~ 7

7he accumulated knowledge about the psychological, social, pharmacological and demographic aspects of the smoking problem is a small fraction of the thlrty-thsee thousand studies on smoking In the world literature. The sciences concerned with behavior have lagged far behind biomedical science in developing the techniques necessary to better understand smoking and in applying those techniques to fill the gaps in knowledge. These gaps are si9nlflcant. ?or example, while the ma~orlty of the ~ million former smokers quit on their own, little is known about their methods, metlvatlonst consumption patterns, relapse rates, basic demographics and other determinants of successful quitting. Little is also known about what effect parental quitting may have on teenage smoking. Without more knowledge about such key factors, policies and programs to prevent smoking and encourage quitting depend on anecdotal and incomplete data, thus limiting their effectiveness. There are also major gaps in our understsndlng of adolescent smoking and the determinants of decisions to take up smoking. The most recent data on teenage smoking patterns and attitudes were collected in 1979 and although there are indications that major changes may have occurred, no comparable new data are available. The problem is further complicated by the fact that much of the available data were collected by telephone surveys of small samples. These data not only lack statistical power, but ere also deficient in identifying racial end ethnlc origins. Questions have also been raised about the validity of telephone

d responses to sensitive questions asked wlth parents present. Wlthout better and more accurate knowledge, programs aimed at preventing teenagers from starting to smoke may be out of step wlth teenage attitudes and behavior. There are several basic reasons for this critical shortfall in understanding smoking behavior. Smoking is a complex set of behaviors involving psychological anP physiological dependence on tobacco, complicated by social relnfsrcements including efforts on the part of the tobacco industry to depict smoking as safe, attractive and socially acceptable. In addition, the natural evolutlonmry gap between biomedical and behavioral science has been widened by decisions allocating far greater resources to biomedical research than to behsviorml research on smoking. Structural problems within the research and public health communities have also contributed to the knowledge shortfall. While many groups and organlzatlons have placed greater emphasis on smoking related behavioral rssearch in recent years, coordlnatlon and follow through have been slow in coming. Because of a lack of leadership, coordlnetlon or awareness, researchers have missed opportunities to make significant strides through the analysis of emerging trends or the impact of new policies. Because of the political sensitivity of the smoking Issue, government agencies have been slow to exert leadership In these areas or have suffered cuts in resources, ~aking it difficult for them to respond. There is no place that fundinc agencies can turn to find out, es research priorities, w~at It is -t¸ CJ Gq

t we do not know about smoking that could be known that would contribute to effective public and private policies. The impact of this shortfall in knowledge has been to limit the capacity of lasesrehars and pollcy makers to design new and • ora effective ~pproaches to smoking prevention and control. While smoking has declined dramatically, greater momentum and new direction must be generated if greater success is to be achieved in preventing young people from taking up smoking and helping the 54 million Americans who still smoke. Without better snd more targeted research on smoking behavior, better coordination and olose~ ties between research and policy development, public health officials will have to apply m limited, outdated knowledge base to solve the smoking problems of the 1980's and 1990's. A New Resource for Smokino Researnh In response to the need for better direction, coordination and continuity in research on smoking behavior and policy, the John F. Kennedy School of Government is establishing a permanent center for the study of smoklng. This center, to be named the Instltute for the Study of Smoking Behavior and Policy, will have as its primary goal the development of new knowledge about smoking behavior and the translation of that knowledge into program designs and policy options. TO achieve this goal, the :~ Institute will draw on the resources of the Harvard co~,munity and ~b will reach out to those individuals and Institutions in the ~ United States and abroad who are addressing many of the same problem s. i ~:!!: '~ : ..... lO ....

The Institute will undertake a variety of functions designed to fill research gaps, examine policy options and stlmulate the behevleral and p@llcy research efforts of others. Primary ~mpha~Is in all of the Instltute's undertakings will be on broadening the knowledge base by increasing the participation of researchers from a wide range of disciplines. A second and equally important emphasis will be on serving the smoking research community, provldlng information and coordination for resesrch end policy d~velopment efforts. Broadly stated, the Instltute's mission will be to: • o Serve as e focal point @n~ 8n info~matlon resource for smoking behavior and policy research nationslly and internationally; o Create a mechanism for continuous assessment of the state of the art in smoking research; o L~artaks ~esearc~ p~ojects ~ith potential for program er policy sppllcations and, monitor events and change~ in pol~cles to identify research opportunities; o Gather and analyze detailed personal data on smoking behavior in order to develop a comprehensive natural history of smokimg as a research and poiicy resource.

t o Examine the relatlonshlps between smoking research and key policy Issues on a csntinuous basle and target research to support and enhance policy devmlopment; o Explore new epploeohes to tr~sl~ti~ research findings into programs and broad strategies for smoking prevention and control in settings ranging from schools to health care deilvery to natlonal leglslat~on; and o Provlde eoordlnatlon and oontlnulty ~n smoRing research and pollcy issues, especially with respect to the many research reoommendatlons developed Over the past several years, In short, the Instltute will endeavor to create a framework of information and expe~t judgment that can provlde dlreotlon to smoking ~esesrch in years to come. ~hls framewor~ will be eharacterlzed by a continous process involving the examlnatlon of research progress, needs and opportunitles and the stimulatl@n of new Ideas. CO "rip ~ The uitlmate goal of the Institute wlll be preventlon: preventing chi1~en from taking up smoking an~ preventlng the ~ damage caused by smoking° Given the wl~e range of concerns about the effects of smoking -- children, pregnant women, high rlsk

adults -- and the variety of intervention points including schools, health care settings, the home and the workplace, the Institute will develop its research priorities according to the best available advice on risk and opportunity. However, the known dependent vatlables in smoking behsvlor and the increasing experience of inteIvention p~ojeets already suggest that research on preventing smoking among children and adolescents should receive the highest priority. Consequently as the analytical framework and speclfic research functions and projects evolve, the Institute will direct primary attention to efforts that address children directly or that have substantlal indirect benefit in preventing childhood smoking. n n h i The history of smoking research funding for and counter to establish the Institute on a broad base of private grant endowment support from corporations, foundations and other sources, The Institute has the full support of Graham Allison, is one of wide variations in support, due often to fluctuations in political support public interest in smoking control and prevention. TO this tendency, the Kennedy School of Government intends and Dean ,L of the Kennedy School of government and Julius Richmond, Director ¢m of the Oivlsiom of Health Policy Research and Education. The KennePy School and the Division have already contributed in ~.~ excess of $30,000 to be~in planning and development for the Institute. Derek Dok, Presldent of the Unlversity and Howard ~"~

Hiatt, Oean of the School of Public Health have also given their full support to this effort. The University has offered assistance in identifying sources of endowment funds. There have been many other expressions of support and encouragement from within the Harvard Community. Over the life of the Institute, these will be translated into substantial contributions of advice and collaboration, greatly enhancing the Institute's available resources° TO carry on the work of creating a strong and permanent research center, the Kennedy School is seeking a total of $1.35 million for the three year period the Institute will need to become fully operational. This core support will enable the institute to launch several key research initiatives as well as to lay the base for a larger, continuous program of research and services following this first three year phase. Of the total amount required, $658,000 is being requested from the Carnegie Corporation to fund the basic program end Operating costs of the Institute for three years. The programs and activities to be supported by these funds are described together with the other major projects Institute's first phase. Tha remaining sections of this Institute, its goals, structure and in detail in Section IV, which comprise the proposal describe the objectives, with primary emphasis on the organizational and research objectives for the three year start-up period. Appendices include: a schedule detailing the major steps to implementation of the Institute; a ¢@

" q breakdown of the Institute's on key personnel. budget, and; background information ~bi ~ ~¸ : 15

.ESTABLISHING THE INSTITUTE O~ ?~ ~ 7.. 16

ESTABLISHING THE INSTITUTE F w Research on smokin@ behavior and policy has been hampered by • lack of resources and direction. An important part of the Instltute's mission will be helping to rectify these problems by injecting an element of organization into the collective thinking of researchers and policy makers by addressing one basic question: what are the smoking behavior research questions that are answerable and whose answers are immediately applicable to more effective programs and policies? TO carry out this mission, the Institute will develop an analytical framework to serve as a dynamic research agenda; a strategy development and priority setting process to help direct research efforts towards filling key gabs in knowledge. The framework will be based on assessments of the state of the art, needs, priorities and opportunities; filtereP by the Judgement of knowledgeable researchers snd policy makers and continuously amended as new knowledge becomes available. The process leading to the development of the analytical framework will draw on the broadest possible range of input and advice from the research community and from a permanent research advisory committee of experts in smoking research, policy research and related fields. The primary point of departure for developing framework will be by new knowledge, the analytical the identification of issues which, if resolved ~=~ will suggest new programs or policies. A prime ;~ m

example is the issue of the effect of cigarette advertising on decisions by young people to take up smoking° This is a powerful issue, regularly confronted by policy makers ccnsldezlng leglsleti~e recommend~tlone on smoking education and info~matlon. And subsumed under this issue are a variety of questions: can the effects of advertising per se be studied?; can an impact on young peoples' decisions or sttltudes be shown?; if there is a measurable effect, what are the policy options available to mediate that effect? what is the effect sd~rtlslng on teen~gers?; ~hatt if shy response of young people to advertising of counter (anti-smoklng) f~ctore ~iffe~entlate the for alcoholic beverages? By approaching the analytical framework in this fashion, ~Ith children an~ high risk groups as o~ossouttlng priorities, the Institute will attempt to create a more structured and deliberate process for pursuing smoking research, Functions of the Institute Orawlng on the analytical framework and its advisory committee, the Institute will carry out five principal functions: i i. Conducting Research - the Institute's own Tesearoh will be heavily influenced by the priority concerns and research opportunities already discussed and by the degree to which existing researchers within the Harvard community respond to those opportunities. However, the Institute will develop basic ~=~ capabilities in: the collection and analysis of Ha interview and survey data with particular emphasis ~ .~,,~

~L 2q ~Q on children and adolescents in the natural history of smoking, Interventlon ~eseBrch, with an emphasls on targets of opportunity where the Instltute's capabilities can augment or be augmented by collsborBtlve efforts. Hn exampl~ ~ould be worklng wlth the Harvard Community Health Plan on further r@seBrch Intervening wlth pregnBnt women smokers. 5tlmulat~ng Research - the Institute will use the analytical f~a~ework to attract new researchers and to focus attention On promising areas of inquiry. By convening conferences and $emlnarsI by prov~dng small seed grants and by highlighting progress, the Institute will attempt to stimulate new interest from researchers and fundlng sources° For e×amplej s conference add~es$1ng t~e Issu~ of th~ impact of advertlslng might spawn a variety of research ideas with potential for policy applications. Coordination - the ~nstltute w~ll conduct an ongoing program to foster better coordination of efforts @mong ~ntere~ted researche~So The Institute will alert groups about impending opportunities and help ensure that researchers take advantage of those opportunltie~ w~ile avoiding duplication. • ~ ~!~ ~ ~• /~ ~i~~• • .... •~ ~ ~,

f 4. Research Information/Program - as an adjunct to its cocrdinatlve efforts, the Institute wlll monitor a varlety of sources, including data on research collected by the federal goverhme~t's Office on Smoking and Health, and wlll develop a specialized Information program to serve the smoking behavior and policy research community. Through llnkages with government at all levels, voluntary health agencles mnd other research centers, the Instltute will mei~tein s current file of research in progress end other Informatlom cf use to researchers. S° Communication - as the Institute's program evolves, the communication of progress and findings will recelve priority attention, as will the enhancement of communication about smoking research in general° The Institute will explore a ranging from a newsletter to smoking research and policy. variety of options a Journal dedicated to The transfer of research findings into policy-making forums will also be addressed through approaches such as ~he publication of monographs on key research findings and their ~elevance to policy issues. j k~ j~ ~ L

"4 The Institute is an outgrowth of the scblvitles of Harvard's Division of Health Policy Research and Education and the Center for Health Policy $nd Management in the Kennedy School of Government. Among the principal functions of both the Division and the Center is the identification of areas such as smoking behsvior research and support for the development of appropriate institutional responses. Dne of the first activities of the Division was to set up Unlverslty-wide working groups, Including one on health promotion and disease prevention. This working group in turn iPentlfied cigarette smoking as a hlgh priority and convened a conference on smoking cessation in November of 1982. Following the conference, there was considersble interest in continuing a dialogue about smoking behavior research. In response, the Division established a permanent seminar, bringing together interested parties from the Schools of Medicine and Public Health, the Kennedy School and others from the Boston health care community end around the nation• It is from the deliberations of this group over a period of seven months thst recognition of the need and the concept for the Institute emerged. Throughout this brief history, the first Director of the Division, Dr. Oavld Hamburg and its current Director. Dr. Julius Richmond h~ve taken an active role in d~fining the ~ission for the Institute anb planning for its development. O~ ~D p.w ~D

The Instltute will operate withln the context for Health Pollcy experience In the research efforts. of the Center 8rid NBnagement, drawing On the center's design, Implementatlon end management of Dr. Dav~@ Blument~al, Executive Director of the Center has glven invaluable essCetance in translating the concept of the Institute into viable plans. The ~nstltute will also work closely with the blvlelon, drawlng om its outreach snO coordinative experience. The Institute will resemble existing ecedemlc research centers end programs In that it will be en integral part of the Hervord ecademlc community with strong support from and access to ell relevant depBrtme~ts, centers end schools within the University. l~ particular, the Institute will seek active Involvement from the Schools of Medicine and Publlc Health, from economists, behavioral sc~entlsts, demographers, epldemlol~glsts an~ flom the extensive ~e~Ith csr~ ~eli~ery resources of the Boston @tea. The Division Of Health Pollcy Reseorch and Education will provide invaluable guidance end assletance In att~acting the suD~t and involvement ~f these ~esour~es. The Institute will establish two permanent bodies to eid in csrrylng out its mlss~on. The first is an Advisory Board to oversee the iQng te~m dev~l~me~t of the Institute end Its funding base. The members of the Board will include leaders in science, medicine, philanthropy, bus~ness and law. The second bQdy Is a Research Advisory Committee, to be ~ade up of experts in smoking ~esesrch 8n~ related fields• This Committee will CO ~b Ma .~ ~ , " , 22

e, assist in the development of the delineation of specific research anslytlcal framework, the projects and the establishment of communications end coordinatlon mechanisms. To ensure effective coordination within the University, a third group will be established on a less formal basis. This group will be an informal steering committee made up of representatives of the various centers, schools end departments and will meet regularly to review progress and identify potential problems. It will be an extension of the seminar on smoking research established following the conference on smoking cessation. The staffing plan for the Institute will evolve as the various functions and programs are implemented. The Institute will draw its initial administrative support from the Center for Health Policy end Management. All programs initiated by the Institute will draw on support through collaborative efforts with other grogrems in the Harvard Community, The Institute will be under the overall direction of Thomas C. Schelllng, Lucius N. Littauer Professor of Political Economy. Or. Schelling will devote h~if time du~ing the academic year a~d ~ full time during the summer to the Institute. TO assure the of this enterprise, the Kennedy School of Government is success underwriting the financing of Dr. $chelling's salary for the ~ ~ Oo intitlal three-year development period. It is hoped that ~=~ i ~

-. 1++ • y within that time a portion of these funds may be recouped from project grants. John M. Pihney, former Director of the federal Office on Smoking and Health will serve as full time executive director. Their curricula vitae are in Appendix C. Throughout the first phase of the Institute's development, Mr. Pinney will continue to reside in Washington, D.C. and will divide hie time between Boston and Washington. while In Washington, he will carry the Institute's success. maintaining close iialscn out a number of functions important to These include: establishing and with the policy process through contacts wlth the legislative and executive branches and voluntary agency Washington lepresentatlves; working closely with agencies constituting the major data sources on smoking (Office on Smoking and Health, National Center for Health Statistics, Centers far Disease Control, NIH), and; enhancing the OOO~ination and progre~ develop~e~t functions of the Institute through regular meetings with key agencies and participation in conferences and seminars. In addition to Dr. Schelllng and Mr. Pinney, the Institute will hize a core staff of one zesearch assistant and one secretary. Other professional staff will be hired on a project basis and will generally devote part time to their individual projects. They will be drawn primarily from within the Harvard community from teaching and research areas relevant to the Institute'$ program. A more detailed description of the projects planned for the first three years of the Instltute's program is provided in Section IV.

T~TgoT069

~HE RES£~RCH P~OGR~ As dlscussed in the pr~41ous se~tiDn, th~ Institute's ~eSeB~ch program ~iiI be gulded by t~e &nalyt1~&l framework ~d th~ ~dv1~e o~ the ~search ~dvls~y Co~mlttee. T~e~e sources • 111 held ensure the Drogr&m's ~elevance ~d timeliness a~d ~ill aid £~ m~inta~nlng the bal&nce of behavlor~1 &nO pollcy research. A hlgh prlorlty will be pl~ced on identifying in advance ~hose events which o?fer $1gn£flcant research opportunltles. For ex~mDle, excise tax Inc~a~es or changes in the c~g~rette warnlng label may occur w~thln the next one to three yeers, offerlng grea~ potential fo~ research on the ~mpact of economlc and envlronment~l influences on smoking behavior and evaluating these pollcles. Development of the sn~lytlcal f~amework w~ll ~nvolve an examlnat$on of the myrald ~ecommendat~ons comp~led In recent years in the annu~l Surgeon General's Reports and Dy ~onfe~ences su~ ~s the National Conference on Smoking ~r Health ~onvened in 1981 by the American Cancer Society. In~orm~tlon on ~esearcn in Drogr~ss w111 be dr@wn f~om the members of the advisory ~omm~ttee and f~om sources such as the blannua~ D~rectory of Research on $moklng and Health complled by the Offlce on Smoking ~nd Hea~th. The Instltute will seek ~ddltlonal s~urces of ~nforma~1on on work in progress, particularly in other ~ountrles. In?o~m~t1~n on smoking patterns and r~seerch in developing countries will be sought through ~he World Health Org~nlz~tion, Int~rnatlonal Union C~

Against Canee~ (UICC) ~nd the American Ca~ce~ Society. The information @ethersd through this process will also be used LO astabllsh a date base for the Information program functions o? the Institute. R R The Institute will draw heavily on the research resources available from within the Harvard community. These include the Schoals of Medicine an~ Public Health, the Kennedy School and its Center for Health Policy, the Harvard Division of Health Policy Resear:h and Education and the vast resouzces of the health care system affiliated with Harvard: HMO's, acute care hospitals, specialty hospitals and free-standing clinics. These settings offer enormous potemtlal for research into prevention an¢ intervention strategies, ~he ~ealth of d~t~ an emokl~g ~Ire~dy collected by surveys is another major resource. Much of this data )emains to be analyzed for Its contri)utions to understanding smoking behavior. Surveys such as the National Healt~ Interview Survey contain basic data on smoking patterns, quit attempts and health status. The 1979 survey of teenage smoking behavlor and attitudes conducted by the National Institute on Eduoatlon end the annual survey of high school seniors conducted by the National Institute on Drug Abuse offe~ important InsiQhts into teenage smoking. IAnd, in 19@), the Office on 5mokin0 and Health plams to conduct e mejo~ survey of teenage and adult tobacco use which will provide the first comprehensive data on smokin9 behavior since 1975. One ~w i

4 of the Instltute's major objectives will be to examine these sources and encourage widespread analysis and utillzatlon of the data. Research conducted by state health departments as part of their increased efforts in dlsease prevention offers another important resource. The health departments have conducted surveys of a variety of health behaviors and many have established the cepaoity to monitor key indicators of health related behavior. The Institute will establish liaison with state health departments in the region and with the Centers for Diseese Control which supported the collection of state date. ~ The extensive experience of other countries in dealing with ! their own smoking problem offers a partlculerly important end promising research resource. Crass-cultural comparisons of smoking behavior, for example, may prove invaluable in isolating socio-culturel variables unique to the American smoker. Or conversely, international comparisons may lsolate common characteristics of smoking behavior not easily Cdentifiec through studies of this country alone. Clearly, the challenge facing ene Institute will be to identify the most relevant and useful of these promising resources end to apply them in the solution of key research questions. R~ h = n Not only is the list of unanswered questions aDOU~ smoking behavior large, it is filled with many of the most basic questions imaginable: why do young people take up smoking in ~ne A•2, ~b 26

I~dLvtdual Patterns of Smoking and ~ulttino - Profiles of smoking behavior; initiation, ~ttempts at cessation, successes and relapses; relevant vstlables such as consumption, health status, motivation, exposure to prevention/interventlon programs, oc~upatio~l spousal smoklng! brand, beliefs and attitudes about smoking, aid in quitting, effects of quitting, concern about relapse. Oem~raohics of $moklno and guittlno - Aggregate profiles of smoking behavlor by age, sex~ race, socloeconom~c status, health status, occup~tlon, alcohol and Orug consumption, and beliefs. Social Hlstorv of Smoking - smoklng~ influence of peers exe~clse, attitudes Social status of on teenage uptske and maintensnce attitudes toward allowing or disallowing smoking in various settings including schools, willingness of nonsmokers to complain, compliance of smokers, the self-consciousness of smokers with particular emphasis on teenagers; the influence of these factors on smoking ~ehavio~ and the susceptibility of the smoker to the social environment; policy implications o~ the social ~a ~5 ~a

environment an~ other health-behavior tre~ds such as Oi~t, exeroise, alcohol consumption and ~rug U se ° e k n - Bellefs about the health hazards of smoking particularly as dlfferentlated by age, sex, rac~ and soc1o-economic ~tafust the ~ela%ive be~efit~ ~f l~e~ tar ~d nicotine clgarettesj the relevance of tar and nlcotfne measurements to Starting to smokel b~and choices and qulttlng, bellef$ about the value of qultt~n@ for vBrlous age groups Including the very young and the elderly. envlronment, dlfferen~ial senslt~vlty to nicoLine, the differences between social an~ a~d~ctfve smokers, t~e p~tentlal for screenlng ¢hlldren for susceptlb~llty to addictive smoking. ThermoSes - the relaflve e~fect~ve~es$ of averslve ~onditi~ni~, ~elf-gu~ded quitting, hy~nos~, acupuncture, medle~tion, group and Ind~vldu81 counsel~ngI pro~essio~al and comm~roi~l mod~s| strategies for young SmOkers and other $peclfic grouD$ Such as high ~Isk smokers, "low" ~k $~ok~sI p~gnant wD~ po~t-~I~ pQ~t-op~atlve. C~

"6 Str~t~oi~% f@~ Self-Msn~oememt - and self-management for quitting or cutting down consumption; when, at what age, where~ how, with what assistance, opportunities for lnltlatlng self-management, the role of brand sw~tchlng, exercise @~d ot~er health behaviors. f k - ~he relatlonshID of nicotine tD cigarette addictlon, components of addiction, the effects of other Ingredlente and smoke components, the effects of taste, testing for nicotine sensitivity. Nicotlne Administration - Nicotine chewing gum; higher nicotine, lower tar cigarettes; effects of nicotine levels on smoking behavior and brand choices; effects on Inltlatlcn. - ~he nature of compensation (increased consumption or modified patterns to preserve "satlsfectlon" after changing from a higher to a lower yield cigarette); effects on smoking behavlo= patterns; relationship to attitudes and beliefs about risk. Informatlcn and £~ucation . The effects of Self-modific~tlon campaigns particularly on the young; attitudes ano beliefs before and after; impact on declslcns to k.b pa &1

start or to quit in various age groups; media selection; message selection. - The relationship between advertising the uptake of smoking and smoking behavior, both pro- and anti-smoking advertising; advertising of lower tar and nicotine cigarettes; the potential effects of advertising restrictions; differential impact on subgroups of smokers. n m n ~ v s - The impact of price on demand for cigarettes and on consumption, brand choices, initiation and cessation; differential taxation of tar and nicotine yeilds; price as a barrier to taking up smoking. n v ~ - The effectiveness of incentives in formal cessation programs, non-monetary incentives; negative incentives such as employment restrictions. n v - Development of an inventory of existing and plausible laws, regulations and other restrictions on smoking; barriers to access by children, evaluation of discriminatory hiring o? nonsmokers, workplace regulations; restrictions on public smoking, labelling; restrictions on sales to minors. 4 ~O ~q

These questions represent • sample of the many behavioral and policy research questions to which the Instltute will direct its attention in the development of the analytical framework and in launching a ~eseareh program. The p~iorlty assigned to each question and the research ~ctu~lly undertaken ~ill depend on the Lnput end perceptions of a wide range of sources and advisors, These questions which offer the mast promise for significant advances in knowledge with ~mmediate appllcsbillty to high priority program and policy development will receive the greatest ettentlon. within the initiation smokers smoking As discussed earlier, special emphasis wlll be placed snalytlcsl f~e~ork, on questions relating to of smoking by young people and qulttlng by those shown to be most significant in influencing childhood behsvior. : i 34

ti PR OR TIE AND PR RAM FOR THE FIRST THREE yEARS 25 O~ M,,II

t, PRIORITIES AND PROGRAMS FOR THE FIRST THREE YEARS The establishment of an active and viable research institute I$ a substantial undertaking. The planning, organizational and fund raising activities alone constitute a major challenge. However, it is essential that these instltute-building tasks proceed space with launching an active research program. To this end, the Instltute's operational objectives for the first three years will be: I. To establish the Institute as a functioning entity within the Kennedy School of Government. 2. TO $ecura funding f~r specific research pro~ec%s and basic operating costs. 3. To initiate programs and projects in each of the five functional areas. AS discussed earlier, the Institute will place the highest priority on activities which directly or indirectly contribut significantly to preventing smoking among childrec ~d adolescents. The Instltute's plans call for eight programs or projects In the first three years, Each of these involves a b~oad range of information gathering, data analysis, research ~. pmllnlng and information dissemination activities intended to QD CD support the Instltute's mission. Within each of the eight projects, smoking among children and adolescents will be the first concern addressed. It is expected that this cross-

Smoking is having a particularly insidious impact on developing countries where tobacco Is grown. Worldwide as well as domestic demand has greatly increased tobacco acreage. As a result, more land has been cleared and more wood cut to cure the tobacco, creating serious problems of deforestation, soll etoslon, air pollution and the diversion of agricultural resources from food production. Smoklna Amouno Young Peoole The most setlous problems posed by smoking are among children and adolescents. Early research findings on the hazards of smoking focused on adults and the long-latency diseases such i,~ as cancer. However, since 1964, an increasing body of knowledge :~ has accumulated on the effects of smoking on young people. Perhaps most important is the finding that teenage smoking habits are the major determinants of lifelong smoking dependence• Very few smokers begin thelr habit after the age of twenty. In addition, there is overwhelming evidence that smoking during pregnancy has a serious impact on the wellbeing of the fetus and the health of the newborn. Other effects on the young include: o Haternal smoking retards fetal growth and increases the Iisk of spontaneous abortion, (~ cb fetal death and neonatal death; ~-~ o Children of smoking mothers mey have ~ :~ deficiencies in physical growth, intellectual and emotional development;

o Young cigarette smokers have evidence of Irrevarslble small airway dysfunction; o Teenage and young adult smokers have a higher prevalence of respiratory symptoms than nonsmokers; o There is a significant relation between children's respiratory illness and parental smokiog; o Children whose parents smoke are twice as likely ~to become smokers than children from nonsmoking familles. These disquieting facts about the effects of smoking on children illustrate the significant interrelationship of adult and childhood smoking at all stages of development: maternal smoking can affect fetal and neonatal health and overall development; parental smoking can affect childhood health and can determine teenage smoking habits; teenage smoking can determine lifelong smoking habits with both short and long term health effects. It is clear from these interrelationships that programs aimed at preventing children from smoking or encouraging them to qult must consider the full spectrum of smoking behavior. They must focus on pregnant women, young children, young adult role models and peers, parents and other adult exemplars. And they must be based on a thorough adolescent behavior, In the p= understanding of smoking be~avlos and broader Context of adolescent

i, risk-teklng and experimentation with alcohol and other drugs. However, the strong llnk between childhood smoking and adult dependence argues that regardless of the specific policy or polnt of intervention, the ellmlnation @f smoking in ou~ society will ultimately depenb on the elimination of smoking among young people. 'r' Understandlno Smoklna Behavior The reasons for the dramatic changee in American smoking patterns a~e not nearly as apperent as the changes themselves, nor are the reasons why so many young Americans oontlnue to take up smoking and why so many adults smoke, despite widespread knowledge of the risks. The public health efforts launched in -,~ ~ i, the sixties must have played a major role. The information, education and regulatory programs implemented by the federal government, voluntary agencies and state and lo~al governments .~ have somehow hap a measurable impact on smoking behavior, public knowledge end awareness and even on the social status of smoking. ! ~ What is not known is how these efforts worked and why they succeeded with some smokers and not with others. It is also not understood what other varlsbles have played independent oz dependent roles in changing smoking behavior. ~i ~ he l:h onseq e oes of ,ell 0 documented, the behavlorlal aspects are not -- what makes young people start S[~Oking, ~hy it is SO h~rd to quit, who succeeds ~nd~ i . G1 how, why relapse is so frequent, even slier long periods of / abstinence. 7

"o The sccumuletad knowledge about the psychological, social, phar~acologicsl and demographic aspects of the amoklng problem is e smell fraction of the thirty-three thousand studies on smoking in the world literature. The sciences concerned with behavior have legged far behind biomedical science in developing the techniques necessary to better understand smoking and in applying those techniques to fill the gaps in knowledge. These gaps are slgnlflcant. For example, while the mejorlty of the ~3 mllllon former smokers Quit on their own, little is known about their methods, motivations, consumption petteens, relapse rates, baei~ demographics and other determinants of successful quitting. Little is also known about what effect parental quitting may have on teenage smoking. Without more knowledge about such key Tectors, policies snd progzems to prevent smoking and encouzege gulttlng depend on anecdotal and incomplete data, thus limiting .their effectiveness. There arm also major gaps in our understanding of adolescent smoking and the determinants of decisions to take up smoking. The most recent data on teenage amoklng patterns end attitudes were collected in 1979 and although there are indications that major changes may have occurred, no comparable new date are available• The p~oblem is furthe~ complicated by the fact that much of the available data were collected by telephone surveys of d~ smell samples. These data not only lack statistical power, but ~T~ are also deficient in identifying racial and ethnic origins. Questions have also been ~aised about the validity of telephone

responses to sensitive questions asked with parents present. Without better end more accurate knowledge, p~og~ame aimed at preventlng teenagers from starting to smoke may be out of step wlth teenage attitudes and behavloe. ~here Ore Several basle reasons foe this c~itloal shortfall in onderstandlng smeklng behevlor. Smoking is a complex set of behavlore involving psyehologleei and phyelolegleal depenOence on tobacco, complicated by seclel relnforcements including efforts on the part of the tobacco industry te deplot smoking as safe, att~actlve and soelally acceptable, In adOition, the natural evelutlsnary gap between blomedleal and behsvlorsl science has be~n ~iden~ by Oe~islons slloc~ting fa~ ~reatee ~esouro~s to blomedloal ~esee~oh than to behavioral research on smoking. ° Structural proDlems within the research and puDiLo health communitles have also csntrlbuteO to the knowledge shortfall. While many groups and o~gsnlzations have plaoeO greater emphasis on smokln9 ~elated behevloral ~esearch in recent yee~s, coo~dlnstlon and ~olio~ through have been slo~ in comlng, Because o~ a lack of leedeeshlp, eoo~dinatlon o~ awareness, researchers have missed opportunlties to m~ke signiflcent striOes through the anelysls e~ eme~glng trends o~ the impact of new policies. Because of the p~liticsl sensitivity of the smoking 0~¸¸ issue, government agencies have been slow to exert leade~shlp ~n ha these a~e~s o~ h~ve suffered cuts In resources, ~akl~g It ~ difficult fe~ them to respond. There is no place that funding .~} i ageneles can turn to find ~ut, as research prlo~ities, wha~ it is ~i*

we do not know about smokinG that could be known that would contribute to effective public end pzlvate policies. The impect of this shortfall in knowledge has been to llmit the capacity of researchers and policy m~kers to design mew end more effective approaches to smoking prevention end control. while smoking has declined dramatically, greater momentum and new direction must be generated if greater success is to be eehleved in preventing young people from taking up smoking and helping the 54 million Amelicena who still smoke. ~ithout better and More targeted ~esesroh on smoking behavior, better ooordlnatlon and closer ties between research and policy development, public health officials will have to apply a limited, outdated knowledge base to solve the smoking problems of the 1980's and 1990's. ~New Resource for Smoking Research In response to the need for better directlon, coor~inetlon and contlnulty in research on smoking behavior and policy, the 3ohn F. Kennedy School of Government is establishing a permanent center for the study of smoking. This center, to be named the Institute for the Study of Smoklng Behavior add Policy, will have as its primary goal the development of mew knowledge about smoking behavior end the translation of that knowledge into program designs and policy options. To achieve this goal, the Institute will draw on the resources of the Harvard community end will roach out to those Individuals and Inatitutlons in the United States and abroad who are addressing many of the same problems.

The to flll research gaps, examine policy eptions and stimulate the behevloral and policy research efforts of others. Primary emphasis In all of the Instltute's undertakings will be on broadening the knowledge base by increasing the participation of researcners from a wide range of disciplines. A second and equ@lly Important emphasis will be on serving the smoking research community, providing information and coordination for researcn she policy development efforts. Broadly stated, the Instltute's mission wlll be to: o Serve as a focal point and an information resource for emoklng behavior and policy research nationally and internationally; o Create a mechanism for continuous assessment of the state of the art in smoking research; o U~Oertake research projects with potentiel for p~ogram or policy applications and, monitor events mne changes in policies to identify research eoportunlties; o Gather and analyze detailed personal data on snoklng behavlor in order to develop a comprehensive natural history of smoking as a research end pollcy resource, Institute will undertake e variety of functions designed M~ 11

e, o Exsmlne the relationships between smoking zessarch and key policy issues on a continuous basis and target research to support and enhance policy development; o Explore hew spprasche$ to translating research flndings into programs and broad strategies for smoking prevention and control in settings ranging from schools to health care delivery to national legislation; and o Provide coordination end ccntlnulty in smoking research ~nd policy issues, eepeclally with resoe~ to the ~ny researo~ recommendations developeo o~er the past several years. In short, the Institute will endeavor to create s framework of information sno expert judgment that can provide direction to Smoking research in yesrs to come. This framework will be characterized oy a contlnous process involvlng the examination of research progress, needs and opportunities and the stimulation of ~ew ideas. "n P " The ultimate goal of the Institute will be prevention: preventing children f~om taking up smoking and preventing the M~ damage caused by smoking, r-ivan the wlde range of concerns about -~ the effects of smoking -- children, pregnant women, high risk ~ •L i~¸

4 $$ adults -- and the variety of intervention points including schools, health care settings, th9 home and the workplace, the institute will develop Its research priorities socordlng to the best available advice on risk and opportunity. However, the known dependent ~a~lables in smoking behavior and the increasing experience of intesvention projects already suggest that research on-preventlng smoking among children end adolescents should 'receive the highest priority. Consequently as the analytical framework end specific research functions and projects evolve, the Institute will direct primary attention to efforts that addless children dlrectly or that have substantial indirect benefit in preventing childhood smoking. F n no h , , The hlstosy of smoking reseasch is one funding support, due often to fluctuations in political support for and public interest in smoking control and prevention. To counter this tendency, the Kennedy School of Government IntenDs to establish the Instltuts on a broad base of private grant and endowment support from co~por~tlons, foundations and other sources. The Institute has the full support of Graham Allison, Dean of the Kennedy School of Government and Julius Richmond, Director of the Division of Health Policy Research and Education, The Kennedy School and the Division have already contributed in excess of $30,000 to begin planning and Institute. Derek Bok, President of the % ~! .... 13 of wide variations in development for the ~.bL University and Howard ~,~:~,?. k

"j Hlatt, Dean of the School of Public Health have also given their full support to this effort. The University has offered assistance in identifying sources o? endowment funds. There have been many other expressions of support end encouragement from within the Harvard Community. Over the life of the Institute, these will be translated into substsntlel contributions of advice and collaboration, greatly enhancing the Instltute's available resources° To carry on the work of creating a strong and permanent research center, the Kennedy School is seeking e total of $1.35 milllon far the three year period the Institute wlll need to become fully operational. This core support will enable the Institute to launch several key eesearch to lay the base for a larger, continuous services following this first three year initiatives as well as program of research and phase. Of the total amount required, $658,000 is being requested from the Carnegie Corporation to fund the basic program and operatlng costs of the i Institute for three years. The programs and activities to be " t supported by these funds are described in detail in Section IV, ; :!' together with the other major projects which comprise the Institute's first phase. ; The remaining sections of this proposal desceibe the !~i'~ ' Institute, its goals, structure mnd objectives, with primary M~ emphasis on the organizational and research objectives for the three year start-up period. Appendices include: detalllng the major steps to implementation of the s schedule Institute; a

"6 breakdown of the Institute's on key personnel. budget, and; background information 15

ESTABLISHING THE INSTITUTF C,D i.i,

ESTABLISHING THE INSTITUTE hn Fw Research on smoking behavior end policy has been hampered by a lack of resources and direction. An important part of the Inst~tute's mission wlll be helping to rectify these problems by injecting an element of organization Into the collective thinking of researchers and policy makers by addressing one basic question: what are the smoking behavior research questions that are answerable and whose answers are Immediately applicable to more effective programs and policies? TO carry out this mission, the ~nstitute will develop an analytical framework to serve as a dynamic research ngenda; a strategy development and priority setting process to help direct research efforts towards filling key gaps in knowledge, The framework will be based On assessments of the state of the art, needsp priorities and oppoztunities; filtered by the Judgement of knowledgeable researchers and policy makers end continuously amended as new knowledge becomes available. The process leading to t~e development of the analytical framework will draw on the broadest possible range of input and advice from the research community and f~om a permanent research advisory committee of exgerts in C~, smoking research, policy research end related fields• ~r The primary point of departure for developing the analytical framework will be the identification of issues which, if resolved .~J by new knowledge, will suggest new programs or policies. A prime ,

° example is the issue @f the effect of cigarette advertising on decisions by young people to take up smoking. This is a powerful issue, regularly confronted by policy makers considering leglsletive recommendations on smoking education and information. And subsumed under this issue are a variety of questions: can the effects of advertising per se be studied?; can an impact on young peoples' decisions or attitudes be shown?; if there is s measurable effect, what are the policy options available to mediate that effect? what is the effect of counter (antl-smoking) advertising on teenagors?; what, if any factors differentiate the response of young people to advertising for alcoholic beverages? By approaching the analytical framework in this fashion, with children snd high risk groups as crosscutting priorities, the Institute will attempt to create a more structured and deliberate process for pursuing smoking research. Functions of the Institute Drswlng on the analytical framework and its advisory committee, the Institute will carry out five principal functions: i. Conducting Research - the Instltute's own research will be heavily influenced by the priority concerns and research opportunities already discussed end by the degree to which existing researchers within the Harvard community respond to those opportunities• However, the Institute w~ll develop basic capabilities in: the collection and analysis of inte~vie~ and survey d~ta with particular emphasis

2, ~q on ehlldren and adolescents in the natural history of smoking, intarventlon research, with an emphasis on targets of opportunity where the instltute's capabilities can augment @r be augmented by collaborstlve efforts• An example would be working with the Harvard Community Health Plan on further research intervening with pregnant women smokers. Stimulating Research - the Institute will use the analytical framework to attract new researchers and to focus attention on promising areas of inquiry. By convening conferences and seminars, by provldng small seed grants and by highlighting progress, the Institute will attempt to stimulate new interest from researchers and funding sources. For example, a conference addressing the issue of the impact of advertising might spawn a variety of research ideas ~ith potemtial for policy applioatlons. CoOrdination - the Institute will conduct an ongoing program to foster better coordination of efforts among interested researchers. The Institute will alert groups about impending opportunitles and help ensure that researchers %a~e advantage of those opportunities while avoiding dupllcatlon. ~b 0 k=& 0 b,i

~. Research Information/Program . a~ an adjunct to its coordinative efforts, the Institute will monitor a variety of sources, including data on research collected oy the federal governmert,s Office on Smoking and Health, and will develoo a soeclalJzeo information program co serve the smoking behavior and policy research community. Through llnkages with government at all levels, voluntary health agencies and other research centers, the Institute will maintain a current file of resesron in progress and otr~r information of use to researcners. 5. Communication - 8s ire Institute's program evolves, the communication of progress end findings will receive priority attention, as will the ennancemen~ of communication scout smoking research in general. The Institute will exolore a variety of ootlons ranging from a newsletter to a journal dedlcazeo to smoking research and policy. The transfer of research findings into mollcy-maklng forums will also be addressed through aooroacnes sucr as the #ubllcetlen of monographs on key researc~ findings and their relevance to policy issues• ~=~ O8 2O

The Institute is an outgrowth of the activities of Harvard's Division of Health Policy Research and Education and the Center for Health Policy and Management in the Kennedy School of Government. Among the principal functions of both the Division end the Center is the identification of areas such as smoking behavior research and Support for the develooment of approoriate Institutional responses. One of the first activities of the Division was to set up ! z. University-wide working groups, including one on health oromotion and disease prevention. This working group in turn identified cigarette smoking as a high prlority and convened a conference on smoking cessation in November of 1982. Following the conference, there was considerable interest in continuing a dialogue about smoking behavior research. In response, tne Division established a permanent seminar, bringing together interested oertiee from the Schools of Medicine end Public Health, the Kennedy School and others from the Boston health care communlt7 and around the nation. It is from the deliberations of this grouo over a oeriod of seven months that recognition of the need and the conceot for the Institute emerged, Throughout this brief history, the first Dlrector of the Division, Dr. David Hamburg and its current Director. Dr. Julius Richmond have taken an active role in defining the mission for the Institute and planning for its development. • • • ~F

o 6 The Institute will operate within the context of the Center for Health Polloy and Management, dr.awing on the center's experience in the design, implementation and management of research efforts. Dr. David Blumenthal, Executive Director of :i the Center has given invaluable assistance in translating the concept of the Institute into viable plans. The Institute will also work closely with the Division, drawing on its outreach and coordinative experience. The Institute will resemble existing academic research ~ centers and programs in that it will be an integral part of the Harvard academic community wlth strong support from and access to all relevant departments, centers and schools within the University. In particular, the Institute will seekactlve involvement from the Schools of Medicine and Public Health, from economists, behavioral scientists, demographers, epidemiologlsts and from the extensive health care delivery resources of the Boston area. The Division of Health Policy Research and Education ~ill provide invaluable guidance and assistance in attracting the support and involvement of these resources. The Institute will establish two permanent bodies to aid in carrying out its mission. The first Is an Advisory Board to oversee the long term development of the Institute ant its funding base. The members of the Board will include leaders in science, medicine, philanthropy, business end law. The second body is a Research Advisory Committee, to be made up of experts In smoking research and related fields. This Commlttea will L t ~L ilii

Q assist in the development of the analytical framework, the delineation of specific research projects and the establishment of communicatluns end coordination mechanisms. To ensure effective coordination within the University, m third group will De established on a less formal basis. This group will be an informal steering committee made up of representatives of the verlous centers, schools and departments and will meet regularly to ~evie~ progless and identify potential problems. It will be an extension of the seminar on smoking research established following the conference on smoking cessation. ........ Staffino .... "'~ " The staffing plan for the Institute will evolve as the : various functions and programs are implemented. The institute will draw its initial administrative support from the Center for ii Health Policy and Mansgement. All programs initiated by the i ~nstltute will draw on support through collaborative efforts with other programs in the Harvard Community. The Institute will be under the overall direction of Thomas C. Sehelling, Lucius N. Littauer Professor of Political Economy. Dr. 5chelllng will devote half time during the academic yea~ and ~!~ full time during the summer to the Institute. To assure the success of this enterprise, the Kennedy School of government is (~ ~:, .. underwriting the financing of Dr. Schelling's salary for the Intitial three-year development period. It is hoped that .i!~ • ~ 23 • ii

$ wlthln that time a portion of these funds may be recouped from project g~ants. John H, Plnney, former Director of the federal office on 5moklng and Health wlll serve as full time executive director. Their curiicula vitae are in Appendix t. @h~oughout %he first phase of the Institut~'s development. Hr. Pinney ~ill continue to reslde i~ Washington. O.C. and ~ill divide hl$ time between Boston and Washington. Whlle in Washington, he will carry out a number of functions Important t~ the Institute's success. These include: estebllshlng amo maintaining close lieisen with the policy process through contacts with the legislative and executive branches and voluntary agency Washington representatives; working closely with agencies eonetitutinQ the m~Jor data sources on smoklng (Office on ~oklng and Health, Natlonel Center for Health 5tstistice, Centers for Olsesse Control, NIH), and; enhancing the coordination and program development functions of t~e Instltu~e through regular meetlnge with key agencies amd participation in conferences an~ seminars. ~n ~dditlo~ to Or. Schellln9 a~d Hr. Pitney, the Institute will hire e core staff ef one reseereh assistsnt and one secretary. Other professional staff will be hired on a project basis and wlll generally ~evote part time to their individual projects° They will be drawn primsrily ?~om within the Harvard ~ v:. L~ community from teaching and research areas relevant to ~ne Institute's p~ogram, A more detailed descrlptio~ of ~e projects~ planned for the first three years of the Institute's program is provided in Section iv.

q ~J ! i¸ ~ S¸

THE RESEARCH PROGRAM As discussed in the previous section, the Institute's research program will be guided by the analytical framework and the advice of the Research Advisory Committee. These sources will help ensure the program's relevance and timeliness and will aid in maintaining the balance of behavioral and policy research. A high priority will be placed on identifying in advance ~nose events which offer significant research oppoztunitles. ~or example, excise tax increases or changes in the clgare~te warning label may occur within the next one to three years, offering great potential for research on the impact of economic and • " environmental influences on smoking behavior end evaluating ~nese policies. Development of the analytical framework will involve an examination of the myreld recommendations compiled in recent • years in the annual Surgeon General's Reports end by conferences such as the National Conference on Smoking or Health convened in 19el by the American Cancer Society. Information on research in progress will be drawn from the members of the advisory committee and from sources such as the biannual Directory of Research on Smoking and Health compiled by the Office on Smoking and Health. (~.,,!.-\~ The institute will seek ad@itlonal sourcee of information on work ~ , . in progress, particularly in other countries. Information on ~=~ ~ smoking patterns and research in developing countries will be ~ ' sought through the world Health Organization, International Un~on ,~,,

i Against Cancer (UICC) and the American Cancer Society. The information gathered through this process will also be used to establish a data base for the information program functions of the Institute. Research Resources The Institute will draw heavily on the research resources available from within the Harvard community. These include the Schools of Medicine and Public Health, the Kennecy School ano its Center for Health Policy, the Harvard Division of Health Policy Research and Education and the vast resources of ~ne health care system affiliated with Harvard: HMO's, acute care hospitals, specialty hospitals and free-standlng clinics. These settings • offer enormous potential for research into prevention ano intervention strategies. The wealth of data on smoking already collected by surveys is another major resource. Much of this data remains to be analyzed for its contributions to understanding smoking behavior. Surveys such as the National Health Interview Survey contain basic data on smoking patterns, quit attempts ano health status. The 1979 survey of teenage smoking behavior and attitudes conducted by the National Institute on Education and the annual ~D ,' survey of high school seniors conducted by the National Institute ~ on Drug Abuse offer important insights into teenage smoking. ~ And, in 1985, the Office on Smoking and Health plans to conduct a ~ major survey of teenage and adult tobacco use which will prsvide the first comprehensive data on smoking behavior since 1975. One % +.

t of the Instltute'e major objectives ~ill be to examine those sources end enoouroge widespread analysis and utillzotion of the data. Resoorch conducted by state health deportments as port of their increased efforts in dlsease prevention offels another important resource• The health departments have conducted Surveys of a v~rlety of health behaviors and mony have established the copocity to monitor key indlcatore of health eeleted behavior. The Institute will establish llolson with state health departments in the region and wltb the Centers for Disease Control which supported the collectlon of state dote. The extensive experience of ether countries in doallng wltr their own smoklng problem offers e particularly important ano pre~iei~g reaee~ch reoource. Cross-tultulal cempalisons of smokin~ behavior, for example, m~y prove invaluable in isolating soclo-culturel variables unique to the Amerlcan smoker• Or conversely, international comparisons moy isolate common cherecterletica of smoking behavior not easily laentlfieo through studies of thla country alone. Clearly, the challenge facing ~ne Institute will be to identify the most relevant and useful of these promlsin9 resources and to apply them in the solution of key research questions. Research Ouestlone Not only is the list of unanswered questions about emoklng behovlor forge, it is filled with many of the most basic questions Imaglnoble: why do young people take up smoking C~ in the

/c7 r • i face of knowledge that they may become addicted?; why is it so difficult for some smokers to quit while others have a relatively easy time quitting?; what changes in smoking patterns occur over the llfe of the average smoker that may suggest prime points for intervention?; at what point do young smokers become addictive smokers and what is their Quitting experience?; what psychological or social factors account for the extremely high relapse rates among former smokers? Many of these basic questions suffer from a common knowledge gap: the lack of a complete understanding of the natural history of smoking. Without this knowledge, much of what can be learned about smoking behavior has no reference point, no basis for interpretation. For example, the possibility that males between the ages of 40 and 50 might have an extremely high spontaneous successful quit rate would have enormous implications for our investigation of the addictive nature of smoking. Unfortunately, much of what is known about the natural history of smoking is fragmented or lies unanalyzed in survey and interview data. And far more important aspects have never been explored. The natural history and demographics of smoking will be unifying elements in all of the Institute's research efforts. The following are examples of the many questions still examined• to be G@ r 29

Indlvldual Pattern~ of Smoklno and Ou~ttlno ° Profiles of smoking behavior; Initiatlon, attempts at cessation, successes and relapses; relevant vaslables such as eensumption~ health stetus, motivation, exposure to prevention/interventlon programs, occupetion, spousal smoking, brand~ beliefs and attitudes about smoking, aid in quitting, effects of quitting, concern about relapse. Demooraohi~s of Smoklno end Quittlno - Aggregate profiles of smoking behevior by age, sex, race, sooloeeonom~c status, heaith status, occupation, alcohol and drug consumption, exe~clse, ettltudes end beliefs. S~clal Hi~torv of Smoklno - Soelal status of smoking, influence of peers on teenage uptake an~ malntensnce attituOes toward allowing or disallowing smoking in various settings including schools, wlllingnese of nonsmokers to complain, compliance of smokers, the self-consclousness of smokers with particular emphasis on teenagers; the influence of these factors on smoking behavior and the susceptibility of the smoker to the soelel environment; policy implications of the soclsl O~

4 / environment and other health-behavior trends such as diet, exercise, alcohol consumption and drug use. f m - Beliefs about the heslth hazards of smoking particularly as differentiated by age, sex, race and soclo-economic status, the relative benefits of lower tar and nicotine cigarettes, the relevance of tar and nicotine measurements to starting to smoke, brand ~holcas and quitting, beliefs about the value of quitting for various age groups including the very young and the elderly. Indivldu~l Va~iable~ - Gecetics, personality, environment, differential sensitivity to nicotine, the differences between social and addictive smokers, the potential for screening children for susceptibility to addictive smoking. - the relative effectiveness of averslve conditioning, self-guided quitting, hypnosis, acupuncture, medication, group and indivldual counseling, professional and commercial modes; strategies for young smokers and other specific groubs such as high risk smokers, "low".~lsk smokers, pregnant women, post-M1, post-~peratlve. k~ Fa G6 b~

t • Strateoles for Self-Manaoement . Self-modification and self-management for quitting or cutting down consumption; when, at what age, where, how, with what assistance, oppo£tunltles for inltlatlng self-management, the role o? brand switching, exezclse and other health behaviors. _, _ ~ m k~n - The relationship of nicotine to cigarette addiction, components of addiction, the effects of other Ing~edlsnta ano smoke components, the effects of taste, testing for nicotine sensitlvlty. Nicotine Admlnlstr~tion - Nicotln'e chewing gum; o higher nicotine, lower tar cigarettes; effects of nicotine levels on smoking behavior and brand choices; effects on initiation. - The nature of compensation (increased consumption or modified patterns to @£eserve "satisfaction" after changing from a hlghe: to a lower yield cigarette); effects on smoking behavior patterns; relationship to attitudes and beliefs about risk• Information ~nd Education - The effects of campaigns particularly on the young; attitudes eno beliefs before and after; impact on decisions tt 32 ~b

• i t+ start or to qult in varlsus age selectlon; message selectlon. groups; media : i~¸ - The relationship between advertising the uptake o? smoking and smoking behavior, both pro- and antl-smoklng aOvertising; advertising of lower tar and nicotine cigarettes; the potential effects of advertising restrictions; differential impact on subgroups of smokers. Economic Incentives - The Impact of price on demand for cigarettes and on consumption, brand choices, initiation and cessation; differential taxation of tar and nicotine yeilds; price as s barrier to taking up smoking. • 0~ - The effectiveness of incentives in formal cessation programs, non-monetary incentives; negative incentives SUCh as employment restrictions. n v - Development of an inventory of existing and plausible laws, regulations and othe~ restrictions on smoking; barriers to access by children, evaluation of discriminatory hiring of nonsmokers, workplace regulatlon~; restrictions on publi= smoking, labelling; restrictions on sales to minors. ~b 0

These questions represent a and policy research questions to its attention in the development in leunchlng a research p~ogram. sample of the many behavioral which the Institute will direct of the analytical framewoek and The priority assigned to each question and the research actually undertaken will depend on the input eric oerceotlons of a wide range of sources and advisors. Those ouestiens whlch offer the most pzomlse for s~gnificant aovences In knowledge with immediate apblieability to high Drlority program aria policy development will receive the greatest @ttentlon. As discussed earlier, special emphasis will be placed within the analytical framework~ on questions relating to Initiation of amoklng by young people and quitting by those smokers shown to be most significant in Influencing childhood smoking behavior. 34

690106193

4, PRIORITIES AND ~RDORAM$ FQR THE FIRST THREE YE~R~ J The establishment of an active and viable research institute is a substantial undertaking. The plannlng, organizational and fund raising activities alone constitute a major challenge. However, it is essentlal that these Instltute-buildlng tasks proceed apac~ with launching an actl~e r~sesrch program. ~o this end, the Institute's operational objectives for the first three years will be: i. To establish the Institute as e functioning entity within the Kennedy School of Government. 2. TO secure funding for specific research projects and basic p~ereting costs. 3. To initiate programs and projects in each of the five functional areas. As discussed earlier, the Institute will place the highest priority on activities which directly or indirectly contribut significantly to preventing smoking among children and adolescents. The Instituts's plans call for eight programs or projects in the first threa years. £ach of these involves a broad range of information gathering, data analysis, research pallning and information dissemination activities intended to support the Institute's mission. Within each of the eight projects, Smoking among children and adolescents will be the first concern addressed. It is expected that this cross- • •::I¸ ~D W~ ~L• /

sectional approach will ensure that the early results of these efforts will be focused in whole or In great part on childhood and adolescent smoking behavior research. In addition to helping achieve the three operational objectives listed mbove, the funds requested from the Csrnegle Corporation ~ill support the follo~i~ three basic programs: i. Develoolno the Analytical Framework. AS discussed in the preceding sections, the analytical framework will be a dynamic process which will permit the Institute to focus on the major gaps in knowledge and the opportunities for policy-relevant research. It will serve as the basic planning overle~ ?or the Institute, guiding the organizational, staffing and research planning efforts. Developing the framework will involve three steps: a) Examining the research recommendations developed over the past several years by conferences, groups, individuals and institutions. The recommendations will be indexed and consolidated into a workin~ paper for use by the Institute and its Research Advisory Committee. b) Seeking the advice end input of the Research Advisory Committee. Institute plans call for convening the Committee twice each year to discuss research needs and briorlties and to help the Institute staff plan specific research projects. {D O ~b 37

c) A major po:tlon of the commlttee's agenda in its first two meetings will be devoted to discussion of the fr~ewo;k, and the Issuas ~ost relevant to smoking among children and adolescents. A smaller but still significant portion of the Committee's work in subsequent years will be directed towards assessing progress and keeping the framework current s~d relevant. Establishing linkages with other research institutions and individuals for input to the framework. Contact will be initiated with NIH, with researchers at universities such as UCL~, Michigan, Texas, Minnesota and others active in smoking research. Congressional staff members, government and voluntary agency officials will also be contacted through correspondence and an active travel schedule. ~hls outreach will augment the more formal input of the Committee and will also lay the groundwork for improved communlcetlon and coordination. At the end of the first year, the Institute will Issue a position paper discussing the state of research on smoking behavior and policy with particular emphasis on children and adolescents. Plans call for this paper to be an annual report with wide circulation, ¸¸/¸7 ' • ..... .

21 highlighting research opportunities and the accomplish- ments of the entire field. This effort will be a continuing responsibility of the Instltute's core staff under the direction of Dr, Schelllng end Mr, Plnney, _ ~ ~ n _ n. The objective of thls effort is to annanoe the quality, extent and timeliness of research both within the Harvard community and nationally. In the first year, major emphasls wlll be placed on: a) the identification of ongoing research on smoking behavlez and policy, particularly research sddreseing smoking among children and adolescents - extensive information is already available on published research, principally from the Office on Smoking and Health in the Department of Health and Human S~vlces. ~he Office also surveys ongoing research every two years end publishes s directory of abstracts submitted in response to the survey. The Institute will work closely wlth the Office on Smoking and Health and other sources to develop more timely information on research in progress and will explore ways of making that information accessible to the field. b) improving access to assistance on questions of research design and methodology - smoking behavior end policy Teseerch has been criticized in the past

c) for a lack of quality research design and methodologlcsl soundness, lhe lnstltute will attempt to identify Specific problems and match them with sources of advice and asslst~ncs, Thls information wlll be made available to those ressarchers developlng resesrch ideas. Consideration w111 be given to developing s £e?erral system to match problems with sources of help. identifying the full range o? funding sources for Smoking behavior and policy research - the Institute w111 Identi~y those sources and their particular interests and requirements. 7. variety of products will emerge from these efforts during the first three years, includlng monographs and ~ulletlnso However, the first year wlll be devoted to information gathering @nd the evaluatlon of alternatives for improving coordination. Models • ~ f~o~ othe~ field~ ~lll be examined ~d i~ormstio~ on ~ the needs of individual researchers will be Sought. ~ This effort will also be the continuing responsibility of the Instltute'$ core staff. ~I~ R~earch Information Proaram. The object of the program will be to organize the information derived from the coordination • effort and other Sources into an ongoing Service that will ~i~!'¸¸ :

! ~espond to inquiries from individual researchers as well as provldlng regular informBtlon bulletln$ on develoblng issues end reseereh epportunities• Durlng the first yeer~ approaches such as en-line blbllogrephlc end other 11brery services will be exemlned together wlth wey~ of reepondin~ to Vsrleue types of inquiries° The Instltute will carry euts needs eeeessment to determine the types end extent of servloes rebulred by reseBrch~Te° In subsequent ye~rs~ olans cell fo~ t~e ~reBt~o~ Of ~ ~r~s~e~t i~fo~m~t~n ~s~ter ~B~ ~ill complement the Instltute's other functions while serving the research community. Thls pregram will be another basic function of the ~nstltute and w~11 be the reepenelbillty of the core staff. ~ro~eot ~rant In additlon to the three basic program elements, Instltute plans call for five distinct research @ro~ect~ durln~ the f£rst three years to be undertaken as promptly as fundlng can be secured. N~ fu~ f~r th~se ~o~eets is b~in~ req~este~ f~o~ the C~rnegle Corporation; the Institute will seek separate g~an~ fun~s ~or e~ch project. ~hey ~re presented here to show ~e full rsnge of the Inst~tute's aetiv~tle$ during Its Inltiel three year phsse° As In the case of the basic program, smoking by children and adolescents will have flret priority ~n these p~oJee~s. I. The N~turel History of C~o~rette Sm~k~n~o As discussed earlle¢ in th~s proposal, shout the naturel h~etory the~e ~re many ~nanswere~ questiens ~ , of smpklng - smokln~ behevior st

-i tne [ndividual level - and that which is known nas not Been assembled into a coneren~ ~icture. Without a clear understanding of whet is knowr, planning for new researcn is difficult and misconcemtlons about smoking behavior persist. Thus the Institute will place a high ~riority on assessing ~ne state of knowledge in this critical area In order to establish a baseline for future research. The project will involve two separate out interrelated activities: a thorough review of the literature including both oublished and unoubllshed data, and; interview researcn on specific aspect~ of the natural histbry. It is antioioa~eo that some asoects can Be developed by further analysis of existlno data, prlmari]~ large survey interview data. However, interview research is an important tool in understanding smoking behavior, The Institute will attemot to deve]oo ~ne caoablllty to concuct sucn research and make it a basic function, a) Review Pro~ect. The review project will Be osrrieo out by an individual researoner recruited from within the Boston-Harvard community. The Instltute's Director and Executive Director will provide assistance ant guidance, In addition, one or more working grouos will De formed to held guide ~ this effort anc assist in identifying and evaluating sources and analyzing data. The working groups will be comooseo of members of the Institute's Research ~ ,i 42

j• b) Advisory Committee and other knowledgeable researchers= Thls project will requlre two years to complete, culminating in the publication of a report defining the state of knowledge and the major gape, together with recommendations for the types of ~esearch needed to fill those gaps. The report will be widely distributed both nationally and internationally. _n _ v:w R = =h° Interviews with smokers and former smokers form the basis of much of the available data on smoking behavior. These data are mainly from large scale interview surveys such as the Natlonal Health Interview Survey• The Institute proposes to explore ways of using smaller, less costly interviews that can yield data on specific aspects of smoking behavior especially teenage smoking and attitudes. While research of this type may not provide data generalizable to the total population, it can provide important new insights end supplement the more general findings of large surveys. This project wlll move in tandem with the review project, under the overall guidance of the Instltute's Director° It is anticipated that the review project will provide important data on which R rE •

9 • to base decisions about what questions, both substantive and methodologlcslp should be addressed in the interview research. The work on this segment will be carried out by an individual researcher and • orklng group of k~owledgaable raseBrcha~s will be formed to help guide the project. The project is expected to require approximately 2 i/2 years to complete and will produce a minimum of two sample surveys and a final report detailing findings on methodology, smoking behavior and research opportunities. ~ob~cco O~oenden~e. One of the most impoltant components of smoking behavior is tobacco dependence: the habituating and/or addictlng properties of smoking that support maintenance and complicate cessation. In the last five years, increasing research attention has been focused on defining the nature of tobacco dependence with particular emphasis on the role of nicotine• Smoking has been defined as en addiction in the International Classification of Diseases (ICO-9) and Its addictive properties have attracted the attention of researchers knowledgeable about other addictive substances and the dependence process in general• In this project, the Institute plans to review the state ~a of knowledge about tobacco dependence in order to produce a ~ ~ :i baseline report similar to the report envisioned in the ~ natural history gro~ect. ~his effort ~ill consider published 44

~o end unpublished research as well as reviewing the nature and extemt of research in progress. As In the case of the natural history of smoking, a basic review of knowledge about tobacco dependence is critical to effective planning for future research and policy initiatives. This project will be carried out by e knowleOgeable researcher with the assistance of an advisory 9rouo of exoer;s. The project will require approximately two years, including preparation of the report. ~. This project is intended to broaden the range of partlcioatlo~ in smokimg policy research by estsblishlng a program of policy analysis with papers prepared by doctoral level stu@ents under a competltlve fellowship program " soonsoreo oy the Institute. The project will offer three fellowships per year, one from within the Harvard community and two from outside, general guidelines for topics will be developed by the Institute based on advice from the Research Advisory Committee with special emphasis in the first two years on issues relating to smoking by young people, r As currently envisioned, the project would be a two year effort with swards beginning in the second year. However, efforts will be made to secure longer term funding in order to establish this project as a major source of research and analysis• smoking policy ~ , 45

P • y 4. -= --n R ~ _, . In rBcent years, there has been an increase in the amount of research on new interventions for preventlng young people from atartlng to smoke one helping smokers to quit. The Institute will function within one of the most active edueatlonal and health care dellvery environments in the world. The variety of settlngs -- schools, unlversities, acute care hospitals, s~eciallzed clinics, HMO'e, -- which this environment offels, represents an unparalleled resource for research on Interventions in - smoking behavior. This project is designee to utillze that resource by achieving two primary objectives: establishing a permanent focal point for smoking intervention research ir the ~arvard-Boston health care community, and; conducting reserach to identify alternative intervention models for smoking prevention and lntervent3on. The project will be carried out by a researoner recruited locally• With the active assistance ano participation of the Institute staff, this individual will assume an entrepreneurial and advocacy role In attemDting to interest local institutions in eon~uctlng intervention research, structuring a process fol identifying oromislng research ideas, and linking these wlth mew developments in health care delivery. The Project Director will also ace as a broker, attempting to match research ideas with funding SOUrCeS, 46

• j 7 The project wlll be designed to lay the groundwork for an ongoing program of smoking data analysis. The Project Director and Institute staff will work closely with the If thls project succeeds, it wlll have achieved a high degree of coordination among the wide array of service delivery institutions, successfully designed and secured funding for a number of intervention research projects, and developed a model for research coordination useful throughout the smoking research community. A major component of the project mlll be periodic published articles on aspects of intervention research. Smoklno Patterns and Demoorsohle~. The quality and extent of aggregate date on smoking behavior suffer from many of the same problems as individual data -- much data exists but has not been widely disseminated, much raw data remains unanalyzed end, there is no central source of information or analytical activity to which other researchers can turn for advice or assistance. Of particular importance is the lack of a central source of information on data from other countries. This project will accomplish three objectives: identify sources of U.S. and Inte~natlonal smoking data a~d assess their availability and accessibility for analysis; develop an agenda for the analysis of research end policy relevant data, and; conduct an analys~s of U.S. data ecd compile a report on~,~. ,!,~ the demographics of smoking in the U.S. (~, ,

Office on ~okin9 ~nd HeBlth~ Na%ionsl Center for H~BIt~ Stat~stic$~ American Cancer Society and other~ who regularly or perlodically collect data on smoking. One of the long ~ange objectives of this project and the Instltute will be to foste~ active Inteze~t in ~nd ~se of smok~9 d~ta by students o~d ~se~r~hers~ m~ny of whom are unawBre of the weB1th of Information available from organlzatlons without the ~esources to fully analyze the data they colle~t° 0% 4B

I APPENDIX A IMPLEMENTATZDN SCHEDULF • i¸,

ill Milestones I. Grant Award Initial Startup Completed Analytical Framework Plan Completed 4. Research Advisory Committee Meeting 5. Research Coordination Plan Completed 6. Advisory Board Meeting 7. Long Range Funding Plan - Draft 8. Project Grant Proposals (3) Completed Plan Completed First Project Grant Awarded Research Advisory Committee ~leeting 2. Report on Smoking Behavior and Policy Research Completed 3. Second Project Grant Awarded $0 90 069 IMPLEMBNTATION SCBEDBLE Year i - 4184 - 5/85 I 2 3 4 5 6 7 o o o o o o o o o ^-I Month 89 10 11 12 13 0 0 0 14 o

Z H X 60~90~069 J

Thomas C. Scheiling Lucius N. tittauer Professor of Politic~l Economy in the John F, Kennedy School of Government. and Professor of E=onomlca, Harvard University Born: 1921 A.B., Economics, University of California, Berkeley, 1943 Ph.D., Economics, Harvard University, 1951 Mr. Schelling served in the Economic Cooperation Administration in Europe, 194B and 1950 and in the White House and the Executive Office of the Presldent, 19S1 to 1953. He joined the DepartmenL of Economics st Yale in 19~3 and in 195B was appointed Professor of Economics at Harvard. Mr. Schelling has been a consultant to the Departments of State and Defense, to the Arms Control end Disarmament Agency, the Central Intelligence Agency, and is a frequent lecturer st the Foreign Service Institute end the several war colleges. He is currently e member or Fellow of: Mr The Institute of Medicine The Commission on the Behavioral and Social Sciences and Education, National Academy of Sciences American Academy of Arts and Sciences American Asscciatien for the Advancement of Science (Chairman, Section K, Economic and Political Sciences, 1982) Research Advisory Board, Committee for Economic Development, (Chairman, 1983-) Policy Council, Association for Public Policy Analysis & Management Chairmen, Smoking Behavior Study Group, Harvard University, Division of Health Policy Research and Education • Schelling ~as e member of the Committee on Substance Abuse ~.v and Habitual Behavior of the National Academy of Sciences from it's organization In 1976 until its termination in 1985, and a member of the Panel on Alternative Policies Affecting the ~ Prevention of Alcohol Abuse and Alcoholism of the National ~=~ Academy of Sciences from its organization in 1978 until its ~ termination in 1983. •

,J $ " ,w . b t i: r ?/• He is the author of: n m , 1951 nr, 1958 f nf , 1960 ~, 1966 Micromotives and Mac~obehavlor, 1978 Thinkino Throuoh the Enerav Problem, n n n , 1984 1979 He has published articles on military strategy and arms contlol, energy and environmental policy, climate change, nuclear proliferation, organized crime, foreign ald and international %~ade, conflict amd bargaining theory, ~acial segregation and intergratlon, the military draft, and ethical issues in policy and in business, His publications on health and related behaviol include: "Self-Command in Practice, in Policy, and in a Theory of Rational Choice," The Richard T. Ely Lecture, The American n R v , May 1984. Ethics, La~, andthe Exercise of Self-Command. The Tanner n H m n V u , VOI. IV. Sterllng M. McMurrin (ed,), University of Utah Press, 1983, 43-79. "The %mtlmate Contest for Self-Command," The Publlo lh~;est #60, Summer 1980. "Standards for Adequate Minimum Personal Health Services," MilbBnk Memorlal Eund Ouarterlv/Hea]th and Society, 1979. Micromotlves and Macrobmhavlmr, W,W. Norton and Company, 1978. "Strateglc Relationships in Dying," Death and Deelslon, Ernan MeMulIIn, ed., AAAS Selected Symposium Series, The Westvlew Press, 1978, 63-73. "£gonomfos, Or the Art of Self-Management," The American Review, Vol. 68, (May 1978), 290-294. Co author of Chapter ), "Choosing the Sex of Chlld=en", Aa~esa~no Bio-Medlcal Technolootes, Committee on the Life Sciences and Social Policy, The National Research Council, The Natioinal Academy of Sciences, 3uly 1977, 32-58. "On Exercising Choice," Acceptance address for the Frank E. Seidman Distinguished Award in Political Economy, The P.K. • Seldman Foundation, Memphis Tennessee, August 1977, pp. 15. C~ 0 M~ 0 N

"Medical Dare Guarantees: £oon6mics of Choloe," I~DlicBtisns of Guaranteelno Medlcal Care, National Academy of Sciences, 1975. Another verslon, "Government and Health," in New Directions in Public Health Care, Institute fo~ Contemporary Studies, 1976. "General Comments," Ethlcal end Leoal Issues of Social ~, Allce M. Rivlin and P. Michael Timpane, ed., The 8rooklngs Institution, Washington, D.C., 1975, 165-180. "Choosing Our Children's Genes," n" ns , Meek Lipkin, Or. end Peter T. Rowley, ads., Plenum Press, 1974. "The Life You Save May Be Your Own," m n P I Exoendlture Analysis, Samuel B. Chase, Jr., ed., The Brooklngs institution, Washlngton, D.C., 1968. He was invited to give the Henry L. Stlmson Memorlal Lectures, Yale imlverslty, 1955; the 7homas D. White Memorial Lecture, the U.S. Air War College, 1968; the Tanner Lecture on Human Values, The University of Michigan, 1982; the Frank W. Abrams Lectures, Syracuse University, 1983; and the Richard T. Ely Lecture, The American £conomlc Assoclatlon, 1983. He received the Frank £. Seldman Distinguished Award in Political Economy in 1977. He was Lady Davis Visiting Professor at the Hebrew University, Jerusalem, in 1976. ¢b ~D ~0

,% fi) / / 3ohn M. Pinney President, Oohn M. Pinney Associates, Inc., Washington, D.C., a disease prevention and health policy consulting firm. Born: 1943 B.A., History, Yale University, 1965 Hr. Plnney received an NROTC scholarship at Yale and served as an officer in the U.S. Navy from 1965 to 1971. He served in Vlet Nam from 1968 to 1969 and was swarded the Bronze Star Medal. In 1971, Mr. Pinney Joined the staff of the Asslstsnt Secretary for Administration and Management in the Office of the Secretary, Department of Health, Education and Welfare. Mr. Ptnney served as a management analyst with responsibility for analysis of 811 health related management issues. Me was involved in the implementation of the National Cancer Act, National Instltute on Drug Abuse, National Institute on Algohol Abuse and Alcoholism, President's Nursing Home Initiative and the reorganization of the Public Health Service. Mr. Pinney was Managing Director of the Washington Office of the Natlonsl Council on Alcoholism from 1978 to 1978. He also served ss proJec~ administrator for a $2.8 million federal grant to estsblish employee alcoholism programs in Fortune 500 companies in iO ms~o~ U.S. cities. Mr. Pinney also served as a consultant to the National Institute on Alcohol Abuse and AlCoholism and the American Lung Association. In 1978, Mr. Pinney Joined the staff of the Secretary of Health Education and Welfare ns a Special Assistant to the Secretary and Director of the Office on Smoking and Health in the Public Health Service. In that position, Mr. Pinney was responsible for all aspects of federal policy towards cigarette smoking 'including ~esea~ch, prevention and public education. From 1981 until the present, Mr. Pinney has operated s health policy and ~Isease prevention consulting fi~m. Clients have included voluntary health organizations, trade assoclatlons and government agencies. Mr. Pinney was executive editor, responsible for content and all aspects of preparation and publication of: y 8 0

I. The Health Conseouences of Smoklnq: A ReDDrt of Th~ ~: U.S. Dept. of MEW 1979. The Health Con~eouence~ of Smokino for Women: A R@OOIt of n n ; U.S. Dept. of HEW, 1980. The Health Conseouence~ of Smoklno: The Chanolnq ~; U.S. Dept. of HHS, 1981. Asbestom. Smokino and Disease: the Scientific Evldenem; Commercial Union Insurance Co., 1982. In 1983, Mr. reductlor Council of Life Insurance and the Health Association of America, Mr. Pinney recelved the Secretary of HEW'$ in I~72. In 1973 ne received the President's Management Improvement Certlflcate. He received the Publlc Health Service Special Recognition Award in 1981. Plnney co.authored a guide to workplace smoking programs prepared for members of the American Insur snce Special Citatlon \ r.D ,, : : C'