Department of Health and Human Services
Public Health Service
National Institutes of Health
John E. Fogarty International Center
For Advanced Study in the Health Sciences
Eighty-fourth Meeting of the Advisory Board
Minutes of Meeting
February 9, 2016
John E. Fogarty International Center for Advanced Study in the Health Sciences (FIC) convened the eighty-fourth meeting of its Advisory Board on Tuesday, February 9, 2016 at 9:00 a.m., in Stone House, Building 16, National Institutes of Health (NIH), Bethesda, Maryland. The closed session was held on February 8, 2016, prior to the open session meeting, as provided in Sections 552(b)(4) and 552(b)(6), Title 5, U.S. Code, and Section 10(d) of Public Law 92-463, for the review, discussion and evaluation of grant applications and related information. The meeting was open to the public on February 9, 2016 at 9:00 a.m., until adjournment at 3:00 p.m. Dr. Roger I. Glass, Director, FIC, presided.
Board Members Present
Roger I. Glass, M.D., Ph.D. (Chair)
Michele Barry, M.D.
Waldemar A. Carlo, M.D.
King Holmes, Ph.D., M.D.
Joseph C. Kolars, M.D.
J. Stephen Morrison, Ph.D.
Janine Austin Clayton, M.D., ORWH (ex-officio)
Gregory Germino, M.D., NIDDK (ex-officio)
Vikas Kapil, M.D., CDC (ex-officio)
Catherine Y. Spong, M.D., NICHD (ex-officio)
Board Members Absent
Wafaa M. El-Sadr, M.D., M.P.H.
George C. Hill, Ph.D.
Michael Merson, M.D.
Rebecca Richards-Kortum, Ph.D., M.S.
Kristen Weymouth, Executive Secretary
David B. Abrams, Steven A. Schroeder National Institute for Tobacco Research and Policy Studies, Legacy
Wladimir J. Alonso (by video teleconference)
Nalini Anand, FIC
Kathleen Blair, FIC
Michele Bloch, NCI
Joanna Cohen, Johns Hopkins University Bloomberg School of Public Health
Pamela Collins, NIMH
Wilson Compton, NIDA
Kristie Foley, Wake Forest University (by video teleconference)
Michael P. Johnson, FIC
Rajesh N. Kalaria, Newcastle University (by video teleconference)
Flora Katz, FIC
Patrick Kelley, IOM/NAM
Peter Kilmarx, FIC
Marya Levintova, FIC
Kathy Michels, FIC
John Monahan, Georgetown University
Patricia Powell, NIAAA
Francine Sellers, FIC
Donald Silberberg, University of Pennsylvania (by video teleconference)
James Thrasher, University of South Carolina (by video teleconference)
Cecile Viboud, FIC
Ken Warren, NIAAA
Mitch Wolfe, OGA
Director's Update and Discussion of Current and Planned FIC Activities
Dr. Roger Glass
Dr. Glass called the meeting to order and welcomed Dr. Waldemar A. Carlo, the newest Board member. He congratulated Dr. George Hill on becoming the new chief diversity officer at Vanderbilt University, Dr. Rebecca Richards-Kortum on being named to the National Medal of Science Committee, and Dr. Peter Kilmarx for receiving the Rotary Paul Harris Fellow Award. He noted that Dr. Derek Yach, a former Board member, recently published an article highlighting Fogarty’s importance in uniting NIH’s global health portfolio in JHU’s Global Health NOW.
In October, NIH received the first delegation of Cuban visitors in 54 years for a special symposium. Topics included vaccines, tropical diseases, biotechnologies, and the Ebola response. Dr. Chris Murray, Director of the Institute for Health Metrics and Evaluation (IHME) at the University of Washington, visited NIH on November 18, and presented findings from the Global Burden of Disease Study 2013. The Global Alliance for Chronic Disease (GACD) held its Annual Scientific Meeting from November 9-11 and its Board Meeting on December 7. The Heads of International Research Organizations (HIRO) group met on December 8. Since the last FIC meeting, NIH has received several foreign visitors, including Dr. H. Fahrettin Kelestemur from the Turkish Institute of Health, and Makoto Suematsu from the Japan Agency for Medical Research & Development.
NIH has made a parallel-funding arrangement with Brazil’s Foundation for Applied Research for Sao Paulo State. The United States has also partnered with Canada to invest $21 million for environmental and occupational health research hubs in developing countries.
Dr. Glass flew to Haiti in January and met with a group of Fogarty Fellows. He noted that two of those Fellows, Drs. Carl Nathan and Kathy Walsh, are looking at repurposing nitazoxanide for the treatment of tuberculosis (TB). Dr. Glass’ trip to Haiti included a visit to a GHESKIO hospital dedicated to patients suffering from multi-drug resistant TB, as well as a new cholera treatment ward.
The Medical Education Partnership Initiative (MEPI) PI Council started with 13 grantee Deans around Africa, who over the past five years have brought in additional Deans. Currently a quarter of the medical school Deans in Africa are involved in this program. Earlier in February, the African Association for Health Professional Education & Research Workshop in Kampala brought together 20 African leaders in health education.
The third edition of the Disease Control Priorities Project (DCPP3), an economic evaluation for health, was recently published.
Dr. Glass thanked Executive Secretary Kristen Weymouth for putting this meeting together. Upcoming events include the Ebola meeting on February 10, the BRAIN Network meeting from April 5-7, the 7th Annual Consortium of Universities for Global Health (CUGH) Conference from April 9-11, the NIH-Bill & Melinda Gates Foundation Annual Meeting on April 18, the GEOHealth Network meeting from May 12-13, the World Health Assembly from May 23-28, the Fellows & Scholars Orientation from July 4-8, and the MEPI meeting in Nairobi from August 1-4. The next two FIC Board Meetings will be held May 10-11 and September 12-13.
Dr. Glass invited Nalini Anand to provide an update on the Center for Global Health Studies. Ms. Anand noted the launch of a Global Health course on non-communicable diseases (NCDs) in January 2016. The BRAIN Network meeting in April will include implementation science training. Also that month there will be a President’s Emergency Plan for AIDS Relief (PEPFAR) workshop on integrated models of HIV/NCD care delivery. A clean cooking implementation science meeting will take place in May. June events include the mHealth Research Training Institute and the publication of a supplement in the Journal of Acquired Immune Deficiency Syndrome. A publication on the prevention of childhood obesity is expected in July.
Dr. Michael Johnson provided an update on the Global Fund. The Fund is a non-technical, grant-making partnership organization, publicly and privately funded, with a staff of approximately 600 professionals based in Geneva. Most of the programs the Global Fund supports are in sub-Saharan Africa, but there are some in Asia, the Middle East, Latin America, and Eastern Europe. Between 2002 and mid-2015, $15.5 billion of Global Fund money went to fight HIV/AIDS, $7.6 billion to malaria, and $4.3 billion to TB. The Global Fund accounts for 50 percent of total resources in the fight against HIV; for TB, that figure is 83 percent, and for malaria, 41 percent. From 2004 to mid-2015, the Fund’s efforts led to the treatment of 548 million HIV/AIDS patients, the diagnosis and treatment of 13.2 million TB cases, and the distribution of 8.1 million insecticide-treated nets for malaria. It is estimated that 17 million lives have been saved through Global Fund investments. For data systems and operational research from 2003-2014, the Fund budgeted $357 million for HIV, $251 million for malaria, $53 million for TB, and $49 million for health systems strengthening. The Global Fund Strategic Framework 2017-2022 has four pillars: mobilize increased resources; build resilient and sustainable systems for health; promote and protect human rights and gender equality; and maximize impact against HIV, TB, and malaria.
Dr. Patrick Kelley briefed the Board on a study by the Institute of Medicine (IOM, now the National Academy of Medicine (NAM)) on the U.S. commitment to global health. IOM launched this study prior to the start of the Obama Administration. The study was led by Ambassador Thomas Pickering and Harold Varmus of the National Cancer Institute (NCI). A committee was formed with about 14 people representing the U.S. and several partner countries. Dr. Kelley says he believes the study influenced President Obama’s Global Health Initiative. With the upcoming presidential election, Dr. Kelley believes it is time to revisit the issue. NAM has about 70-75% of the funds it needs for a new study. Seventeen NIH institutes and centers (ICs) have lent their support, as have the United States Agency for International Development (USAID), PEPFAR, several Defense Department agencies, the Food and Drug Administration, Merck, and several other agencies, companies, and foundations. The plan is to have 12 members on the new study committee. There have been several recommendations for committee co-chairs; Dr. Kelley said he would appreciate additional suggestions. Ideally the committee will have experts in diplomacy and national security, the economic dimensions of global health, and medical research and development. It is slated to meet four times this year. Its report may come out in two forms: one very early to influence the highest levels of the administration, and a final report a few months later for a broader audience.
Dr. J. Stephen Morrison gave a presentation on the perspectives of the Center for Strategic and International Studies (CSIS) on global health priorities. CSIS launched a task force on women’s and family health in October. Its primary focus is on four sectors: family planning and reproductive health; maternal, newborn, and child health; immunization; and nutrition. A microsite dedicated to this task force was launched in November. The group has 23 members and is co-chaired by two trustees, Helene Gayle and John Hammergren. It includes six members of Congress. Meetings have been scheduled for April 25 and September 19.
Dr. Cecile Viboud spoke about the activities of Fogarty’s Division of International Epidemiology Studies (DIEPS). She showed a slide depicting the global distribution of the arbovirus vectors Aedes aegypti and Aedes albopictus. Knowing this has helped DIEPS identify high risk zones for Zika virus activity and promote stringent vector control in those areas. DIEPS has been using administrative databases to evaluate the impact of the Zika virus epidemic on microcephaly in Brazil. The goal is to model the baseline rates of microcephaly by state from 1998-2014, and estimate the excess for 2015-16. The Brazilian Ministry of Health maintains a birth registry which notes the presence or absence of microcephaly. Important Zika virus research questions include: does the virus spread across the entire Aedes mosquito range, what are the best strategies for vector control, is there a link with microcephaly and Guillain-Barre syndrome, what is the role of immunity to Dengue, and what is the role of Zika as a second flavivirus infection. DIEPS maintains a vast international network of affiliates and collaborators which fosters strong links between academia and government, and promotes an informed use of models to guide policy during public health crises.
Fellows and Scholars Program Concept
Dr. Flora Katz, Acting Director, Division of International Training and Research, FIC
New concepts for programs are normally presented in the open session, but because of uncertainty about the weather and the need to get these concepts cleared, they were presented in the closed session the previous day. One of the concepts concerns the reissue of the Fellows and Scholars Program, a pipeline to give early stage investigators at least one year of research experience. FIC supports about 80 Fellows and Scholars a year. The concept will be up on the FIC website in the near future. Dr. Katz said she would contact the various ICs to see if they wanted to participate in the program. The second concept, Fogarty’s International Tobacco and Health Research and Capacity Building Program (TOBAC), will be discussed in the afternoon session.
Brain Disorders across the lifespan Nature Supplement
Ms. Nalini Anand, Director, Center for Global Health Studies, FIC
Ms. Anand said the overarching purpose of the session was to share some key findings that have emerged from an activity run out of the Center for Global Health Studies (CGHS) in close collaboration with several NIH ICs and Drs. Silberberg and Kalaria. The end results of the activity were published in a Nature supplement dedicated to looking at the emerging research and capacity building priorities in global neuroscience, with a particular emphasis on needs and opportunities in low and middle income countries (LMICs). Ms. Anand said she hoped sharing these themes would stimulate discussion among Board members.
2013 marked the ten-year anniversary of the Global Brain Disorders Program administered by Fogarty. The program evaluation team embarked on a comprehensive evaluation of the program. The team found that the program was instrumental in enhancing empirical evidence, catalyzing funding beyond NIH, building a global network of researchers, and informing international and national practice and policy. In February 2014, FIC held a brain disorder symposium, followed by a two-day writing retreat. Twenty-eight U.S. and LMIC scientists participated. The Nature supplement, published on November 19, 2015, consisted of nine articles. The intent was to stimulate dialogue on existing and future research and capacity-building priorities, not to be comprehensive or all-inclusive.
Dr. Donald Silberberg, Professor, Dept. of Neurology, University of Pennsylvania
Dr. Silberberg set the stage for the presentation: neurological, mental health, developmental, and substance use (NMDS) disorders account for one third of all diseases and disabilities worldwide, but resources to support NMDS research are scarce. Current classification methods often fail to capture these disorders. Challenges to normal neurodevelopment include environmental impacts, poverty, infections, nutrition, conflict and displacement, genetic abnormalities, and environment-gene interactions. Research opportunities include preventing and treating the impact of malaria on the developing brain, designing and implementing pre- and postnatal care packages for pregnant adolescents, building capacity to achieve universal access to optimal and affordable hydrocephalus treatment for infants, and linking genetic studies to environmental factors.
Adolescence is a pivotal age for the development of self-control and regulation. Little is known about the emergence of self-control and regulation in LMICs where environmental threats are more common. Research must develop or adapt appropriate assessments of adolescent ability and disability, social inclusion and exclusion, normative development, and NMDS disorders.
There is also not much known about the pathophysiological process that drives the links between environmental exposures on childhood and adult neurological and psychiatric health. Longitudinal population-based studies of countries that have and have not met key United Nations (UN) Millennium Development Goals are warranted.
Trauma is the leading cause of loss of human potential around the world, especially in LMICs. There is a need to study central nervous system injury in the setting where it most commonly occurs: the patient with multiple injuries. An emphasis on promoting the design of true “ecological” studies that include evaluation of human behavior and factors in relation to the process of care is crucial.
Dr. Rajesh N. Kalaria, Professor of Cerebrovascular Pathology (Neuropathology), Institute of Neuroscience, Newcastle University
Dr. Kalaria said that each article in the Nature supplement addresses cross-cutting aspects including specifics on the implementation of knowledge and improving capacity building at every level. There is a complex interplay between mental health and substance use disorders; the agenda must be revitalized. The burden of disease from infections is much greater in LMICs. Research priorities include accurate estimates of burden, point-of-care assays for infection diagnosis, improved tools for assessment of sequelae, vaccines and other interventions for prevention, improved understanding of pathogenesis, operations research to implement known interventions, and improved methods of rehabilitation. It is crucial to understand the mechanisms of functional genetics, epigenetics, and metagenomics at the interface between risk factors and neurological outcomes. There is currently a lack of well-trained NMDS clinicians and scientists. More concerted efforts in research capacity-building activities are necessary. The efforts should be systematic, purposeful and goal-oriented.
Dr. Kathy Michels, Program Officer, DITR, FIC
Dr. Michels presented the Board with a series of questions: how can we break down silos to address current problems and emerging threats? What are the highest priority areas for research that involve interdisciplinary collaboration? What are the most critical areas for trans-NIH collaboration? What are the needs and opportunities for research capacity building? What topics may have been missed by the Nature supplement?
Dr. Pamela Collins, Director, Office for Research on Disparities & Global Mental Health Disorders and Office of Rural Mental Health Research, NIMH
Dr. Collins directed Board members to an article on the NIH website: Schizophrenia’s Strongest Neurogenetic Risk Deconstructed, about a groundbreaking study for mental health research. This study would not have been possible without global collaboration. Enough evidence-based interventions have been tested in LMICs that scientists can think about scaling up and developing the implementation science around this. Dr. Glass said this highlights amazing changes in the global health perspective and research agenda.
Dr. Wilson Compton, Deputy Director, NIDA
Dr. Compton said that partnering with Fogarty has been a key part of the National Institute on Drug Abuse’s (NIDA) efforts to link scientific endeavors in the United States with a host of emerging international issues. He pointed out that tobacco addiction is not yet widespread in sub-Saharan Africa, which makes the region a good target for preventive measures. Another area he highlighted was policies and laws dealing with illegal drugs and how they relate to health. Finally, Dr. Compton mentioned the Adolescent Brain Cognitive Development study, a landmark trans-NIH effort.
Dr. Ken Warren, Senior Consultant to the NIAAA Director
Dr. Warren said the National Institute on Alcohol Abuse and Alcoholism (NIAAA) has a number of extensive international activities, particularly in South Africa and Eastern Europe. Researchers at the University of Stellenbosch have developed technology to identify physical features of fetal alcohol syndrome that cannot be detected by the human eye. There is currently a major study in Ukraine on the prevention and treatment of individuals impaired by alcohol in pregnancy. Dr. Peggy Murray, NIAAA’s international officer, pointed out that unreported and unregulated alcohol was a huge problem in Asia and sub-Saharan Africa. For adolescents, the problem is not alcohol use disorders but alcohol exposure. When discussing environmental toxins, it is important to consider alcohol as a part of the environment. Dr. Warren added that NIAAA has a joint effort with the National Institute of Child Health and Human Development (NICHD) addressing sudden infant death syndrome.
Dr. Catherine Spong, acting director of NICHD, said that priority areas for her institute included early development, its influence on cognitive health, and the need for interdisciplinary collaboration. She cited a 10,000 person study in Cape Town, South Africa, and a similar effort on the Northern Plains Indian Reservation looking at alcohol exposure during pregnancy. NICHD is strongly concerned with the impact of nutrition, infection, and the environment on cognitive outcomes. It looks forward to working with national and international partners on issues like the Zika virus.
Dr. David Abrams highlighted the importance of epigenetics and transmission. While scientists are starting to talk about these issues, Dr. Abrams did not believe they were getting enough weight and emphasis. Dr. Janine Clayton observed that she had not seen much attention to sex and gender factors. She recommended parsing them out explicitly in a more intentional way, as well as better disaggregation of data with regards to sex/gender and race/ethnicity. Dr. Compton said that exposure to violence could have important gender-specific issues that could be examined in international settings. Dr. Collins pointed out that social experience was one of the key new areas on the NIH Strategic Plan for Research. She added that the Brain Disorders Program was probably the only global initiative in which every single division of her institute was represented. Dr. Abrams said he saw a unique opportunity to come up with a core set of minimal screening assessment measures that could be used across studies to pick up on critical early developmental vulnerabilities. Dr. Collins replied that NIMH recently launched an initiative on scaling up evidence-based interventions for mental disorders in LMICs.
Dr. Glass concluded the discussion with four points: a simple cost-effective intervention may change and save lives; much of what this research identifies is a link between local and global; a neuroimaging study of child kickboxers in Thailand illustrates the relations among neurological, pediatric, and social problems; and Fogarty has several programs, such as the Fellows and Scholars Program and the Foreign K Award, which can help create a global health network to address these issues. He expressed his appreciation for the presentation and discussion and recessed the Board for lunch.
Accomplishments of Fogarty’s International Tobacco and Health Research and Capacity Building Program: A New Concept
Dr. Marya Levintova, Program Director, TOBAC Program, DITR, FIC
Dr. Levintova outlined the purpose of this program: to strengthen and expand tobacco prevention and control research and research capacity in LMICs, with a goal of reducing the global burden of morbidity and mortality from tobacco use. The program received its first grants in 2002. There have been 34 projects funded over three five-year funding cycles. TOBAC has trained almost 4,000 individuals. The program was evaluated in 2013; the report is available on the Fogarty website. A workshop on harnessing research evidence and control was held in June 2013. Although the program has achieved some success, numerous issues remain, including new forms of tobacco, aggressive marketing by the industry, and limited research capacity in LMICs.
Dr. Kristie Foley, Professor and Program Leader, Cancer Prevention & Control, Wake Forest University; Building Capacity for Tobacco Research in Hungary and Romania
Dr. Foley said her project had two main goals: advance the scientific activity of Central and Eastern European scholars in the field of tobacco research, and create a network of scholars whose work could advance tobacco control policies and programs.
There were several components to building capacity for advancing tobacco research and control in Hungary: mentoring, formal training in research to practice, building networks, exposure to other models, dissemination, and monitoring. Building capacity in Romania has been similar, with a few key differences: co-mentoring by Hungarian and American scientists, earlier exposure to the media and decision makers, and more cross-training. The program has led to widespread publication and scientific partnerships, improved medical practice, and legislation, including a comprehensive clean air law in Hungary, and a Romanian ban on smoking in bars and playgrounds. The Hungarian government is more tightly regulating the retail sale of tobacco.
Dr. Foley summarized the principles of scientific capacity building: understanding local culture, team diversity, focus on translation, early recognition by external stakeholders, bidirectional learning, clear and high expectations, adaptability, and excellent communication.
Dr. Jim Thrasher, Associate Professor, Arnold School of Public Health, University of South Carolina; Cinema Smoking and Youth Smoking in Latin America (Co-PI)
Dr. Thrasher said his project has been going on for about three and a half years. The team is composed of scientists at the National Institute of Public Health in Mexico, researchers at the Centro de Estudios de Estado y Sociedad in Argentina, Jim Sargent’s team at Dartmouth College, and Dr. Thrasher’s team at the University of South Carolina.
For capacity building, Dr. Thrasher said the project’s philosophy was to train by doing. The primary focus is to get the research done, but team members have become more conscious of the need to establish informal mentoring structures. The team has been increasingly engaged in data analysis workshops. There has been widespread dissemination to the public from all components of the team.
One of the primary interests of Dr. Thrasher’s project is to develop the capacity to track tobacco use and tobacco brand appearances. Studies have shown a decline in tobacco use in Mexican films but not in their Argentine counterparts. The second aim is to build the capacity for conducting longitudinal surveys to determine the importance of both media and marketing risk factors for the onset of early adolescent smoking. A key finding is that movies that are produced domestically appear to have a stronger effect on the adolescent uptake of smoking than U.S. films. The team has also found that young people perceive flavor capsule packages as most attractive, and are trying them with greater frequency. The last aim of the project was to identify leverage points for policy development. Dr. Thrasher felt the team had done a good job working with the World Health Organization (WHO) and other agencies to get its message across. There are seven publications in press and a variety under review, as well as a number of conference presentations, invited talks, and workshops with key stakeholders.
Dr. Michele Bloch, Chief, Tobacco Control Research Branch (TCRB), Behavioral Research Program (BRP), NCI
Dr. Bloch pointed to a quote from former NCI director Harold Varmus, who said there is a consensus that tobacco use is by far the most important modifiable risk factor for cancer at the global level. A 2008 WHO report indicates that tobacco use is a risk factor for six of the eight leading causes of death in the world.
Tobacco mortality is growing and shifting to LMICs. Among individuals age 15 and older, global overall prevalence is 41.1 percent among males and 8.9 percent among females, meaning there is an opportunity to prevent uptake among women. However, the tobacco industry is increasingly marketing itself to women. Maternal smoking and secondhand smoke is a leading cause of poor pregnancy outcome in many countries. Pregnancy is an opportunity to intervene with mothers and families.
The annual global cost of tobacco is estimated at $500 billion. This figure includes direct health care costs, as well as loss of income through illness and premature death, and the cost of time spent by family members caring for an ill relative. Tobacco relates to several UN Sustainable Development Goals, including eliminating poverty and hunger, and promoting good health and quality education. Driven by the Framework Convention on Tobacco Control (FCTC), many countries are introducing new and innovative tobacco control policies. There are also ongoing changes in patterns of tobacco use, the types of products being marketed, and social and economic environments.
The NCI Center for Global Health was established in 2011 to support NCI’s goal to advance global cancer research, build expertise and leverage resources across nations to address the challenges of cancer, and reduce cancer deaths worldwide. USAID encourages and supports anti-tobacco efforts worldwide, including studies through its Partnerships for Enhanced Engagement Research program in Indonesia and Thailand. NCI participates in the TOBAC Program, supports grants through its regular grants pool, and conducts regional research capacity building and evidence-to-policy trainings.
Dr. Wilson Compton, Deputy Director, NIDA
Dr. Compton said that NIDA is one of the largest investors in tobacco research in NIH. Its work is primarily in the basic neuroscience, the basic mechanisms, and the genetics, particularly in the area of treatment development. NIDA has placed a major emphasis on co-morbidity research. Keeping tobacco use among women low is also a goal of the institute.
Dr. Joanna Cohen, Director, Institute for Global Tobacco Control, Johns Hopkins University Bloomberg School of Public Health
Dr. Cohen said the burden of tobacco control was massive. To help countries combat the unnecessary death and disease caused by tobacco products, the WHO has developed MPOWER, a policy package to reverse the tobacco epidemic. Much progress has been made in protecting non-smokers from involuntary exposure to secondhand smoke, creating tobacco dependence treatment programs, requiring health warning labels about the dangers of tobacco, and banning tobacco advertising, promotion, and sponsorship, but there are many countries that lag behind in these areas. A three-legged stool, consisting of government, research, and civil society, is essential for progress. There is a lot that countries can learn from one another. Dr. Cohen cited India’s ban on gutka, Brazil’s prominent health warnings, Uruguay’s limiting each cigarette brand to one pack design, and Russia’s banning the sale of tobacco in kiosks.
Dr. David Abrams, Executive Director, Steven A. Schroeder National Institute for Tobacco Research and Policy Studies, Legacy
Dr. Abrams talked about the biomedical intersect of tobacco with TB and HIV in LMICs. TB and HIV patients are three times more likely than other individuals to use tobacco products. Tobacco smoking has structural, lung-specific, and systemic implications for the immune system. Dr. Abrams directed the Board to a tobacco prevalence survey and smoking cessation trial among HIV/AIDS patients in South Africa. The study found similar prevalence across age groups and income and education levels, but men were more likely to smoke than women, the employed were more likely to smoke than the unemployed, and alcohol users were more likely to smoke than non-alcohol users. Of the 556 patients enrolled in the smoking cessation trial, 317 have reached the six-month outcome.
There are questions surrounding the efficacy and impact of alternative nicotine delivery systems and their relative harms compared with the inhalation of combusted tobacco smoke. Dr. Abrams cited a study recently published in Lung Cancer which indicates that while electronic, or e-cigarettes, are not safe products for non-smokers, they offer a dramatic decrease of risk, and should be considered by practitioners for patients with cancer who continue to smoke.
Discussion Moderated by Dr. Steve Morrison, Senior Vice President and Director, Global Health Policy Center, Center for Strategic and International Studies (CSIS)
Dr. Morrison said he was struck by the sense that tobacco control was an area of unrealized potential. A lot of research had been done, but there was insufficient energy and leadership emerging around these issues. He added that the U.S. and 11 other countries had recently signed the Trans-Pacific Partnership (TPP), which includes a carve-out exempting anti-smoking measures from any lawsuits that could be undertaken under the Investor State Dispute Settlement. If Congress ratifies the TPP, it would take away one of the industry’s most potent weapons. Dr. Morrison invited Board members to submit questions and comments.
Dr. Kapil asked if anyone looked at countermeasures, pointing out that the industry can be creative in responding to anti-tobacco interventions. Dr. Cohen said that was an important topic for research. Dr. Bloch added that NCI and other agencies are aware of the role of industry and do their best to track it; the bigger problem is counteracting it. Dr. Abrams spoke of the need for rapid learning and comparison of behaviors across countries and regions.
Dr. Holmes pointed out that when a product is responsible for outbreaks of diseases like Listeria, Shigella, or Salmonella, that product is recalled. He asked why similar efforts have not been undertaken to recall tobacco. Dr. Cohen replied that there is a widespread belief that such an effort would not work given the prevalence of tobacco use. Instead most work has been done around the edges to reduce the appeal of tobacco while increasing its cost. The eventual goal is to get to a state where so few people are using tobacco that banning it becomes feasible, but there is still a long way to go.
Dr. Morrison observed that the influence of the tobacco industry in Congress has waned, because manufacturing has been transferred offshore, reducing the number of states producing tobacco to a minimum. Dr. Bloch agreed this created the opportunity to enact major change, but pointed out that there still were not enough votes in the Senate to ratify FCTC. Dr. Monahan commented that the President can do a lot to raise awareness an issue. He added that the TPP could put the U.S. in a place where it could be a leader on tobacco issues. Dr. Bloch reminded the Board that change can take time.
Dr. Monahan said it was important to consider the global research agenda and how it relates domestically. He added that he was co-chairing a commission on global health and law, and that there was a lot of interest in tobacco in the initial deliberations.
Dr. Glass praised TOBAC as an amazing program, but he pointed to his work with Sir Richard Doll on a smoking study begun in the 1950s and a 40-year-old Surgeon General’s Report identifying the risk of tobacco. He has come to the realization that his grandchildren will be dealing with the issue of tobacco, even though its dangers have been known for a long time. Approximately six million people worldwide die from tobacco use each year. Dr. Glass compared this with Ebola, which has garnered much attention from public health officials by claiming a fraction of that figure. He is encouraged by the work of the TOBAC Program, but cautioned Board members that much still needs to be done. He cited Malcolm Gladwell’s book The Tipping Point; to end the tobacco use epidemic, it is necessary to reach that point. It will require more funding for anti-tobacco programs, and strong leadership.
Dr. Glass thanked everyone for their attendance and contributions, and adjourned the meeting.