Tobacco Related Disease Research Program
- Cardiovascular Research Institute, and Cancer Center
- Institute for Health Policy Studies
- University of California
- San Francisco, CA 94143-0130, USA;
While the most visible battles about tobacco are political, the politics is driven by science and the tobacco industry has always fought scientific work that would elucidate the dangers of smoking and, in recent decades, passive smoking.1 From the beginning the tobacco industry understood the potential importance of the research program that Proposition 99 created—the Tobacco Related Disease Research Program (TRDRP)—and carefully monitored it using standard industry tactics, such as periodic public records act requests.2Just a month after the voters enacted Proposition 99, the tobacco industry's primary “political” law firm in California, Nielsen-Merksamer, had already prepared recommendations for how to minimise the impact of the research program that Proposition 99 required.3 Since most of the public controversy around the tobacco control efforts created by California's voters when they passed Proposition 99 centred on the high profile anti-tobacco education program, particularly the anti-smoking advertising campaign,4 5 TRDRP was established with minimum interference from the tobacco industry. Once TRDRP funded research threatened the industry and its political allies, California Governor Pete Wilson and pro-tobacco legislators led by Assembly Speaker Willie Brown (D–San Francisco) shut it down. The program was revived following a strenuous political campaign led by the American Heart Association and Americans for Nonsmokers' Rights.5
My work was at the centre of much of the controversy that the tobacco industry and its allies generated about TRDRP, and it is from this perspective that I offer this commentary.
When I received the first call for applications from the new TRDRP program, I considered applying for a grant to study the tobacco industry. The industry, after all, had spent years studying the public health advocates and I thought it would be interesting to return the favour. Just as stopping malaria required understanding mosquitos, preventing heart disease and cancer requires understanding the tobacco industry.
After briefly toying with this idea, I decided not to bother applying. I expected TRDRP to be a traditional medical model program with little understanding or interest in the policy and political aspects of tobacco control and figured that, in any event, the University of California (which administers TRDRP) would never have the nerve to support such a study. As the deadline approached, however, I had second thoughts and submitted an application.
To my surprise, TRDRP funded the grant, which permitted the first systematic studies of how the tobacco industry fought the tobacco control community.
Investigating the tobacco industry
Investigating how the tobacco industry sought to influence the policy making process naturally led to a study of its campaign contributions to members of the California legislature, particularly its leader, Assembly Speaker Willie Brown.6-8 After Proposition 99 passed, tobacco industry campaign contributions skyrocketed, to the point that the industry was spending more on California legislators than members of Congress.9 This result was not surprising given the fact that the new California tobacco control program was driving smoking down rapidly and serving as a model for the world.
The tobacco industry and its allies vigorously attacked our project, as well as the University of California for funding it. They claimed that this work was “politics” rather than “research,” despite the fact that the key to implementing Proposition 99 was the political process surrounding passage of the implementing legislation. Our regular reports documenting the accelerating campaign contributions to Assembly Speaker Brown (who by 1993 had received a total of $474 217 in campaign contributions from the industry, more than any other legislator in the country, including members of Congress) particularly infuriated Brown.10 At one point Brown found himself in an elevator with the director of UCSF's Institute for Health Policy Studies (which was located in the same San Francisco office building as Brown's district office) and Brown demanded that something be done to silence me. In a later meeting with UCSF vice president for health affairs, Cornelius Hopper, on an unrelated budget matter, Brown again attacked. A journalist who was writing a profile of Brown observed the following:
“One morning in a sudden burst of temper, Brown pitilessly dressed down top executives of the University of California because a researcher at UC San Francisco had written a report that Brown didn't like about the political influence of tobacco companies. The university officials had come to see him on an unrelated matter, but the Speaker used the opportunity to launch his attack anyway. ‘You’re going to have trouble with me on every single appropriation!' Brown said, jabbing an index finger. ‘If that guy gets one more cent of state money, you’ll have trouble with me!'.”11
Hopper responded that the university believed in academic freedom and would not interfere with the work or the peer review process.
The same year the state legislature had to pass legislation again authorising the spending of the Proposition 99 research money. This process proceeded without much public controversy, other than complaints by the public health groups that too much money was being spent on basic studies with little direct relevance to tobacco and not enough on studies with a more immediate relevance to tobacco control. The university beat back the health groups and the bill passed unanimously. Governor Wilson surprised everyone when he vetoed the bill, shutting down the entire program. We were all suspicious that Wilson's action was making good on Brown's earlier threat to punish the university if it did not quieten me. Ironically, by the time the governor and Brown shut down the Research Account, I was being funded by the National Cancer Institute, not Proposition 99.
California Medical Association
By 1994, the California Medical Association (CMA), which had been supporting cutting the anti-tobacco education program and diverting the money into medical services since before Proposition 99 even passed,5 12 13 had the Research Account in its sights. The CMA's chief lobbyist was Steve Thompson, Brown's former chief of staff.
A “hit list” of “silly” research and anti-tobacco education projects, including my work on tobacco industry political influence, was widely circulated within the legislature. When asked whether the CMA had prepared the “hit list” of health education and research projects, that was widely circulated within the legislature and the media as part of the effort to divert funds into medical services out of health education and research, Elizabeth McNeil, one of the CMA lobbyists, said they had not and declined to speculate about who had prepared them. She went on to say:
“But research by far got the most criticism and they didn't do a good job at defending themselves . . . And they [the Conference Committee] took those dollars to balance the budget basically and fund some kids' health programs that I have to say are very worthy. And that was a tough call but we did support the overall dynamics because of the political pressures on getting the budget and with budget deficits and the importance that we place on some of these indigent programs and when there was some frivolous research projects going on perhaps . . . we really didn't support that shift being made, but in the end, we supported the whole deal. Felt like it was the best compromise we were going to get.”5
In contrast, Steve Scott, political editor of the widely respected publication on state politics, California Journal, reported that he got the list from the CMA. More important, he saw their support of the diversions as important to getting them through the legislature:
“The California Medical Association got successively more brazen in its approach and its willingness to kind of undermine the tenets of the education fund. I remember in the Conference Committee meetings on 816, Assemblyman Isenberg [author of the bill authorizing the expenditure of Proposition 99 funds] started rolling out the horror stories about the Research Account and how the Research Account was being used for these . . . ridiculous grants. And I got a list of those ridiculous grants from the California Medical Association. It was leaked to me through the CMA . . .You talk to their lobbyist and she'll deny that they were openly advocating the diversions, that it was an unfortunate necessity that they had to agree to the diversions to make the tradeoff. But in truth they were right in there pitching subtly on the whole question of and not so subtly, increasingly less subtly on the issue of the problems with the Research Account . . . So a lot of the pushing against the Research and Education account, or in favour of more money going to direct medical services, was coming from the California Medical Association.”5
Two years later, in 1996, the public health groups, led by the American Heart Association (AHA) and Americans for Nonsmokers' Rights, attacked the CMA and eventually separated it from the tobacco industry. Once the industry and the governor were isolated, the health groups successfully restored funding for the research program.
There was, however, one more fight about the research program. The Democrats lost control of the Assembly to the Republicans and Brown went off to become Mayor of San Francisco. Following the lead of his predecessor, the new Republican Assembly Speaker Curt Pringle tried to insert language in the authorisation for the research account that would block it from funding research of a “partisan political nature”.14 (The American Nonsmokers' Rights Foundation and AHA ran an advertisement protesting this incursion of politics into the Research Account, which included side-by-side photos of Pringle and Brown, who despised each other.) The university responded that none of the research being done, including mine, was of a “partisan political nature”.
The TRDRP program was restored in 1996 and has functioned without political threats since then. The three year hiatus in funding was, however, associated with some reassessment of the program's structures and goals. The current program has a much stronger orientation towards problems of direct tobacco relevance, including secondhand smoke, nicotine addiction, and development of effective prevention strategies, while continuing investments in fundamental research. In addition, the program has developed new approaches to linking researchers with people in the field at both the community and school levels.
When it began, TRDRP was an echo of National Institutes of Health (NIH); now it is the model NIH should be following if it wants to develop a true program in tobacco control.