A recent study by Murray DM et al., published in the American Journal of Preventive Medicine, aimed to provide an analysis of the level of NIH support for primary and secondary prevention research in humans by field and stage of research. The study was conducted between 2012 and 2017 and included all 27 Institutes and Centers at the NIH that collaborate with the Office of Disease Prevention (ODP). This study followed an earlier one by Calitz C et al. that was published in 2015 in the same journal. Calitz et al. presented the first comprehensive analysis of the NIH’s prevention portfolio over 3 years (2010–2012) for human behavioral interactions aimed at preventing noncommunicable diseases (NCDs), although they included only eight of the 27 Institutes and Centers.

Murray et al. showed that prevention research received 22.6% of NIH funds for research grants or cooperative agreements. Primary prevention (prevention of a new health condition, promotion of health in the general population, or identification of risk factors for a new health condition) was the most common type of prevention research in the portfolio (62.3%). Secondary prevention (prevention of disease progression or the recurrence of a known health condition, and identification of risk factors for disease progression or recurrence), however, represented only 18.1% of prevention research in the portfolio. Only 16.7% of projects funded by the NIH constituted primary and secondary prevention research.

Based on a recent report by Mokdad AH et al., 74% of the variation in life expectancy among counties in the United States is attributed to a combination of socioeconomic and race/ethnicity factors, health care factors, and behavioral and metabolic risk factors. Murray et al. showed that many of the leading risk factors (alcohol, obesity, diet and nutrition, and physical activity) for NCDs, namely, cardiovascular disease, many cancers, diabetes, and chronic respiratory disease, were selected for an estimated 5% of the research portfolio. While tobacco smoking is the single most preventable cause of several NCDs, it was selected for only 5.1% of the research portfolio. Smoking remains the main unhealthy behavior that contributes most to NCD-associated death and disease, and socioeconomic inequalities in health compared with physical inactivity, alcohol use, and unhealthy diet. When Murray et al. coded projects based on their exposure factors and outcomes, results showed that tobacco did not appear to present a significant trend in either. Nevertheless, tobacco use is the most preventable cause of morbidity and mortality – each year it is responsible for more than 7.1 million deaths worldwide and 480,000deaths in the United States.

The ODP defines treatment for smoking as secondary prevention research. Could harm reduction products also be considered as secondary preventive measures? A recent smoking cessation landscape analysis, which was supported by the Foundation, showed that current smoking cessation tools and services produce very low quit rates (successful 1-year cessation in only 13%-23% of smokers who use them), and that there are few novel cessation drugs in the pharmaceutical pipeline. Similarly, the World Health Organization estimates that pharmacological therapies such as nicotine replacement therapies can increase quit rates by only about 7%. Data from a recent study on smokers who switched to a reduced harm product, e-cigarettes, suggest that these devices may reverse some of the harm caused by tobacco smoking in patients with chronic obstructive pulmonary disorder (COPD). Given that smoking is the most common cause of COPD, what if this risk factor were eliminated by the use of reduced harm products—could they significantly reduce the prevalence of COPD? A recent report, “No Fire, No Smoke – Global State of Tobacco Harm Reduction 2018” (GSTHR), suggests that reduced harm products have the potential to offer significantly high public health benefits.

Overall, the current study confirms and expands upon key findings of the study conducted by Calitz et al. Prevention research is underfunded and the nation could certainly benefit from an increase in NIH funding in this field. Risk factors for death and disability—including tobacco smoking—warrant more adequate funding than the current NIH funding estimated at 5%, especially given the high variability in life expectancy that is in part attributed to risk factors such as smoking. Furthermore, intervention research to help smokers quit or switch to reduced risk products must receive proper attention and funding. Prevention research projects remain dominated by a high proportion of observational studies (63.3% of projects included observational studies versus only 18.2% of projects that included a randomized intervention). However, there is a dire need for more innovative and efficacious interventions, rather than “descriptive” studies, to end smoking among American adults. We look forward to seeing an adequate increase in NIH-funded research on smoking prevention and cessation, as well as tobacco harm reduction.