Philippe Boucher's Rendez Vous: Nancy J. Kaufman

Rendez-vous with . . . Nancy J. Kaufman

Vice President at the Robert Wood Johnson Foundation Princeton, New Jersey, USA

By Philippe Boucher
RENDEZ-VOUS 91 Monday, February 26 , 2001

PB: Thank you Nancy for accepting our rendez-vous. May I ask you to introduce yourself?

N K: My name is Nancy J. Kaufman. I grew up in Wisconsin-- on Lake Michigan about an hour north of Chicago. I attended the University of Wisconsin, first receiving an bachelor of science degree in nursing, and then later going back to the UW Medical School for a graduate degree in Administrative Medicine. My entry into tobacco control was relatively simple. On my first clinical rotation I was assigned to the "lung ward" of the large Veteran's Hospital in Madison. Imagine my shock when I found huge wards of old, dying veterans spitting hospital-provided Copenhagen into brass spitoons placed conveniently next to the hospital beds!! The ward was a living horror gallery of the devastation nicotine addiction leaves in its wake. Men smoking through stomas (holes in the throat that remain after laryngectomy). Men who had lungs removed and post surgery were so addicted that they needed Spit tobacco. Men struggling for breath in iron lung machines-- machines so old that most American hospitals had stopped using them years before. And one woman-- a nurse like me, but older-- an army nurse dying of lung cancer. The scene there shook me to my very core. It was the first time I'd come face to face with the ravages of tobacco. My reaction was that there was something grossly wrong here-- these people had served their country in WWI and WWII and come home addicted. I knew then that in some small way I'd try to stop this.

I specialized in public health, and worked for the State's Health Department, eventually becoming deputy director of the public health wing of the department. Wisconsin is one of 14 tobacco growing states and Philip Morris is the largest employer due to owning Miller Brewing, Oscar Mayer Foods, and Kraft cheese. Needless to say, tobacco control was a tough sell, but we managed some progress.

In 1991, I was recruited to become a Vice President at The Robert Wood Johnson Foundation. One of the reasons I took the job was that the Foundation's new President, Steve Schroeder was interested in doing something about tobacco and encouraged me to lead the way.

Q1. Can you tell us about the origins of the RWJF, was tobacco control part of its priorities from the start, how big was it then and how big is it now (budget, staff, number of projects)?

N K: The Foundation became a national philanthropy in the early 1970's, through the generous bequest of Robert Wood Johnson, the owner of the Johnson & Johnson companies. His will established the Foundation, whose mission is to improve health for all Americans. The Foundation is now the largest philanthropy in the U.S. devoted exclusively to health. We make grants only in the U.S., and in 2001 we anticipate awarding over $400 million. We have roughly 200 staff, and over 2000 active grants.

When Dr. Schroeder arrived in 1990, the Board & staff adopted 3 goals to direct its funding: (1) improving access to health care, (2) improving care of those with chronic health conditions, and (3) reducing the harms caused by substance abuse. It is under this 3rd goal area that our tobacco work falls.

Q2. How do you decide to support such or such project? Do you have a strategic plan that identifies core priorities like -for instance- smoke less states for coalition building? What areas of tobacco control do you consider as key areas for the Foundation to support?

N K: At the Foundation, we have a small Tobacco Team. Our team sets the strategic directions we will take. We have a plan, with measurable objectives. We have 2 focal points for our work: (1) preventing the use of tobacco by youth and young adults through the application of state and federal tobacco control policies (e.g. Increases in tobacco taxes, indoor air policies, advertising restrictions, access measures) and (2) helping addicted users quit (with special emphasis on pregnant women, enrollees in managed care health plans, and youth/young adults. We have an estimated budget for each year and the team is responsible for creating high-leverage projects that will help us attain our measurable objectives (e.g. By 2005, to double the excise tax on tobacco. While there are many worthy projects and ideas we might support, we focus most of our funding on projects that will help us achieve results related to our objectives. Our Smoke Less States program, for example, was designed to develop private sector coalitions in states to educate the public and advocate for changes in tobacco policies. These projects bring together key advocates from major voluntaries at the state level (heart, lung, cancer) with tobacco control researchers and activists. Or the Smoke Free Families program, that is conducting research into new methods for helping pregnant women quit and stay quit. The vast majority of our grants go to projects staff solicit. A small percentage are awarded from ideas others send to us. Each potential grant is reviewed for its relevance to our priorities, creativity, potential leverage, feasibility, quality, and cost. Foundation staff debate and vote on each others' proposals. Large or controversial projects are approved by the Board. See for more info on us and the projects we support.

Q3. Over the years the Foundation has supported many projects, many people. How many? Do you keep in touch? Is there a network of people/institutions you have worked with that continues to work together? If you were to select a few people/projects that you were especially impressed with, which names would come to your mind?

N K: Since 1991, the Foundation has authorized more than $350 million in tobacco grants, funding over 670 tobacco projects. This does not count a most recent Board authorization for a $50 million expansion of Smokeless States, because we have not yet made the grants.

We keep in contact with them--holding annual meetings of our national program grantees, and building on the work of grants that have come before. We often call these experts together to help us plan new projects, and are in the process of planning a conference of all of out current tobacco grantees.

Picking some favorite projects is very tough, but these stand out as high leverage investments:

(1) Tobacco Policy Research Program-- small grants to policy researchers to provide scientific bases for key policy questions, like Frank Chaloupka's early price/tax research; supporting economists to develop the formulas to account for the cost of smoking to state medical assistance programs, that allowed the attorney's general to sue the industry; effects of smoking bans on restaurant revenues.

(2) a $50,000 grant (small for us) that developed the criteria and ways to measure health provider compliance with questioning patient smoking and providing referrals. These were incorporated into a national system for evaluating primary care plan performance.

(3) founding the Center for Tobacco Free Kids-- now a national resource and highly visible voice in any U.S. tobacco debate.

(4) co-hosting the 11th World Conference and planning the program.

(5) the Tobacco Etiology Research Network-- a group of top researchers from different fields (psychology, biology, child development, sociology, neuroscience, genetics, epidemiology) that are doing research together to try to find out how young smokers transition from no use to casual use, to regular use, to addiction.

(6) supporting the development and dissemination of national clinical practice guidelines for treating tobacco dependence.

(7) Smoke Less States-- our program currently in over 20 states and in the process of expanding to 50, that organizes grassroots support for tobacco control and advocates for policy change.

(8) the research of Pierce, Gilpin et al that established the link between exposure to advertising/promotion and uptake/progression of tobacco use.

Q4. Supporting many projects in a field that can be very confrontational with a powerful industry, was the Foundation under attack because of its involvement in tobacco control?

N K: Yes, the Foundation and its employees and grantees have withstood attacks--project oriented and personal-- from the industry or industry front groups. We have had challenges to our tax-exempt status (we cannot and have not lobbied on specific legislation), had our records subpoenaed and grantees hauled in to testify in industry lawsuits, and been noted on various "hit" lists. Luckily, we have enough resources at our disposal to hire the most expert legal help.

Q5. What do you consider as priorities for tobacco control in the future?

N K: Priorities for future tobacco control work in our field:

(1) finding treatments that work for youth, young adults, and women. Our current technologies are not as effective in these populations.

(2) making pharmaceutical treatments accessible and affordable for more of our world's addicted users.

(3) global bans on advertising/promotion of tobacco products.

(4) bans on "light" cigarettes.

(5) increasing tobacco taxes--an ongoing process.

(6) working much more effectively as a global tobacco control community-- to predict the industry's next moves, share ideas and resources, and provide a source of strength to our colleagues, and share lessons learned.

Q6. Is there anything you would like to add?

N K: Finally, let me add what a privilege it has been to play a tiny part in this cause. Against almost insurmountable odds and with few resources, this movement has created change. There are none more dedicated, spirited, and creative in any area of public health. I wish to thank all my colleagues who have and continue to teach me how to be more effective-- and who have helped the Foundation choose its investments for maximum impact. The work of Judith Mackay in Asia, the achievements of the Australians, Thais, Singaporeans, South Africans, Brits, and Canadians provide a constant reminder of how the "impossible" becomes "possible".

PB: Thank you Nancy for taking the time to be with us today.

Rendez-vous is supported by a contract from the Robert Wood Johnson Foundation

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