term follow-up in prevention studies, and build prevention research capacities through training grants. These priorities provide much-needed direction across other institutes as well.

Scientifically, prevention research has been overwhelmingly focused on the need to change behavior, specifically maladaptive behaviors that increase risk for disease. Extensive work has examined changing behaviors related to tobacco use (Winders et al., 1999), obesity and nutrition (Spear and Reinold, 1999), physical activity (Sanderson and Taylor, 1999), and alcohol and drug abuse (Schumacher and Milby, 1999). Behavioral changes needed to prevent specific health outcomes, such as cardiovascular disease (Raczynski et al., 1999), cancer (Reynolds et al., 1999), pulmonary disorders (Kohler et al., 1999), and HIV/AIDS (DiClemente et al., 1999) have also been studied. Prevention research has encompassed the life span (Albee and Gulotta, 1997; Millstein et al., 1993), including early interventions for children at risk, fostering resilient outcomes in children of divorce, promoting life skills training for adolescents at risk, and developing adult programs to promote reemployment following job loss.

These prevention endeavors bring to the fore issues of responsibility —that is, does the individual or the collective bear responsibility for enacting effective behavior change (Fischhoff, 1992)? Depending on the response, some programs have focused competence promotion and education at the individual level, including helping individuals make effective choices regarding their own health and well-being (Clemen, 1991; Dawes, 1988; Fischhoff et al., 1997), while others have addressed broader issues of environmental support and community organization (Albee and Gullotta, 1997). Prevention is thus a formidable challenge of wide scope, influenced not just by virus, gene, and physiological processes but also by individuals' cognitions, emotions, and behaviors, all of which exist within particular environmental, interpersonal, economic, and cultural contexts. Clearly, advancing the science of primary prevention is a multidisciplinary task.

The committee recommends that NIH usher in a new era of prevention research, spanning all institutes and targeted at a refined understanding of these complex connections. For example, adverse health consequences follow from numerous behavioral and psychosocial factors (problem drinking, smoking, sedentary lifestyles, poor stress management), and yet notably limited progress has been made in understanding why only one in four Americans exercises regularly or why the prevalence of smoking (especially among teenagers) remains unacceptably high (National Heart, Lung, and Blood Institute, 1998). Much prior work rested on the belief that informed individuals would make good behavioral choices: teach people about the dangers of smoking and they will not smoke; teach people about the danger of drugs and they will not use them; teach people about the importance of exercise and nutrition, and they will stay fit and eat properly. Unfortu-



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