UW-CTRI
UW Center for Tobacco Research and Intervention

2013 Report

OVERVIEW: This report constitutes the eighth in a series of six- and twelve-month updates on UW-CTRI research. These reports, released on or around January 1 and July 1 each year by the UW-CTRI Communications Office, summarize published and in-press manuscripts, as well as new and ongoing grants, contracts and other research projects.

SUMMARY: In 2013, the UW-CTRI research team produced:

21 published papers
10 papers in press
3 new studies
9 active studies
3 studies recently completed

THANK YOU: UW-CTRI is grateful to its partners, the UW Department of Medicine, the UW School of Medicine and Public Health, the Wisconsin Department of Health Services, NIH, CDC, Robert Wood Johnson Foundation, and the Wisconsin Partnership Program.

Note: Names in bold are current UW-CTRI employees.

Published Papers

Belsky D, Moffitt TE, Baker TB, Biddle AK, Evans JP, Harrington HL, Houts R, Meier M, Sugden K, Williams B, Poulton R, Caspi A. Polygenic Risk Accelerates the Developmental Progression to Heavy, Persistent Smoking and Nicotine Dependence: Evidence from a 4-Decade Longitudinal Study. JAMA Psychiatry. 2013 May;70(5):534-42

Summary: For teens who tried cigarettes, being at high genetic risk increased the likelihood they would: 1) convert to daily smoking; 2) progress to heavy smoking; 3) become nicotine dependent; and 4) struggle with cessation. These findings suggest that programs and policies to prevent teen smoking, or to discourage teens who do smoke from becoming regular smokers, may be an effective intervention with those at highest genetic risk for lifelong heavy smoking.

Bergen AW, Javitz HS, Krasnow R, Nishita D, Michel M, Conti DV, Liu J, Lee W, Edlund CK, Hall S, Kwok PY, Benowitz NL, Baker TB, Tyndale RF, Lerman C, Swan GE. Nicotinic Acetylcholine Receptor Variation and Response to Smoking Cessation Therapies. Pharmacogenetics and Genomics. 2013 Feb;23(2):94-103.

Summary: “Risk” alleles previously associated with smoking heaviness were significantly associated with reduced abstinence in the placebo group and with increased abstinence in patients who received active nicotine-replacement medications.

Fiore MC, Baker TB. Should Clinicians Encourage Smoking Cessation for Every Patient Who Smokes? (editorial) JAMA. 2013 Mar 13;309(10):1032-3.

Summary: JAMA published three articles addressing smoking cessation in the issue. One addressed the question: Do the health risks of weight gain that typically follows smoking cessation trump the cardiovascular health benefits of cessation? Their answer: No. Another commentary addressed a long-standing misunderstanding in clinical medicine: A concern that patients should not quit smoking in the month prior to surgery. After analyzing the findings of the two papers, the authors’ strong recommendation was that clinicians should encourage all patients to quit.

Kim, S-Y, Mun E-Y, Smith S. Using Mixture Models with Known Class Membership to Address Incomplete Covariance Structures In Multiple-Group Growth Models. British Journal of Mathematical and Statistical Psychology.2013 Feb 25.

Summary: In this study, Su-Young Kim and his co-authors developed a creative solution to a statistical problem in complex longitudinal multi-group studies. In these kinds of studies, missing data and related problems can pose challenges in the statistical analyses. The proposed statistical solution was tested with data from studies conducted at UW-CTRI and was shown to perform well. This solution offers researchers a way to effectively deal with missing data and other data problems that commonly occur in applied research.

Piper ME, Rodock M, Cook JW, Schlam TR, Fiore MC, Baker TB. Psychiatric Diagnoses Among Quitters Versus Continuing Smokers 3 Years After Their Quit Day. Drug and Alcohol Dependence. 2013 Feb 1;128(1-2):148-54.

Summary: After controlling for pre-quit (past-year) diagnoses, participants who were smoking at the Year 3 follow-up were more likely to have developed and maintained a substance-use disorder or major-depressive disorder by that time than were individuals who were not smoking at Year 3. Quitting smoking does notappear to negatively influence mental health in the long-term and may be protective with respect to depression and substance use diagnoses; this should encourage smokers to make quit attempts and encourage clinicians to provide cessation treatment.

Smith SS, Keller PA, Kobinsky KH, Baker TB, Fraser DL, Bush T, Magnusson B, Zbikowski SM, McAfee TA, Fiore MC. Enhancing Tobacco Quitline Effectiveness: Identifying a Superior Pharmacotherapy Adjuvant.Nicotine and Tobacco Research. 2013 Mar;15(3):718-28.

Summary: In this study involving nearly 1000 callers to the Wisconsin Tobacco Quit Line, three different quitline enhancements were tested: using two kinds of nicotine replacement medications (patch and gum); longer medication treatment (6 weeks vs 2 weeks); and specialized counseling. Results showed that using two kinds of nicotine medication for 2 or 6 weeks increased 6-month abstinence rates by 10% and 13%, respectively, over rates produced by 2 weeks of nicotine patch alone when offered with quitline counseling. A 10% improvement would potentially yield an additional 50,000 quitters annually, assuming 500,000 callers to U.S. quitlines per year.

Schlam TR, Baker TB. Interventions for Tobacco Smoking. Annual Review of Clinical Psychology. 2013 9, 675-702.

Summary: In this review, the authors use “the phase-based model of tobacco use (Baker et al. 2011) to guide the evaluation of smoking interventions. This model depicts pragmatically defined phases in the natural history of tobacco dependence that present different challenges and opportunities for intervention.” The chapter provides a comprehensive review of interventions for smokers unwilling to make a quit attempt (motivation phase), smokers willing to make a quit attempt (cessation phase), those who recently quit (maintenance phase), and who recently relapsed (relapse recovery phase).

Gepner AD, Piper ME, Leal MA, Asthana A, Fiore MC, Baker TB, Stein JH. Electrocardiographic Changes Associated with Smoking and Smoking Cessation: Outcomes from a Randomized Controlled Trial. PLOS ONE. 2013 Apr 23;8(4).

Summary: Major electrocardiogram (ECG) abnormalities are independently associated with lifetime smoking burden. After 3 years, smoking cessation was not associated with a decrease in ECG abnormalities.

Deiches JF, Baker TB, Lanza F, Piper ME. Early Lapses in a Cessation Attempt: Lapse Contexts, Cessation Success, and Predictors of Early Lapse. Nicotine and Tobacco Research. 2013; 15(11):1883-91.

Summary: Three of four smokers in a recent study who relapsed said that cigarettes were easily available at that time, meaning they didn’t have to drop everything and run out to a store to get them. While it’s standard practice to advise smokers planning to quit to throw away all tobacco products before they quit, as well as tools associated with smoking—such as lighters and ash trays—as a way to avoid cues and temptation to light up, the authors concluded their findings tell us that this common advice may need more emphasis regarding its crucial nature.

Goldberg S, Davis JM, Hoyt WT. The Role of Therapeutic Alliance In Mindfulness Interventions. Journal of Clinical Psychology. 2013 Sep;69(9):936-50.

Summary: The results support the position that the therapeutic alliance created between mindfulness instructor and participant is playing a role in the salutary effects associated with mindfulness training such as the acquisition of mindfulness skills and changes in emotion regulation and negative affect, but not in regards to quitting smoking. The findings should encourage mindfulness instructors to recognize that the alliance they form with participants may be an influential aspect of the therapy provided, at least for certain outcomes.

Lanza ST, Vasilenko S, Liu X, Li R, Piper M. Advancing the Understanding of Craving During Smoking Cessation Attempts: A Demonstration of the Time-Varying Effect Model. Nicotine and Tobacco Research. August 24, 2013.

Summary: During the first 2 days after quitting, the association between negative affect and craving was significantly stronger among individuals in the placebo group, suggesting an early positive impact of treatment. For the monotherapy and combination therapy groups, during the second week of the quit attempt baseline dependence was less strongly related to craving compared with the placebo group, indicating a different positive impact of treatments later in the quit attempt.

Liu X, Li R, Lanza ST, Vasilenko S, Piper M. Understanding the Role of Cessation Fatigue in the Smoking Cessation Process. Drug and Alcohol Dependence. 2013 Dec 1;133(2):548-55.

Summary: Cessation fatigue was closely related to craving, negative affect, and cessation outcomes. Women reported greater cessation fatigue than men. Current treatments appeared to reduce fatigue and weaken its relations with craving and negative affect.

Davis JM, Mills DM, Stankevitz KA, Manley AR, Majeskie MR, Smith SS. Pilot Randomized Trial On Mindfulness Training for Smokers In Young Adult Binge Drinkers. BMC Complementary and Alternative Medicine.2013;13:215-225.

Summary: This pilot study demonstrated that Mindfulness Training for Smokers shows promise for smoking cessation and alcohol use reduction in treating young adult smokers with alcohol abuse. Results suggest the need for a study with larger sample size and methods that reduce attrition.

Fraser D, Baker TB, Fiore MC, Adsit RA, Christiansen BA. Electronic Health Records (EHR) as a Tool for Recruitment of Participants In Clinical Effectiveness Research: Lessons Learned from Tobacco Cessation.Translational Behavioral Medicine. 2013 Sep;3(3):244-52.

Summary: Patients identified as tobacco users can be seamlessly linked to research and treatment resources by the primary care team using prompting from the electronic health record (EHR) with minimal physician or staff time. The patient need not be motivated to quit immediately in order to begin intervening.

Piper ME, Baker TB, Mermelstein R, Collins LM., Fraser D, Jorenby DE, Smith SS, Christiansen BA,Schlam TR, Cook JW, Oguss M, Fiore MC. Recruiting and Engaging Smokers In Treatment In a Primary Care Setting: Developing a Chronic Care Model Implemented Through a Modified Electronic Health Record. Translational Behavioral Medicine. 2013 Sep;3(3):253-63.

Summary: The electronic health records (EHRs) prompted primary-care clinic staff to invite 65% of patients who smoked to participate in a tobacco-treatment program. Twelve percent of all smokers enrolled in treatment—30% in smoking reduction and 70% in cessation treatment. The chronic-care model developed for treating tobacco dependence, integrated into the primary care system through the EHR, has the potential to engage up to 4.3 million smokers in treatment a year.

Bloom AJ, Baker TB, Chen L-S, Breslau N, Hatsukami D, Bierut LJ, Goate A. Variants In Two Adjacent Genes, EGLN2 and CYP2A6, Influence Smoking Behavior Related to Disease Risk Via Different Mechanisms. Human Molecular Genetics. E-pub: 2013. Print: 2014 Jan. 15;23(2):555-61.

Summary: When genotypes CYP2A6 and EGLN2 are analyzed together, results indicate a previously unappreciated novel mechanism behind genome-wide significant associations with cigarette consumption and disease risk unrelated to nicotine metabolism.

Chen L-S, Bloom AJ, Baker TB, Smith SS, Piper ME, Martinez M, Saccone N, Hatsukami D, Goate A, Bierut L. Pharmacotherapy Effects On Smoking Cessation Vary With Nicotine Metabolism Gene (CYP2A6) Addiction. E-pub:2013. Print: 2014 Jan 15;23(2):555-61.

Summary: This paper shows that the gene CYP2A6 predicts who will respond to quit-smoking medications and who will not. The team discovered that nicotine replacement therapy (NRT) neutralized the genetic risk for fast nicotine metabolism, but bupropion didn’t. CYP2A6 is a different gene from the one in a previous UW-CTRI paper, CHRNA5, which predicted who would respond to NRT or bupropion. Using both genes together helps predict treatment outcomes better than using either gene separately, coding for different types of risk. Researchers are working on a treatment algorithm.

Trail JB, Collins LM, Rivera DE, Li R, Piper ME, Baker TB. Functional Data Analysis for Dynamical System Evaluation of Behavioral Processes. Psychological Methods. 2013.

Summary: Researchers used UW-CTRI research data and applied new methods to understand the dynamics of craving and withdrawal. The results will help us develop treatments to ease craving and withdrawal.

Sims TH, McAfee T, Fraser DL, Baker TB, Fiore MC, Smith SS. Quitline Cessation Counseling for Young Adult Smokers: A Randomized Clinical Trial. Nicotine & Tobacco Research. May 2013;15(5):932-941.

Summary: Relative to self-help, quitline counseling motivated young adults to set a quit date but abstinence rates were not improved. Research is needed on how to motivate young adult smokers to seek cessation treatment including quitline services.

Rouse Arndt, LM, Caskey M, Fossum J, Schmitt N, Davis AR, Smith SS, Kenote B, Strickland R, & Waukau J. Menominee Perspectives on Commercial and Sacred Tobacco Use. American Indian and Alaska Native Mental Health Research. 2013. Volume 20 (3), pages 1-22.

Summary: Tribal community role models and knowledge holders could be incorporated into both new and existing (e.g., youth and school outreach) prevention and intervention efforts to offer traditional options for healthy lifestyles and coping strategies. These efforts could also incorporate input from those who manage the traditional tobacco program at the Historic Preservation Department.

Leventhal AM, Piper ME, Japuntich SJ, Baker TB, Cook JW. Anhedonia, Depressed

Mood, and Smoking Cessation Outcome.  Journal of Consulting Clinical Psychology. Epub: November 2013.

Summary: Results suggest that (1) symptoms of affective disturbance capture depression-relevant risk of cessation failure, which is not adequately demarcated by the lifetime depressive disorder diagnosis, and (2) anhedonia is a more sensitive index of this affective disturbance than depressed mood per se. Clinical attention to anhedonia may facilitate smoking cessation.

In Press

Davis JM, Goldberg SB, Anderson MC, Manley AR, Smith SS, Baker TB. Randomized Trial on Mindfulness Training for Smokers Targeting a Disadvantaged Population. Journal of Substance Use and Misuse.

Davis JM, Anderson MC, Stankevitz KA, and Manley AR. Providing Premedical Students with Quality Clinical and Research Experience: The University of Wisconsin Tobacco Science Scholar’s Program. Wisconsin Medical Journal.

Davis JM, Sandgren AJ, Manley AR, Smith SS. Iterative Optimization of Recruitment Strategy During Recruitment of Human Subjects. Applied Clinical Trials.

Collins LM, Trail JB, Kugler KC, Baker TB, Piper ME, Mermelstein R. Making Decisions Based on the Results of a Factorial Component Screening Experiment. Translational Behavioral Medicine.

Lebrun-Harris LA, Fiore MC, Tomoyasu N, Ngo-Metzger Q. Cigarette Smoking, Desire to Quit, and Tobacco-Related Counseling Among Adult Health Center Patients. American Journal of Public Health.

Christiansen BA, Reeder K, Fiore MC, Baker TB. Changing Low Income Smokers’ Beliefs about Tobacco Dependence Treatment. Substance Use and Misuse.

7) Cole H, Fiore MC. The War Against Tobacco: 50 Years and Counting. JAMA.

Fiore MC, Schroeder SA, Baker TB. Smoke, the Chief Killer – Strategies for Targeting Combustible Tobacco Use.New England Journal of Medicine.

Timms KP, Rivera DE, Collins LM, Piper ME. Continuous-Time System Identification of a Smoking Cessation Intervention. International Journal of Control.

Timms KP, Rivera DE, Collins LM, Piper ME.  A Dynamical Systems Approach to Understanding Self-Regulation in Smoking Cessation Behavior Change. Nicotine & Tobacco Research. 

New Studies

PTSD and Veterans Merit Award. UW-CTRI Researcher Dr. Jessica Cook has reached a major career milestone, receiving a merit award from the Veterans Administration (VA). The primary objective of her research is to produce an empirically validated treatment that increases smoking cessation in veterans with posttraumatic stress disorder (PTSD), one that can be easily integrated into smoking cessation clinics and/or mental health clinics within VA facilities. PTSD is highly prevalent in the VA patient population and is associated with a rate of smoking (53% – 66%) that far exceeds that of VA enrollees in general (22%). PTSD is also associated with unusually high rates of smoking cessation treatment failure. The disparity in smoking cessation outcomes amongst veterans with PTSD may occur because standard smoking cessation treatment does not address PTSD-specific vulnerabilities.

Veterans with smoking-PTSD comorbidity may respond better to treatment that addresses their PTSD and associated affective symptoms, because such symptoms can both reinforce smoking and undermine quit attempts. Recent evidence shows that behavioral activation therapy (BA), a behavioral treatment that increases engagement in reinforcing activities, significantly reduces PTSD symptoms.  BA may improve smoking cessation outcomes amongst veterans with PTSD because it reduces overall PTSD symptom severity and affective distress (low positive affect, high negative affect), which can cause smoking relapse. The funded research will determine whether BA, as an adjunct to standard smoking cessation treatment, (ST+BA) is superior to a comparably intense combination of standard smoking cessation treatment + health and smoking education (ST+HSE) in improving smoking cessation outcomes among veterans with PTSD. The HSE intervention is intended to constitute a credible intervention that controls for contact time.  Secondary objectives are to determine if BA improves PTSD symptomatology and associated affective distress, and to identify potential mediators of BA on smoking outcomes.

A total of 120 veterans with PTSD who are motivated to quit smoking will attend an initial diagnostic and baseline assessment session. Those who are interested, eligible, and who provide consent will be randomly assigned to receive ST+BA or ST+HSE and will be contacted by their individual study therapist to schedule the first treatment session. Participants will be stratified into treatment groups based on: 1) major depressive disorder (MDD; present versus absent), and 2) PTSD symptom severity. All participants will receive eight, individual sessions of ST+BA or ST+HSE. All participants will receive 20 minutes of identical standard smoking cessation treatment in each of the eight sessions. Those in the ST+BA condition will receive an additional 30 minutes of behavioral activation therapy; those in the ST+HSE condition will receive an additional 30 minutes of health education and information about smoking.  All participants will receive 8 weeks of the nicotine patch. Smoking cessation outcomes will be assessed 2, 4, 8, 16, and 26 weeks after the quit date. This research has important clinical and public health significance because smoking is especially common among veterans with PTSD, and it is the leading preventable cause of disease and disability. Reducing smoking rates among veterans with PTSD would result in substantially lower smoking-related illness and death in this vulnerable group of smokers. It would also reduce tobacco-related health-care costs charged to the VA. The grant will support researcher Kirsten Webster and a study counselor. Jan. 2014-Sept. 2019, $770,500. Funded by the Veterans Administration. Jessica Cook, PI.

Can Smartphone Games Help Smokers Quit? Most smokers who try to quit do not succeed. Even if they use evidence-based treatment, only approximately 10% to 30% achieve long-term abstinence. It is known that strong craving for cigarettes is a powerful reason many smokers fail in their quit attempts. Unfortunately, medication and cessation counseling are only modestly successful in quelling craving. The objective of the proposed research is to determine whether smartphone games can help smokers distract themselves, suppress their cravings, and increase their chances of quitting. Dr. Schlam will use the findings from this research as pilot data in a grant application for an NIH K23 Career Development Award. Sept. 2013-Aug. 2014. The $20,000 grant from a UW-CTRI Developmental Pilot Grant is part of UW-CTRI’s NIH P50 Center Grant. The $6,164 grant is from a UW Department of Family Medicine Small Grant. Dr. Tanya Schlam, PI.

Menthol Use Grant. The National Heart, Lung, and Blood Institutes (NHLBI), in collaboration with the FDA, has awarded the University of Wisconsin Center for Tobacco Research and Intervention (UW-CTRI) a $368,000 grant to study the use of menthol cigarettes. This project will add to the body of research the FDA is examining to determine whether or how to regulate menthol flavoring in tobacco products. About 75% of adult African-American smokers and about 25% of adult Caucasian smokers in the US smoke menthol cigarettes. While common, little is known about the risks of smoking menthol versus non-menthol cigarettes with regard to tobacco dependence or quitting motivation and success. Researchers will use the unique resources of the Wisconsin Smokers’ Health Study (WSHS 1 & 2) to determine the associations of menthol-smoking (versus smoking non-menthol cigarettes) with tobacco dependence, attempts to quit smoking, and quitting success. The WSHS 2 is a longitudinal study that spans close to 10 years and comprises two clinical trials of 2,500 participants that evaluate the major types of quit-smoking medications. The WSHS 2 entails comprehensive assessments of tobacco dependence, participant characteristics, and quitting attempts and success over time.

This research will use these data to determine:

  1. The relation of menthol smoking with comprehensive measures of smoking cessation, and whether such relations are stronger for some types of smokers than others (e.g., African Americans, women).
  2. The relation of menthol smoking with making quit attempts.
  3. Which types of smoking cessation medications are most effective for menthol smokers, and whether menthol and non-menthol smokers differ significantly in response to medications.
  4. The causal mechanisms that account for menthol smokers being at a different risk of smoking cessation failure (if they are found to be so) and whether medications work via the same mechanisms in menthol and non-menthol smokers.
  5. The relation of menthol smoking with important participant characteristics such as severity and type of tobacco dependence.

This research will compare menthol smoking versus non-menthol smoking with regard to tobacco dependence and quitting success. The results should be highly relevant to decisions regarding public health policy and the regulation of menthol cigarettes. Aug. 2013-June 2014. $368,000. Funded by the National Heart, Lung, and Blood Institutes, in collaboration with the FDA. Dr. Michael Fiore, Dr. James Stein of UW Cardiology, and Dr. Timothy Baker, PIs.

Active Studies

 Wisconsin Smokers Health Study 2 (WSHS 2). UW-CTRI has been awarded a $10-million NHLBI grant to discover the best ways to help Wisconsin residents stop smoking. The new study essentially extends the Wisconsin Smokers’ Health Study and is known as WSHS 2. It includes potentially life-saving tests—including artery scans that can signal impending risk of a stroke or heart attack—free of charge. Participants get free coaching and medications to help them quit smoking. Dr. Mike Fiore, Dr. Tim Baker, and Dr. James Stein of UW Preventive Cardiology are the lead researchers for this new grant. The original Smoker’s Health Study, launched in 2004, revealed how quitting smoking affects nearly every part of a person’s health, lifestyle, and well-being. Many patients from WSHS are continuing participation in WSHS 2, and their participation will culminate in health data spanning 10 years. The media announcement of WSHS 2 garnered 2,500 volunteers. The Center is recruiting 600-800 smokers as new study participants for WSHS 2. In addition, everyone from the previous study—whether now smoking or not—is welcome to continue their participation. In total, 1,500 individuals will participate in WSHS 2. Each participant gets assistance from a personal quit coach—something many former smokers say is essential because they felt that giving up cigarettes was like “losing my best friend.” The quit coach is a familiar face who ensures that the patient doesn’t feel like s/he is going through the process alone. All participants will be compensated for time and travel. Each individual participant will receive test results, such as cholesterol levels, artery scans, blood counts, and diabetes tests. These results could signal imminent trouble and save lives. The study will employ medical tests—such as carotid artery ultrasound scans and arterial tonometry—to determine how quitting smoking improves health over time, and how continuing to smoke harms health. These tests concentrate on cardiovascular disease, but will also target conditions such as lung disease and diabetes mellitus. While it is well known that smoking is very dangerous, we know less about how quitting (versus continued smoking) affects health. Every participant will get state-of-the-art active medication: 1) varenicline or 2) nicotine patch + nicotine lozenge or 3) just nicotine patch. The first two medication treatments listed above have offered the highest quit rates of all quit-smoking medications, said Tim Baker. However, these two treatments have never been compared head-to-head. “We’ll not only determine which works better,” Baker said, “but also whether one approach works better with some types of smokers than does the other.” At the end of this study, the researchers hope to enhance knowledge of how to treat smoking optimally, how quitting smoking helps participants to reduce their risk of heart disease, stroke, and cancer, and the mechanisms by which these health benefits occur. Sept. 2011-Nov. 2016, $10 million. Funded by the National Heart, Lung, and Blood Institute. Dr.Tim Baker, Dr. Michael Fiore, Dr. Jim Stein, PIs.

State Medicaid Grant: Striving to Quit. Wisconsin has received a five-year, $9.2 million grant from the federal Centers for Medicare and Medicaid Services to help Medicaid recipients to quit smoking through mechanisms such as the Wisconsin Tobacco Quit Line (QL) and the First Breath Program. Approximately $6.2 million is managed by UW-CTRI. The purpose of the grant is to help determine whether monetary incentives increase engagement of smokers into treatment, and whether that leads to more people quitting smoking. The Wisconsin Department of Health Services (DHS) leads the grant, collaborating with the state Medicaid program, First Breath (FB), and UW-CTRI. The grant, called Striving to Quit, has two full-time UW-CTRI regional outreach specialists written in for three years. It will offer evidence‐based cessation counseling plus incentives to two groups:

  1. Adult BadgerCare Plus members who smoke and reside in South Central and Northeastern Wisconsin will be referred to QL. Participants will get five coaching calls and eight weeks of combination nicotine-replacement medication. Some will get incentives, some won’t.
  2. Pregnant BadgerCare Plus members in five counties in Southeastern and South Central Wisconsin will work face-to-face with FB health educators. These participants will receive nine visits and seven monthly phone calls. One group will take four CO tests and receive incentives for participation. Another group will get the same visits and calls but not the incentives.

There are 105,417 adult BadgerCare Plus members in these identified areas. Of these, an estimated 40,000 smoke (38%). Striving to Quit aims to treat 2,000 with incentives and another 2,000 without incentives. If a quarter quit smoking, savings from reductions in health care costs are estimated at $3.2 million over the course of the initiative. The FB component of the grant includes a special focus on engaging pregnant African American women who smoke in counties with extremely high rates of birth disparities. Striving to Quit will link them to evidence‐based treatment services by face‐to‐face contacts through First Breath, supplemented by phone support. The rationale for a different approach for pregnant women is based on findings from the QL data indicating that only one to two percent of all pregnant women who smoke call the QL for assistance. Induction to the QL component of the study is similar to that of UW-PASS. When a BadgerCare Plus member visits a participating clinic, a clinic staff person—generally the medical assistant (MA)—identifies the patient as a smoker via an expanded vital signs protocol that includes an assessment of smoking status. At this baseline visit, the MA also obtains an expired air CO measure from the smoker. Results of the test are tracked either via an electronic health record (EHR) or the member’s HMO tobacco registry. The CO level is also shared with the QL if the member agrees to the referral. The MA briefly explains the availability of free treatment services and monetary incentives and informs the patient that s/he will get a call from the QL within 48 hours. Provider education and awareness materials will mirror that of the UW‐CTRI campaign, “You Can Afford to Quit: Medicaid Covers It.” In addition, DHS, UW‐CTRI and FB will work with the HMOs to host a series of educational events for providers. “This grant offers a tremendous opportunity to improve the health of thousands of Wisconsin residents with low incomes,” said Mike Fiore. “We’re excited to see whether financial incentives increase rates of smoking cessation among BadgerCare Plus members. It’s terrific to be a part of this grant and to partner with our esteemed collaborators.” Sept. 2011-Sept. 2016, $9.2 million. Funded by Centers for Medicare and Medicaid Services. Dr. Tim Baker, PI.

UW Partnership to Assist and Serve Smokers (UW-PASS). A $9 million P-50 grant from the National Cancer Institute is providing five years of funding for UW-CTRI to study various quit-smoking treatments in primary-care clinics throughout Wisconsin. In this study, led by Dr. Michael Fiore and Dr. Tim Baker, UW-CTRI has delivered seamless, cutting-edge treatments for all smokers, including those who are ready to quit and those who aren’t. Beginning in the summer of 2010, UW-CTRI offered participation to patients who smoked and visited select primary-care clinics within two health care systems—Dean Health System and Aurora Health Care. Medical assistants at partnering clinics identified smokers and asked if they were interested in being contacted about a study. They invited all smokers whether they were willing to quit or not. If the patient was interested, an e-mail was generated from the electronic medical record to UW-PASS staff, employed by UW-CTRI, who conducted screening, orientation, patient visits and follow up. The electronic medical records were supported by Epic Systems Corp. and Cerner. The study is now finishing up follow-up; all participants have completed treatment. UW-PASS includes three projects:

Project 1 focuses on increasing the smoker’s motivation to quit. This project offers treatment strategies for smokers who aren’t ready to quit now but are willing to participate in treatment to help them get ready to quit. The hope is to increase their motivation to quit smoking as well as to make actual quit attempts. Treatments include behavioral coaching, motivational interviewing, nicotine patches, and nicotine gum.

Project 2 of UW-PASS examines whether use of nicotine-replacement medication and behavioral coaching—before actually quitting smoking—helps the patient remain smoke-free. Typically, those who use nicotine-replacement medications (such as the nicotine patch or lozenge) quit smoking first, then use medications to stave off cravings and remain smoke free. Project 2 also tests coaching types and lengths, including in-person coaching vs. telephone coaching.

Project 3 is designed to study ways to increase the number of patients who take quit-smoking medication at the proper dosage for the prescribed duration. Most smokers don’t use enough medication or use it the right way. The goal is to see what happens if a patient takes medication as prescribed vs. skipping doses or ceasing treatment prematurely. Adherence treatments include automated-adherence phone prompts, electronic monitoring/feedback and a cognitive-adherence intervention. Project 3 will also look at the outcomes of long-term coaching and medication.

Sept. 2009-Aug. 2014. NIH (NCI) P-50 grant. Dr. Tim Baker and Dr. Michael Fiore, PIs.

Dual Use of E-Cigarettes and Traditional Cigarettes in Primary Care and Community Settings.The National Institutes of Health has awarded UW-CTRI a $1.8 million supplement to its NCI-funded center grant. With this supplement, researchers will investigate questions of importance to the FDA in its role of regulating tobacco products:

  • How dual use of tobacco products (both smoking cigarettes and vaping e-cigarettes) is related to outcomes of public health importance, such as cessation attempts and success.
  • Mechanisms by which dual use affects such outcomes, for instance showing how dual use affects cigarette withdrawal symptoms, smoking reward, and cigarette dependence.

In the existing NCI Center Grant Primary Care study, UW-CTRI researchers will add new measures and analyses to the parent study to see how dual use may (or may not) affect the user’s dependence on cigarettes, withdrawal severity, perception of harm, treatment engagement, and smoking outcomes (smoking reduction and cessation). Participants in the parent grant are recruited through primary-care visits. Dr. Tanya Schlam will be the lead UW-CTRI scientist on this primary care component.

In the new Community Sample sub-study, researchers will use measures and analyses that will elucidate the mechanisms responsible for the associations observed in the Primary Care sub-study. Dr. Doug Jorenby will be the lead scientist on this community sample component, which will recruit 150 daily smokers via advertisements (e.g., convenience stores, TV, social media) throughout the Milwaukee and Madison areas, half of whom will also use e-cigarettes.
These participants will generate real-time data (using an innovative smartphone app) to determine how dual users and exclusive smokers compare on hedonic ratings of cigarettes, cigarette use, daytime tobacco use, mood, suppression of cigarette withdrawal, contexts of use, and exposure. Moreover, data from dual users will reveal how recent use of other tobacco products (OTP) affects cigarette use and reward, especially during periods of reduced cigarette intake. Researchers will use the data to compare risk profiles and determine how to improve cessation.September 2012-August 2014. Funded by NIH and FDA. Dr. Tim Baker and Dr. Michael Fiore, PIs.

Advancing Tobacco Research by Integrating Systems Science and Mixture Models. Dr. Stephanie Lanza of Penn State is the lead investigator Dr. Megan Piper of UW-CTRI is a co-investigator on this R01 grant from theNational Cancer Institute. The project will advance knowledge of how different smoking-cessation treatments work, for whom, and when. Researchers from The Methodology Center at Penn State will integrate time-varying effect models and latent class analysis in order to identify subgroups of smokers who experience the process of nicotine withdrawal differently. Research results will guide future smoking-cessation interventions. Only very recently have new approaches become more common thanks to smartphones and other technological advances. Latent class analysis allows researchers to gauge the impact of exposure to patterns of multiple risks, as well as the antecedents and consequences of complex behaviors, so that interventions can be tailored to target the subgroups that will benefit most. Results from the project will inform the construction of interventions that (1) are tailored to the individual and that (2) adapt to participant response over time. Importantly, the overall impact of this project extends far beyond the proposed analysis; the project’s full potential for accelerating the pace of smoking-cessation research will be realized as a result of programmatic dissemination efforts of important new analytic methods to tobacco researchers. August 2012-July 2015. Funded by National Cancer Institute. Dr. Stephanie Lanza, PI. Dr.Megan Piper, co-I.

Clinical Relevance of Stress Neuroadaptation in Tobacco Dependence. The broad goals of this research are to identify the origin of biomarkers related to how the body compensates for the presence of cigarette chemicals so that it can continue to function. Dr. John Curtin of UW Psychology is the principal investigator, while Dr. Megan Piper of UW-CTRI is a co-investigator on this RO1 grant. It examines stress neuroadaptation in the laboratory via startle potentiation during uncertain threat among nicotine-deprived smokers versus non-deprived smokers and non-smokers. Smokers will be subsequently assigned to one of three smoking-cessation treatment conditions and will report on episodic stressors, negative feelings, smoking urge, and tobacco consumption in real time from their regular environments via smart phones or other digital devices that prompt them to enter data. Treatment outcomes will be assessed at four weeks and end of treatment. Researchers are evaluating the impact of this stress neuroadaptation on smokers’ feelings, urge, and tobacco consumption during smoking-cessation treatment. They are also examining whether first-line pharmacotherapies can dilute the influence of this stress neuroadaptation on smoking-cessation outcomes. August 1, 2012-June 30, 2017. Funded by NIDA. Dr. John Curtin, PI. Dr. Tim Bakerand Dr. Megan Piper, Co-I’s.

Tobacco Interventions Delivered by Community Agencies to Those Living in Poverty. UW-CTRI has received a $332,000 NIH grant to train staff at four Salvation Army centers (in Green Bay, Appleton, La Crosse and Wausau) to provide a brief intervention with clients who smoke. Dr. Bruce Christiansen leads this project, which sprouted from pilot data collected via an ICTR grant awarded to Dr. Christiansen. More than 37 million Americans live in poverty, and they smoke at twice the rate of other Americans. As a result, they bear a disproportionate burden from tobacco-related diseases. Research also shows many people who are homeless or very poor have either mental-health or substance-abuse issues. Both of these groups tend to smoke at high rates and struggle to make quit attempts using evidence-based methods. This grant tests a brief intervention that challenges smokers’ beliefs that discourage quit attempts. These beliefs include:

  1. Smoking is both normal and acceptable.
  2. Willpower is sufficient to quit, rendering outside help unnecessary and irrelevant.
  3. Evidenced-based treatments are not more effective than other methods.
  4. Stop-smoking medicines are ineffective, dangerous, addictive and/or too expensive.
  5. Help in quitting is not available, hard to access and/or too expensive.

The goal of the intervention is to correct these misconceptions so they’ll consider quitting smoking. As a control, another 140 clients are being randomized into a 15-minute intervention with a Salvation Army counselor reading through a booklet on smoking and health, but without any behavioral or motivational interviewing. Another control group, consisting of 140 clients, are being given a booklet to peruse by themselves. All three groups will be compared with 100 participants who are already ready to quit smoking. Researchers have been making follow-up phone calls after three months. Sept. 2011-Sept. 2014, $332,000. Funded by NCI. Dr. Bruce Christiansen, PI.

 Primary Care Research Fellowship. Dr. Tanya Schlam is conducting post-doctoral research on smoking cessation as a Primary Care Research Fellow, supported by a National Research Service Award (T32 Postdoctoral Training Grant) from the Health Resources and Services Administration to the University of Wisconsin Department of Family Medicine. July 2012-June 2014. Funded by the Health Resources and Services Administration. Dr. Bruce Barrett, PI.

Veterans and Smoking Studies. Dr. Jessica Cook is leading a study at the William S. Middleton Memorial VA Hospital in Madison. The study tests the hypothesis that smokers with posttraumatic stress disorder (PTSD) and depression smoke cigarettes to improve aversive mood states and other mental health symptoms. The effect Dr. Cook is most interested in is whether smoking regulates anhedonia, a common feature of both PTSD and depression that is characterized by an inability to respond to pleasurable events. The first part of the study examines how nicotine influences mood responses to positive and negative stimuli. The second part of the study will be done at a critical point, 24 and 48 hours after being deprived of nicotine, which can be the peak of withdrawal. It’s then that the team will explore whether veterans with PTSD and depression have a more difficult time experiencing pleasure in response to rewarding events and whether they experience more withdrawal-related negative affect. Oct. 2007-present. NIH funded (NIDA). Dr. Jessica Cook, PI.

Recently Completed Studies

(In data analysis and preparation of papers)

Qualitative Analysis of American Indian Tobacco Use and Research Participation. Dr. Leah Arndt (UW-Milwaukee) has been the principal investigator and Dr. Stevens Smith of UW-CTRI the co-investigator on this 3-year pilot study (7/1/2010-6/30/2013; $187,562) funded through a parent grant, “Spirit of Eagles Community Network Program” (U54 CA153605; PI: Dr. Judith Kaur, Mayo College of Medicine) funded by the National Cancer Institute. Spirit of Eagles (SOE) is a multidisciplinary national program that coordinates and assesses a national cancer research program for American Indian/Alaska Native (AI/AN) communities to address cancer disparities in this population. Cancer health disparities are addressed in SOE by implementing and assessing innovative and culturally appropriate research through community-driven partnerships. In the pilot study, Dr. Arndt and colleagues are conducting additional qualitative analyses of interview data collected in the Menominee Smoking Cessation Clinical Trial (10/1/2008-9/30/2011; $453,449; funded by the Wisconsin Partnership Program; PI: Dr. Stevens Smith) that tested a culturally-tailored cessation intervention (versus standard treatment) in 108 AI/AN smokers at the Menominee Tribal Clinic. July 2010-June 2013. Funded by NCI and the Center for Urban Population Health in Milwaukee, WI. Dr. Leah Arndt, PI and Dr. Stevens Smith, Co-I.

Mindfulness Study. Dr. James Davis has developed a seven-week smoking-cessation intervention that teaches participants to use mindfulness skills to manage relapse challenges such as triggers, urges, withdrawal symptoms and strong emotions. He has now completed three studies to assess the effectiveness of this intervention:

The first study was a randomized trial (n=198) comparing mindfulness training to the Wisconsin Tobacco Quit Line. It is complete and shows that participants with the mindfulness training have significantly higher abstinence rates than controls in several outcome measures. A paper on this study has been accepted by the Journal of Substance Use and Misuse.

The second study was a randomized trial (n=175) that compares mindfulness training to a time/intensity matched seven-week intervention based on the American Lung Association Freedom from Smoking Program. This study is complete and Dr. Davis is drafting a manuscript on results.

The third study (n=30) was designed to assess the feasibility of providing mindfulness training over the Internet. If a web-based version of mindfulness training appears to be effective, it could provide for wider dissemination of the intervention. This study is complete and Dr. Davis is drafting a manuscript on results. Feb. 2008-Aug. 2013. NIH funded (NIDA). Dr. James Davis, PI.

Helping Patients with Persistent Mental Illness Prepare to Quit Smoking. UW-CTRI is part of a $200,000 community collaboration to help motivate patients with persistent mental illness to quit smoking, partnering with the National Alliance on Mental Illness (NAMI). UW-CTRI Researcher Dr. Bruce Christiansen leads the two-year project, which is reaching out to 172 patients via 13 community-support programs (CSPs). Bruce joined Jennifer Lowenberg (NAMI) and Dr. Jana Frey (Program of Assertive Community Treatment–PACT) to present a webinar on the topic. Certified peer counselors, who are also former smokers recovering from mental illness, deliver the intervention. These coaches were recruited by Lowenberg for this project. Each participant has the same coach throughout the program—a key element to establishing a rapport and offering a social bond to offset the loss of cigarettes, which many smokers consider their “best friend.” May 2011-June 2013. Funded by the UW Institute for Clinical and Translational Research (ICTR). Dr. Bruce Christiansen, PI.