OVERVIEW: UW-CTRI releases a research update in January and July of each year. This report summarizes published and in-press manuscripts, presentations, grants, contracts and other research projects. Archived reports are available here.
SUMMARY: In 2017, the UW-CTRI research team produced:
23 published papers
6 papers in press
37 presentations and posters
3 new studies
6 active studies
6 studies recently completed
THANK YOU: UW-CTRI is grateful to its partners, Centers for Disease Control (CDC), Centers for Medicare and Medicaid Services (CMS), ClearWay Minnesota, Food and Drug Administration (FDA), Health Resources and Services Administration (HRSA), National Institutes of Health (NIH), UW Department of Family Medicine, UW Institute for Clinical and Translational Research (UW-ICTR), UW Department of Medicine, UW School of Medicine and Public Health, Veterans Affairs (VA), Wisconsin Department of Health Services (DHS), and the Wisconsin Partnership Program (WPP), Wisconsin Women’s Health Foundation (WWHF).
Published Papers
Note: Names in bold are current UW-CTRI employees.
Allen AM, Carlson S, Eberly LE, Hatsukami D, Piper ME. Use of Hormonal Contraceptives and Smoking Cessation: A Preliminary Report. Addictive Behaviors. 2017;76:236-42.
Summary: Women using hormonal contraceptives experienced more adverse levels of withdrawal than participants not using them, yet were more likely to achieve short-term abstinence. At end of treatment, the group using hormonal contraceptives was more than three times more likely to quit smoking compared to men. However, there were no group differences in abstinence rates at weeks 26 or 52.
Baker TB. The 2016 Ferno Award Address: Three Things. Nicotine & Tobacco Research. 2017 Feb 11.
Summary: A lack of relevant research, and the likely prospect of significant clinical and public health benefit, underscore the importance of performing research on three topics. Researchers should: (1) identify which contents of smoking counseling are effective; (2) devise innovative strategies that use healthcare systems as conduits of quit-smoking treatment outside of clinical contacts; and (3) use factorial designs to guide their development of smoking treatments. Research on these topics should yield complementary evidence that guides the development of more effective quit-smoking treatments.
Baker TB, Smith SS, Bolt DM, Loh W-Y, Mermelstein R, Fiore MC, Piper ME, Collins LM. Implementing Clinical Research Using Factorial Designs: A Primer. Behavioral Therapy. 2017 Jul;48(4):567-580.
Summary: Factorial experiments have rarely been used in the development or evaluation of clinical interventions. The use of factorial designs in clinical intervention research poses choices that differ from those typically considered in randomized clinical trial designs. However, the great information yield of the former encourages clinical researchers’ increased and careful execution of such designs.
Bekiroglu K, Russell MA, Lagoa CM, Lanza ST, Piper ME. Evaluating the Effect of Smoking Cessation Treatment on a Complex Dynamical System. Drug and Alcohol Dependence. 2017;180:215-222.
Summary: Though the mental battle to not smoke can be exhausting for smokers, combination nicotine replacement therapy helps reduce this cessation fatigue and helps smokers feel like they can be successful in quitting. Researchers found that the use of nicotine patch plus lozenge reduced cessation fatigue and enhanced long-term self-efficacy, while combining bupropion and nicotine lozenge was more effective at reducing negative emotions and craving.
Berg KM, Jorenby DE, Baker TB, Fiore MC. Triple Smoking Cessation Therapy with Varenicline, Nicotine Patch and Nicotine Lozenge: A Pilot Study to Assess Tolerability, Satisfaction, and End-Of-Treatment Quit Rates. Journal of Smoking Cessation. September 2017.
Summary: Thirty five of 36 participants reported at least one adverse event (AE), including Insomnia (75%), abnormal dreams (72%) and nausea (64%). Most were mild to moderate. No deaths, hospitalisations, cardiovascular events or suicidality were reported. Six participants (17%) decreased the dose of at least one medication. Participants were highly satisfied with their medications, and 58% reported quitting at 12 weeks, with 38% reporting prolonged abstinence.
Chen L-S, Baker TB, Brownson RC, Carney RM, Jorenby DE, Hartz S, Smock N, Johnson M, Ziedonis D, Bierut LJ. Smoking Cessation and Electronic Cigarettes in Community Mental Health Centers: Patient and Provider Perspectives. Community Mental Health Journal. 2017;53(6):695-702.
Summary: In four Community Mental Health Centers, 50% of smokers reported interest in using electronic cigarettes to quit smoking, and 22% reported current use. While 82% of smokers reported wanting to quit or reduce smoking, 91% of psychiatrists and 84% of case workers reported that patients were not interested in quitting as the lead barrier, limiting the provision of cessation interventions. Providers’ assumption of low patient interest in treatment may account for the low rate of smoking cessation treatment. This highlights the need for interventions targeting different phases of smoking cessation in these patients.
Christiansen BA, Carbin J, TerBeek E, Fiore MC. Helping Smokers with Severe Mental Illness Who Do Not Want To Quit. Substance Use and Misuse.
Summary: Brief motivational interventions increased engagement in cessation treatment and abstinence among smokers with signification mental illness. These included a motivational element, components designed to prepare the smoker for a quit attempt, and pre-quit nicotine patch. Compared to control participants, smokers receiving the intervention were more likely to be abstinent at the three-month follow-up (8.5% vs. 1.0%). They were also more likely to accept four more quitting preparation sessions (50% vs 29%) but were not more likely to call a telephone tobacco quit line.
Cook JW, Baker TB, Beckham JC, McFall M. Smoking-Induced Affect Modulation in Non-Withdrawn Smokers With Posttraumatic Stress Disorder, Depression, and in those with No Psychiatric Disorder. Journal of Abnormal Psychology. 2017;126(2):184-98.
Summary: Smoking influences emotional responses to rewarding and stressful situations in smokers whether they have posttraumatic stress disorder (PTSD), depression or no psychiatric disorder. Smoking cigarettes with and without nicotine influenced positive and negative emotional responses. Although having PTSD or depression did not appear to enhance the effects of smoking on emotional responses, participants with these disorders experienced more severe negative emotional responses to stressors than those without a mental health disorder.
Cook JW, Lanza ST, Wanghuan C, Baker TB, Piper ME. Anhedonia: Its Dynamic Relations with Craving, Negative Affect, and Treatment During a Quit Smoking Attempt. Nicotine & Tobacco Research. 2017 June 1;19(6):703-709.
Summary: Time-varying effect modeling showed that anhedonia was significantly greater among those high in dependence relative to lower dependent smokers. The placebo group showed elevated anhedonia immediately postquit, which fell to levels similar to the treatment groups by day 7. NRT effectively reduced anhedonia and its time-varying association with craving early in the quit attempt. The positive association between negative mood and anhedonia was moderate and stable over time for both active treatment groups. Anhedonia following quitting smoking is a manifestation of the tobacco withdrawal syndrome.
Fraser DL, Fiore MC, Kobinsky K, Adsit R, Smith SS, Johnson ML, Baker TB. 2017. A Randomized Trial of Incentives for Smoking Treatment in Medicaid Members. American Journal of Preventive Medicine.
Summary: Low-income smokers who received modest payments to quit smoking not only were 57% more likely to quit—but the cost per quitter turned out to be less than for those who didn’t receive those incentives. Medicaid smokers in a research study who received up to $190 to adhere to treatments and be abstinent from smoking quit at a rate of 22%, while those who didn’t receive that level of monetary incentive quit at a rate of 14%. Because significantly more people quit in the incentive group, researchers found that the cost per patient who quit smoking was $660 less than those in the control group.
Han JY, Hawkins R, Baker T, Shah DV, Pingree S, Gustafson D. How Cancer Patients Use and Benefit from an Interactive Cancer Communication System. Journal of Health Communication. 2017 September 18:1-8.
Summary: This study analyzed patient log data as each patient engaged in an eHealth system. Newly diagnosed breast cancer patients were given access for 6 months to one of four different configurations: (1) Information, (2) Information and Support, (3) Information, Support, and Coaching (Full), and (4) Full + Mentor. Usage patterns spread out over the four services. Despite overall decline in usage rates, it was less severe in the Full + Mentor condition, suggesting long-term engagement with the system. Notably, the strongest relation between use and cancer information competence appeared late in the follow-up period.
Hancock DB, Guo Y, Reginsson GW, Gaddis NC, Lutz SM, Sherva R, Loukola A, Minica C, Markunas CA, Han Y, Young KA, Gudbjartsson DF, Gu F, McNeil DW, Qaiser B, Glasheen C, Olson S, Landi MT, Madden PA, Farrer LA, Vink J, Saccone NL, Neale MC, Kranzler HR, McKay J, Hung RJ, Amos CI, Marazita ML, Boomsma DI, Baker TB, Gelernter J, Kaprio J, Caporaso NE, Thorgeirsson TE, Hokanson JE, Bierut LJ, Stefansson K, Johnson EO. Genome-wide Association Study Across European and African American Ancestries Identifies a SNP in DNMT3B Contributing to Nicotine Dependence. Molecular Psychiatry. 2017.
Summary: In the largest-ever genome-wide association study (GWAS) meta-analysis of nicotine dependence, totaling 38,602 smokers (28,677 Europeans/European Americans and 9925 African Americans) across 15 studies, results yielded a novel association in the DNA methyltransferase gene DNMT3B. The intronic DNMT3B rs910083-C allele was associated with increased risk of nicotine dependence. The association was independently confirmed in the UK Biobank (N=48,931) using heavy vs. never-smoking as a proxy phenotype. Rs910083-C is also associated with increased risk of squamous cell lung carcinoma.
Hartz SM, Horton AC, Hancock DB, Baker TB, Caporaso NE, Chen L-S, Hokanson JE, Lutz SM, Marazita M, McNeil D, Pato C, Pato M, Johnson EO, Bierut LJ. Genetic Correlation Between Smoking Behaviors and Schizophrenia. Schizophrenia Research. 2017 Mar 8. pii: S0920-9964(17)30111-1.
Summary: Researchers compared results from a genome-wide meta-analysis of five smoking phenotypes to meta-analysis results from schizophrenia. The genetic heritability for nicotine dependence was statistically higher than the heritability for the other smoking phenotypes. Next, a statistically significant genetic correlation was observed between schizophrenia and three of the five smoking phenotypes. These results suggest that there is a component of common genetic variation that is shared between smoking behaviors and schizophrenia.
Jorenby DE, Smith SS, Fiore MC, Baker TB. Nicotine Levels, Withdrawal Symptoms, and Smoking Reduction Success in Real World Use: A Comparison of Cigarette Smokers and Dual Users of Both Cigarettes and E-cigarettes. Drug and Alcohol Dependence. 2017;170:93-101.
Summary: Vaping electronic cigarettes (e-cigs) didn’t affect the level of smoking or carbon monoxide levels in study participants. Results were biochemically confirmed. While dual users didn’t reduce their smoking any more than the smoke-only group, they did quadruple their vaping during the no-smoking period. Dual users were significantly more likely to completely suspend their smoking during the abstinence part of the study (97.1% vs. 81.2%), but the difference in carbon monoxide levels between the groups was negligible. Amongst women, those who vaped and smoked had higher nicotine levels but also less withdrawal.
King CC, Piper ME, Gepner AD, Fiore MC, Baker TB, Stein JH. The Longitudinal Impact of Smoking and Smoking Cessation on Inflammatory Markers of Cardiovascular Disease Risk. Arteriosclerosis, Thrombosis, and Vascular Biology. 2017;37(2):374-379.
Summary: Researchers evaluated independent associations of smoking heaviness markers with inflammatory markers. Smoking heaviness is associated with increased inflammation. Quitting smoking improves oxidant stress and reduces inflammation independent of weight change.
Mathew AR, Hogarth L, Leventhal AM, Cook JW, Hitsman B. Cigarette Smoking and depression Comorbidity: Systematic Review and Proposed Theoretical Model. Addiction. 2017.
Summary: Using a novel application of incentive learning theory, UW-CTRI researchers found that additional counseling could help supplement evidence-based treatment. The review found evidence that people with depression smoke to increase positive moods, decrease negative moods and improve cognition or thinking. Findings suggest that depressed smokers develop strong expectations about the beneficial effects of smoking on their mood states and thinking, and that these expectations motivate their smoking.
Mitchell CC, Piper ME, Korcarz CE, Hanson K, Weber J, Fiore MC, Baker TB, Stein JH. Echogenicity of the Carotid Arterial Wall in Active Smokers. Journal of Diagnostic Medical Sonography. 2017.
Summary: This pilot study evaluated associations between carotid wall echogenicity, cardiovascular disease (CVD) risk factors, and three markers of smoking heaviness. Common carotid artery (CCA) gray-scale median (GSM) values were measured from sonographic images. Associations between CCA GSM and smoking heaviness markers were not statistically significant after adjustment for traditional risk factors. The results from this pilot study demonstrate the feasibility of measuring the GSM value of the CCA far wall and its association with measures of smoking heaviness and traditional CVD risk factors among current smokers.
Petersen A, Mermelstein R, Berg KM, Baker TB, Smith SS, Jorenby D, Piper ME, Schlam TR, Cook JW. Offering Smoking Treatment to Primary Care Patients in Two Wisconsin Healthcare Systems: Who Chooses Smoking Reduction Versus Cessation? Preventive Medicine. 2017 Dec;105:332-336. Epub October 2017.
Summary: Medical assistants, prompted via the electronic health record, invited smokers to learn more about treatment options to help them either reduce their smoking or quit. Ten percent reported interest in reduction treatment and 24% reported interest in cessation treatment. Patients who selected and ultimately entered reduction treatment were more likely to report: older age; anxiety history; lower motivation to quit; lower primary dependence motives; more close friends or family who smoke. Results suggest that motivational treatment aimed at smoking reduction may increase smoker engagement.
Piper ME, Schlam TR, Cook JW, Smith SS, Bolt DM, Loh W-Y, Mermelstein RJ, Collins LM, Fiore MC, Baker TB. Toward Precision Smoking Cessation Treatment I: Moderator Results From a Factorial Experiment. Drug Alcohol Depend. 2017;171:59-65.
Summary: Intensive counseling with smokers that have psychiatric histories may not lead to higher abstinence rates. Whereas the original outcome paper, published in Addiction, supports the combined use of pre-quit nicotine gum and intensive in-person counseling in all smokers, the current paper sheds light on how multiple intervention components work among different groups of smokers. Heavier smokers also showed a poorer response to counseling interventions than light smokers.
Piper ME, Cook JW, Schlam TR, Smith SS, Bolt DM, Collins LM, Mermelstein RJ, Fiore MC, Baker TB.
Toward the Development of Precision Smoking Cessation Treatment II: Proximal Effects of Smoking Cessation Intervention Components on Putative Mechanisms of Action. Drug and Alcohol Dependence. 2017;171:50-58.
Summary: Pre-quit nicotine gum and patch each reduced pre-quit smoking and enhanced pre-quit coping and belief in their ability to quit. In-person counseling increased pre-quit motivation to quit and post-quit self-efficacy. Withdrawal reduction and reduced pre-quit smoking produced the strongest effects on cessation. The significant effect of combining pre-quit gum and in-person counseling was mediated by increased pre-quit self-efficacy.
Raw M, Olalekan A-Y, Chaloupka F, Fiore M, Glynn T, Hawari F, Mackay J, McNeill A, Reddy S. Recommendations for the implementation of the WHO Framework Convention on Tobacco Control Article 14 on tobacco cessation support. Addiction. 2017;112(10):1703-1708.
Summary: The new plan of action on tobacco has been endorsed by more than 50 experts. The authors suggest countries enact six core measures immediately: Conduct a national situation analysis, develop and implement evidence-based national cessation guidelines, mandate recording tobacco use of all patients in all medical notes, train health care workers to record tobacco use and give brief advice, help health care workers to quit tobacco use, integrate brief advice to all tobacco users into the healthcare system.
Teitelbaum A, Murphy S, Akk G, Baker TB, Germann A, von Weymarn L, Bierut L, Goate A, Kharasch ED, Bloom AJ. Nicotine Dependence is Associated with Functional Variation in FMO3, an Enzyme that Metabolizes Nicotine in the Brain. Pharmacogenomics Journal. 2017.
Summary: Researchers have identified an enzyme associated with how addicted a smoker is to nicotine, and it could suggest new paths to designing medications to help smokers quit. They discovered for the first time that nicotine dependence is associated in part with an enzyme called FMO3, which metabolizes nicotine in the brain. The genetic variants that affect this enzyme are associated with how soon someone begins smoking after awakening, a key aspect of nicotine dependence. It is possible that slowing brain nicotine metabolism via FMO3 activity could be a possible target for smoking-cessation drug development.
Vreede AP, Johnson HM, Piper ME, Panyard DJ, Wong JC, Bartels C. Rheumatologists Modestly More Likely to Counsel Smokers in Visits without Rheumatoid Arthritis Control: An Observational Study. Journal of Clinical Rheumatology.
Summary: Though smoking increases the risk for severe rheumatoid arthritis (RA) and can reduce the effectiveness of RA treatment, rheumatologists rarely provide smoking-cessation counseling with their patients. Researchers hypothesized that, if a patient had RA under control, then their physician would try to tackle the next problem–smoking. That wasn’t the case. If a patient’s RA wasn’t under control, their rheumatologist was more likely to address their smoking. This may have been an effort to improve the patient’s RA by getting them to quit smoking. Researchers called for systematic tobacco treatment.
In Press
Baker TB, Fraser DL, Kobinsky K, Adsit R, Smith SS, Khalil L, Alaniz KM, Sullivan TE, Johnson ML, Fiore MC. Financial Incentives to Low Income Pregnant Women to Engage in Smoking Cessation Treatment: Effects on Postbirth Abstinence. Journal of Consulting and Clinical Psychology. 2017.
Burgess-Hull A, Roberts L, Piper M, Baker T. The Social Networks of Smokers Attempting to Quit: An Empirically Derived and Validated Classification. Psychology of Addictive Behaviors.
Deng S, Piper ME, McCarthy DE, Baker TB, Bolt DM. Extreme Response Style and the Measurement of Intra-Individual Variability in Affect. Multivariate Behavioral Research.
Glasheen, C, Johnson EO, Saccone NL, Lutz SM, Baker TB, McNeil DW, Marazita ML, Hokanson JE, Bierut LJ, Hancock DB. Is the Fagerström Test for Nicotine Dependence Invariant Across Secular Trends in Smoking? A Question for Cross-Birth Cohort Analysis of Nicotine Dependence. Drug and Alcohol Dependence.
Piper ME, Cook JW, Schlam TR, Jorenby DE, Smith SS, Collins LM, Mermelstein R., Fraser D, Fiore MC, Baker TB. A Randomized Controlled Trial of an Optimized Smoking Treatment Delivered in Primary Care. Annals of Behavioral Medicine.
Shirley D, Thibodeau L, Catz SL, McCoy K, Jorenby DE, Safdar N, Sosman JM. Cessation-Related Information, Motivation, and Behavioral Skills in Smokers Living with HIV. AIDS Care.
Research Presentations and Posters
Adsit R, Fiore MC. Using the Electronic Health Record to Deliver Innovative Tobacco Cessation Interventions. National Conference on Tobacco or Health. Presentation. Austin, TX. March 2017.
Berg KM, Jorenby DE, Baker TB, Fiore MC. Triple Smoking Cessation Therapy with Varenicline, Nicotine Patch and Nicotine Lozenge: A Pilot Study to Assess Tolerability. University of Wisconsin Department of Medicine Research Day. Poster. Madison, WI. June 2017.
Boyle R, Keller P, Lien R, Christiansen B. Offering Choices Engages More Smokeless Tobacco Users in a Quitline. Society for Research on Nicotine and Tobacco Annual Conference. Poster. Florence, Italy. March 2017.
Christiansen B, Carbin J, Olsen MJ, Haroldson L. A Tailored Tobacco Dependence Treatment for Those with Severe and Persistent Mental Illness. National Conference on Tobacco or Health. Poster. Austin, TX. March 2017.
Christiansen B and Hanson M. Tobacco Stories: The Role Tobacco Plays in Our Lives. 2017 NAMI Wisconsin Annual Conference. Presentation. Madison, WI.
Christiansen B. How Do We Reach and Help People of Low SES Who Smoke? 2017 Tobacco Treatment Conference: Building Capacity. Presentation. Portland, ME. May 2017.
Christiansen B. WiNTiP: Wisconsin Nicotine Treatment Integration Project. Wisconsin Tobacco Prevention and Control Program Webinar. Presentation. Madison, WI. June 2017.
Christiansen B and Hanson M. A Tailored Approach to Helping Persons with Significant Mental Illness Quit Smoking: The Bucket Approach. Wisconsin Public Psychiatry Network Teleconference. Presentation. Madison, WI. October 2017.
Christiansen B, Olsen MJ, Haroldson L, Rohr K, Hanson M, and Munger B. The “Bucket Approach”: What You Need to Know for Required State Reporting and to Treat Tobacco Dependence. 2017 Mental Health and Substance Abuse Recovery Training Conference. Presentation. Wisconsin Dells, WI. October 2017.
Fiore MC. Achieving the End Game for Tobacco Use in the United States: Policy and Clinical Strategies. Moffitt Cancer Center Grand Rounds. Presentation. Tampa, FL. January 2017.
Fiore MC. Tobacco Control in the Obama Era—Substantial Progress, Remaining Challenges. University of Perugia Medical Rounds. University of Perugia. Presentation. Perugia, Italy. March 2017.
Fiore MC. Achieving the End Game for Tobacco Use in the United States: Clinical and Policy Strategies. Great Lakes Cardiology Symposium. Presentation. Pleasant Prairie, WI. March 2017.
Fiore MC. Treating Tobacco Dependence: Evidence and Recommendations. Interagency Committee on Smoking and Health Meeting: Increasing the Impact of Evidence-Based Tobacco Treatment. Chapel Hill, NC. March 2017.
Fiore MC. Using the EHR to Facilitate Tobacco Cessation Research: Opportunities and Challenges. Seminar: The Art and Science of Promoting Tobacco Use Cessation through Electronic Health Record Technology. University of North Carolina. Chapel Hill, NC. May 2017.
Fiore MC, McNabb S. The Association Between Tobacco Control Policy Implementation at the National Level and Declines in Adult Smoking Prevalence. Society for Research on Nicotine and Tobacco Annual Conference. Poster. Florence, Italy. March 2017.
Fiore MC. A Randomized Trial to Evaluation the Impact of Incentives for Quit Line Smoking Treatment Use and Cessation in Medicaid Members. U.S. Health and Human Services Tobacco Cessation Workgroup Meeting. Washington, DC. September 2017.
Fiore MC. Nicotine Update: Treating Tobacco Use and Dependence. Wisconsin Society of Addiction Medicine 2017 Conference. Madison, WI. September 2017.
Fiore MC. Cancer Center Cessation Initiative (C3I) (P30 Supplements). NCI C3I Kick off meeting. Rockville, MD. October 2017.
Fiore MC. Update on Smoking Cessation and Vaping. UW Cardiovascular Medicine Grand Rounds. Madison, WI. December 2017.
Fraser D, Smith SS, Kobinsky K, Fiore MC, Baker TB. Modest Incentives, Offered to Adult Medicaid Members, Resulted in Greater Treatment Engagement and Biochemically Confirmed Abstinence. Society for Research on Nicotine and Tobacco Annual Conference. Presentation. Florence, Italy. March 2017.
Hollenback C, Jorenby D, Kobinsky K, Piper ME, Fiore MC. Best Practices for Tobacco Research Recruitment Using Facebook. Society for Research on Nicotine and Tobacco Annual Conference. Poster. Florence, Italy. March 2017.
Jorenby D. E-Cigarettes: The Current Science. Wisconsin Cancer Council Conference. Presentation. Madison, WI. May 2017.
Lucido BM, Schauer GL, Babb S, Schecter Anna, Adsit R, Fiore MC, Wall HK, Wright J. Million Hearts Tobacco Cessation Tools: An Intersection of Evidence-Based Interventions and Clinical Practice to Reduce Cardiovascular Disease. National Conference on Tobacco or Health. Poster. Austin, TX. March 2017.
Mundt MP, Baker TB, Fraser DL, Smith SS, Zakletskaia L, Fiore MC. Cost-Effectiveness of Financial Incentives to Medicaid Patients to Quit Smoking. Addiction Health Services Research Conference. Poster. Madison, WI. October 2017.
Mundt MP, Baker TB, Fraser DL, Smith SS, Zakletskaia L, Fiore MC. Cost-Effectiveness Analysis of the Wisconsin CMS Medicaid Quitline Incentive Program. North American Primary Care Research Group Conference. Poster. Montreal, Canada. November 2017.
Petersen A, Berg KM, Mermelstein R, Baker TB, Smith SS, Schlam TR, Piper ME, Cook JW. Who Selects Smoking Reduction Versus Quitting in Primary Care? Society for Research on Nicotine and Tobacco Annual Meeting. Poster. Florence, Italy. March 2017.
Piper ME, Cook J, Schlam T, Jorenby D, Smith SS, Fraser D, Collins L, Fiore MC, Baker T. Randomized Controlled Trial of an Optimized Smoking Cessation Intervention Delivered in Primary Care. Society for Research on Nicotine and Tobacco Annual Meeting. Poster. Florence, Italy. March 2017.
Piper ME, Cook J, Schlam T, Jorenby D, Smith SS, Fraser D, Collins L, Fiore MC, Baker T. Randomized Controlled Trial of an Optimized Smoking Cessation Intervention Delivered in Primary Care. University of Perugia. Poster. Perugia, Italy. March 2017.
Piper ME, Lanza S, Braymiller J, Russell M, Dierker L. Time-Varying Effect Modeling to Shed New Light on the Developmental Course of Nicotine Product Use in the US. Society for Research on Nicotine and Tobacco Annual Conference. Presentation. Florence, Italy. March 2017.
Piper ME. Making the Case for Intensive Tobacco Dependence Treatment Services. Symposium at the National Conference on Tobacco or Health. Presentation. Austin, TX. March 2017.
Piper ME. Addiction: Treating a Chronic Disease. An Invited Talk at the Centro Hispano. Presentation (in Spanish). Madison, WI. May 2017.
Piper ME. Treating All Smokers: An Overview of Effective Interventions and What We Know about E-Cigarettes. Wisconsin Nursing Association’s Advance Practice Registered Nurse’s Forum Pharmacology & Clinical Update. Presentation. Green Bay, WI. April 2017.
Piper ME, Cook J, Schlam T, Jorenby D, Smith SS, Fraser D, Collins L, Fiore MC, Baker T. Randomized Controlled Trial of an Optimized Smoking Cessation Intervention Delivered in Primary Care. University of Wisconsin Department of Medicine Research Day. Poster. Madison, WI. June 2017.
Prince H, Versella M, McCarthy D. Comparative Analysis of Patch, Varenicline, and Combination Nicotine Replacement Therapy Effects on Latent Abstinence and Adherence Classes. Society for Research on Nicotine and Tobacco Annual Conference. Poster. Florence, Italy. March 2017.
Rosenblum M, Cook J, Piper ME, Engle J. Motives for Smoking Among Those With PTSD, Depression, and With No Psychiatric Disorder. University of Wisconsin Department of Medicine Research Day. Poster. Madison, WI. June 2017.
Russell MA, Bekiroglu K, Lagoa CM, Lanza ST, Piper ME. Applying a Dynamical Systems Modeling Framework to Understand Intervention Processes In Adult Smokers. Symposium at the 5th Biennial Conference of the Society for Ambulatory Assessment. Presentation. Belvel, Luxembourg. June 2017.
Skora A, Dier R. Building Enthusiasm among Providers and Patients in Wisconsin’s Successful Medicaid Smoking Cessation Study. National Conference on Tobacco or Health. Poster. Austin, TX. March 2017.
New Studies
Quitting Using Intensive Treatments Study (QUITS). This study began recruiting pilot patients in fall 2017 and began full recruitment January 2018 in the Madison and Milwaukee areas. UW-CTRI is partnering with the UW Department of Medicine Cardiology Division on the study, with UW-CTRI Director of Research Dr. Tim Baker and UW Health Preventive Cardiology Director Dr. James Stein serving as principal investigators. Participants will get free medication and coaching, thanks to a $7 million four-year grant from the National Heart, Lung, and Blood (NHLBI) Institute to UW-CTRI and the UW Department of Medicine.
The study is designed to answer two key questions: 1) whether adding the nicotine patch to varenicline (Chantix) can boost quit rates; and 2) whether extending varenicline or varenicline + nicotine patch treatment for six months (rather than the standard three months) can boost quit rates. All participants will receive coaching to quit smoking.
“We expect both treatment enhancements (either adding the nicotine patch or extending treatment for 6 months) will yield higher cessation rates among people trying to quit,” said Dr. Tim Baker, UW-CTRI Research Director. “Smokers and their clinicians are calling for cessation treatment options that can substantially increase our current modest quit rates and we believe the proposed enhancements will do just that.” June 2017-May 2021, $7 million. Funded by NHLBI. Drs. Timothy Baker and James Stein, PIs.
Quit Line Study on Tobacco Disparities. Over the past five decades, overall smoking prevalence has fallen, but socioeconomic disparities in tobacco use and its burden have grown substantially. Prevention and treatment advances have disproportionately benefited more advantaged smokers. A newly-funded NCI-funded project will evaluate promising strategies to enhance quit-smoking success among low-income smokers. The project will enroll 1,408 Medicaid-eligible or uninsured smokers who have recently enrolled in the Wisconsin Tobacco Quit Line, but who report continued smoking four months after engaging in standard Quit Line services. These smokers will be invited to participate in an experiment that will evaluate the value of augmenting standard Quit Line treatment with more intensive counseling, more intensive nicotine replacement, NCI’s SmokefreeTXT text support program, and/or financial incentives for using Quit Line and SmokefreeTXT support. Analyses will examine the main and interactive effects of these four treatment components at 26 weeks, as well as other quit-smoking outcomes in this at-risk population. UW-CTRI Associate Director of Research Dr. Danielle McCarthy and UW-CTRI Director Dr. Michael Fiore will serve as Principal Investigators. August 2017-July 2022, $3 million. Funded by the National Cancer Institute of NIH. Drs. Danielle McCarthy and Michael Fiore, PIs.
Oncology and Primary Care Pilot Study. For this pilot study, researchers will conduct focus groups with smokers as well as interviews with healthcare staff in oncology settings and primary care settings. The overarching goal of the proposed research is to develop a novel intervention to increase engagement in, and access to, evidence-based smoking-cessation treatment within a clinic setting with minimal staff burden. The research will provide the necessary foundation to develop a novel intervention known as the Learn, Connect and Quit (LCQ) mobile application. Using focus groups, researchers will:
- Determine the feasibility and acceptability of using mobile technology within the clinic exam room to present treatment-engagement focused content to oncology and primary care patients.
- Identify key content and design features to maximize utilization of the mobile technology and engagement in evidence-based treatment.
- Develop pilot content and determine the acceptability and engagement with the content.
April 2017–March 2018, $25,000. Funded by University of Wisconsin Carbone Cancer Center’s (UWCCC), and the National Cancer Institute of NIH. Dr. Megan Piper, PI.
Active Studies
Disseminating and Implementing a Smoking Cessation Program for Pregnant and Postpartum Women. (Status: Enrollment complete; collecting outcome data) First Breath (FB) is a program administered by the Wisconsin Women’s Health Foundation (WWHF) to help pregnant women quit smoking. While FB is successful helping women quit during pregnancy, it is unable to provide support after a woman delivers. This is very unfortunate because about 85% of women relapse and resume smoking when they return home with their new infant. Recently, UW-CTRI partnered with WWHF on a new program, Striving to Quit (STQ), to address this gap in FB by extending the program to help the new mother stay quit after she returns home with her baby. STQ was conducted as a rigorous research study. Unknown is whether STQ will produce similarly positive outcomes when disseminated and implemented in more real-world contexts. This grant is designed to address these issues. Specifically, it will:
- Evaluate STQ in more real-world settings.
- See if STQ produces better outcomes than FB.
- Identify barriers to expanding STQ throughout Wisconsin so more pregnant women who smoke can benefit.
WWHF and UW-CTRI will continue their productive partnership for this project. In addition, four key stakeholder groups will be involved throughout the project:
- Most importantly, women enrolled in STQ will serve in focus groups that will provide candid guidance and feedback regarding smoking cessation education materials, challenges to maintaining smoke-free homes, perceptions of the intervention, unmet needs, and barriers to staying quit.
- Discussion groups with current FB Providers will identify key clinical barriers to dissemination. This will be followed by a statewide survey to all FB Providers.
- Health Educators who will deliver STQ will be observed to ensure that the program is delivered as designed. Results of interviews with these Health Educators will be used to develop statewide training materials.
- Stakeholders who set state policies and payment structures will form a “Sustainability Planning Committee” because their decisions are key to securing sustained statewide financial support of STQ.
This project aims to have a substantial impact on the greatest preventable cause of poor birth outcomes in Wisconsin. Researchers expect the findings to inform public policies regarding the need to embrace smoking-cessation programs that begin during pregnancy and extend them into the postnatal period. October 2016-March 2018. $150,000. Funded by University of Wisconsin Institute for Clinical and Translational Research (UW-ICTR). Dr. Michael Fiore, PI. Lisette Kahlil, WWHF Community Partner Lead.
Transforming the Treatment of Tobacco Use in Health Care: Seizing the Potential of the Electronic Health Record to Deliver Comprehensive Chronic Care Treatment for Smoking. (Status: Several projects ongoing) This study, funded by an R35 grant to Dr. Michael Fiore, is designed to overcome barriers to effective treatment of smokers in the primary care setting. One of the major obstacles to smoking cessation is the lack of treatment effectiveness. Researchers believe that this lack of effectiveness is largely due to two factors:
- First, most treatments delivered in the health-care setting are isolated applications of a single type of cessation treatment. Optimal chronic care for tobacco dependence requires multiple types of interventions that collectively target the different phase of quitting, are sustained over time, and are adaptive.
- A second factor contributing to the lack of treatment effectiveness is that translational science is not yet sufficiently powerful so as to make the most effective smoking interventions appropriate for, and effective in, real-world healthcare contexts.
This research is intended to address this deficit by developing and applying innovative, efficient, and powerful research methods to translate efficacious treatments into clinical use. This study will focus on the treatment effectiveness obstacle by piloting a potentially more powerful combination of two of the most effective pharmacotherapies: varenicline plus combination nicotine replacement therapy (NRT) treatment. Data from this pilot study will help inform the design of future studies that would use this combination treatment as a cessation tool within the chronic care arsenal of treatments. August 2015-July 2022. $6.1 million. Funded by NCI of NIH. Dr. Michael Fiore, PI.
Exhale Study. (Status: Retention and long-term follow-up) As the federal government considers how to regulate electronic cigarettes (e-cigs), the University of Wisconsin has been awarded a $3.7 million, 5-year grant from National Cancer Institute (NCI) and FDA to study them over the next five years. This research will provide in-depth, longitudinal information, based on real-time reports, which will address key priorities that may inform regulatory and health concerns, including understanding the relations between vaping and nicotine dependence; changes in rates of smoking conventional cigarettes; health outcomes such as evidence of exposure to carcinogens, as well as acute and long-term pulmonary health; attempts to quit smoking and the success of those attempts. Specifically, researchers will identify and follow over time 150 participants who exclusively smoke cigarettes and 250 participants who both smoke and vape. Researchers will use smart phones and other tools to collect information on patterns of use of these products, levels of addiction, withdrawal symptoms, success quitting versus relapse, lifestyle factors, carcinogen exposure, and how one group of participants compares to the other over time. This research will provide essential information to inform regulatory bodies, as well as researchers, clinicians, and tobacco users, about the patterns of real-world e-cig use and how such use is related to conventional smoking and the health risks caused by it. March 2015–February 2020, $3.7 million. Funded by NCI of NIH, and FDA. Dr. Megan Piper and Dr. Douglas Jorenby, PIs.
Breaking Addiction to Tobacco for Health (BREATHE). (Status: Recruitment complete; seeing patients) UW-CTRI has received a $12 million 5-year grant from NCI of NIH. The grant will fund research designed to test new phased-based treatments to help patients in the Milwaukee and Madison areas quit smoking. Partners in this research include colleagues from Penn State University and the University of Illinois-Chicago, as well as Aurora Health Care, Dean Health System, and Epic. Under the BREATHE project, any smoker who visits a participating clinic, regardless of the initial reason for the visit, is invited to get treatment through BREATHE. This study implements both an EHR system that increases smokers’ recruitment into treatment as well as a highly effective chronic-care treatment with intervention components for all smokers. First, the EHR system will be implemented in 18 clinics in 2 health-care systems and experimentally evaluated on its ability to increase the recruitment of smokers into chronic-care treatment (Project 1). Then, using highly efficient research methods, researchers will experimentally compare multiple intervention components and identify especially effective interventions for every phase of smoking treatment. This package of components will: increase quitting motivation amongst smokers initially unwilling to quit and prepare them for cessation (Project 2), enhance quitting success and prevent relapse when smokers are ready to quit (Project 3), and re-engage relapsed smokers in treatment and restore their abstinence (Project 4). Our highly integrated research projects will thus implement a powerful new EHR strategy to efficiently recruit primary-care patients who smoke into chronic-care treatment. BREATHE researchers will combine data from all projects and produce an optimized comprehensive chronic-care treatment for smoking that can be readily implemented in primary-care settings by project end. Thus, this research will simultaneously advance both smoking treatment and treatment research methods. June 2014-July 2019, $12 million. Funded by NCI. Michael Fiore and Tim Baker, PIs.
PTSD and Veterans Merit Award. (Status: Recruiting and seeing patients) UW-CTRI Researcher Dr. Jessica Cook has reached a major career milestone, receiving a merit award from the 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 a researcher and a study counselor. Jan. 2014-Sept. 2019, $770,500. Funded by the VA. Jessica Cook, PI.
Genetically Informed Smoking Cessation Trial. (Status: Recruiting patients) This randomized clinical trial is the first genetic study to look at nicotine replacement therapy (NRT) vs. varenicline head-to-head, and how participants with different genetics respond to the medications. Led by Li-Shiun Chen with collaboration from UW-CTRI Research Director Dr. Tim Baker and UW-CTRI Director of Clinical Services Dr. Doug Jorenby, the researchers hope to determine whether genetic markers can be used to optimize smoking cessation pharmacotherapy to enhance efficacy, medication adherence, and reduce side effects. The researchers’ recent work, which suggests that the nicotinic receptor gene CHRNA5 alters the response to NRT, has been replicated in a meta-analysis. New preliminary data suggest that CHRNA5 may be a useful marker for medication choice, because patients with CHRNA5 variant rs16969968 AA/GA genotypes may benefit from NRT and those with GG genotypes (conferring poor response to NRT) may benefit from varenicline, a medication with higher cost and use restrictions. Similarly, other genetic variation such as the nicotine metabolism gene CYP2A6 also alters response to NRT. Currently, there is insufficient evidence to support the clinical use of genotype-based smoking-cessation treatment, because these findings are based on retrospective pharmacogenetic analyses of different trials with markedly different placebo and counseling effect sizes and dissimilar designs. For clinical translation, we need head to head comparison of state-of-the-art interventions, use of key genotypes implicated by current research, and valid assessments of side effects and adherence. This study of 720 smokers uses a stratified randomization trial design based on a subject’s pertinent genotype for smoking cessation. Specifically, in Aim 1, researchers will determine if CHRNA5 genotype moderates the effect of medication (combination NRT, varenicline, vs. placebo) on abstinence. In Aim 2, researchers will determine if CHRNA5 genotype predicts medication adherence and side effects. In Aim 3, researchers will incorporate multiple genotypes and other predictors in order to develop a clinical treatment assignment algorithm for cessation success. This work could result in improved physician care of patients who smoke, overall smoking cessation success, and prevention of cancer, heart, and lung disease. Sept. 2014-July 2019, $90,000. Funded by NIH. Li-Shiun Chen, PI. Douglas Jorenby, co-PI.
Recently Completed Studies
Clinical Relevance of Stress Neuroadaptation in Tobacco Dependence. The broad goals of this research were 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 was the principal investigator, while Dr. Megan Piper of UW-CTRI was a co-investigator on this RO1 grant. It examined stress neuroadaptation in the laboratory via startle potentiation during uncertain threats among nicotine-deprived smokers versus non-deprived smokers and non-smokers. Smokers were subsequently assigned to one of three smoking-cessation treatment conditions and reported 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 prompted them to enter data. Treatment outcomes were assessed at four weeks and end of treatment. Researchers evaluated the impact of this stress neuroadaptation on smokers’ feelings, urge, and tobacco consumption during smoking-cessation treatment. They examined whether first-line pharmacotherapies could dilute the influence of this stress neuroadaptation on smoking-cessation outcomes. August 1, 2012-June 30, 2017. Funded by National Institute on Drug Abuse (NIDA) of NIH. Dr. John Curtin, PI. Dr. Tim Baker and Dr. Megan Piper, Co-I’s.
Integrating Genetics, Adverse Events, and Adherence to Improve Smoking Cessation. Using data from the Wisconsin Smokers’ Health Study, the goal of this project is to identify genetic associations to adverse events arising from pharmacological treatments for smoking cessation and examine how genetics, adverse events, and medication adherence jointly impact the efficacy of pharmacological treatments for smoking cessation. The results could lead to individually tailored treatments that decrease adverse events and increase successful cessation. April 2015-March 2017, $34,000. Funded by NIH. Robert Culverhouse, PI. Megan Piper, Co-I.
Wisconsin Smokers Health Study 2 (WSHS 2). UW-CTRI was awarded a $10-million 5-year National Heart, Lung, and Blood Institute (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. Drs. Mike Fiore, Tim Baker, and James Stein (of UW Preventive Cardiology) are the lead researchers for this grant. The original Smoker’s Health Study (WSHS), 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 recruited smokers as new study participants for WSHS 2. In addition, everyone from the previous study—whether now smoking or not—was invited 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 receives test results, such as cholesterol levels, artery scans, blood counts, and diabetes tests. These results could signal imminent trouble and save lives. The study employs 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 gets 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. However, these two treatments have never been compared head-to-head. “We’ll not only determine which works better,” Dr. 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, as well as 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 NHLBI. Dr. Tim Baker, Dr. Michael Fiore, Dr. Jim Stein, PIs.
State Medicaid Grant: Striving to Quit. Wisconsin received a five-year, $9.2 million grant from the federal CMS to help Medicaid recipients quit smoking. The project, called Striving to Quit, is designed to test the effects of incentives on engagement in smoking cessation treatment and quitting behavior among adult BadgerCare (Medicaid) members who smoke. It includes two distinct evidence-based approaches to smoking cessation. The first focuses on linking adult BadgerCare Plus members to the Wisconsin Tobacco Quit Line (WTQL) where participants receive up to five proactive coaching calls (plus additional calls initiated by the participant). The second focuses on linking adult BadgerCare Plus members who are pregnant with intensive cessation counseling and support via First Breath (FB), a smoking cessation program of the Wisconsin Women’s Health Foundation (WWHF), and additional postpartum services. Postpartum services include four home visits and five support phone calls up to 6 months after delivery. In each of the focus areas, WTQL and FB, half of the enrolled members will receive financial incentives for participating in counseling services and for quitting. The WTQL component of Striving to Quit will serve up to 2,000 members who smoke. Members can enroll via WTQL referral from participating clinics in South Central and Northeastern Wisconsin. Additionally, members who reside in participant counties (Dane, Milwaukee, Racine, Kenosha, Brown, Winnebago, Portage, Marathon, Oneida, Vilas, Oconto, Forest, Fond du Lac and La Crosse) can also call the WTQL to enroll. FB will enroll 1,250 pregnant members who smoke and live in 17 counties throughout the state. This grant offers a tremendous opportunity to improve the health of thousands of Wisconsin residents with low incomes and discover whether financial incentives increase rates of smoking cessation among BadgerCare Plus members. Sept. 2011-Sept. 2016, $9.2 million. Funded by CMS in a grant to DHS. Dr. Tim Baker, PI.
Can Smartphone Games Help Smokers Quit? (Status: Data under analysis for dissemination) 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. Sept. 2013-June 2016. The $20,000 grant from a UW-CTRI Developmental Pilot Grant was part of UW-CTRI’s NIH P50 Center Grant. The $6,000 grant is from a UW Department of Family Medicine Small Grant. Dr. Tanya Schlam, PI.
Primary Care Research Fellowship. Dr. Kristin Berg is 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 and Community Health. July 2015-June 2017. Funded by the Health Resources and Services Administration. Dr. David Rabago, PI.