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A decade of tobacco research and intervention
Setting the Standard
By Lisa Brunette
In the beginning, it was nicotine gum for "a bad habit."
Back in 1992, when the Center for Tobacco Research and Intervention (CTRI) got its start at University of Wisconsin Medical School, the medical case against tobacco was very well established. Virtually no one except those on the payroll of tobacco interests questioned smoking's role in promoting lung cancer, and evidence of its damage to other body systems seemed to accumulate almost daily. The Surgeon General's initial report on smoking was nearly 30 years old, health warnings on cigarette packs had been in place for decades, and TV ads for cigarettes had vanished twenty years earlier.
But in 1992, more than 48 million American adults still smoked. And most had an extremely hard time quitting, even when their motivation was strong. Except for gum, which had been approved by the U. S. Food and Drug Administration (FDA) in 1984, there was little in the way of resources to offer smokers who wanted to quit. Similarly, there were virtually no scientific data on the kinds of approaches that could boost success rates.
"Ten years ago, smoking was still viewed as a 'bad habit,'" recalls Michael Fiore, MD, MPH, the UW Medical School professor of medicine who founded CTRI. "Now we recognize tobacco use as a chronic disease that can be effectively treated. Today, we have five treatments approved by the FDA for smoking cessation: gum, the patch, nicotine nasal spray, the nicotine inhaler and bupropion."
And CTRI, which began its life tucked away in a hard-to-find corner on the seventh floor of the Medical Sciences Center, has become a major international player in tobacco control. In the space of just a decade, Fiore and his colleagues have quietly built the center from a small organization to an internationally recognized research, education and policy powerhouse. Its operating budget has grown from less than $500,000 annually to more than $6 million, with a good share of the funds coming from federal and state agencies. It now has its own suite of offices on Monroe St., just off campus, and a staff numbering more than 70. Most important, CTRI's work has changed how health professionals think about and treat their patients' tobacco use.
 Research is the foundation
Even before CTRI was established, Fiore and key members of the team--associate director Tim Baker, PhD, and clinical services director Douglas Jorenby, PhD--were committed to tobacco research. Their early work together focused on clinical trials of the nicotine patch as well as various counseling approaches to help smokers. All three had been--and still are--involved in the UW Smoking Cessation and Prevention Clinic at UW and they understood firsthand that new, evidence-based treatments were desperately needed.
But the battle has always been about more than individual smokers. Tobacco control specialists have long recognized that any effective fight against smoking must involve health care systems as well. In 1997, The Robert Wood Johnson Foundation chose CTRI as a National Program Office to award grants to health systems and academic institutions in order to evaluate how managed-care organizations could integrate effective tobacco cessation policies and treatments with their health plans. In Wisconsin, for example, CTRI leaders led by Marguerite Burns, MA, worked with the state to extend smoking-cessation treatment coverage to all state employees.
The major turning point in CTRI's research history, however, came in 1999 when it was chosen as one of seven academic centers nationwide to receive a five-year, $10 million grant from the National Cancer Institute. The grant designated CTRI as a Transdisciplinary Tobacco Use Research Center focusing on relapse, one of the most powerful and least-understood obstacles to smokers struggling to stay off tobacco.
Baker, who is also a UW-Madison professor of psychology, guides the three large clinical trials now being conducted under the NCI grant. One aims to create a better measure of tobacco dependence; another traces "the path to relapse" by having study participants record their symptoms and behavior on hand-held computers; and the third assesses whether adding a home-based, tailored computer program to standard treatment will improve long-term abstinence rates.
"Our work shows that tobacco dependence and withdrawal are multidimensional, with tremendous individual variation," says Baker. "We need to understand the various indications of dependence and withdrawal among those trying to quit if we are to prevent relapse to smoking."
Creating national guidelines
Soon after CTRI was created, Fiore was asked to chair a national panel of experts charged with developing evidence-based treatment guidelines for tobacco users. The first U. S. Public Health Service treatment guideline on tobacco use was published in 1996 and its updated counterpart in 2000, both under Fiore's direction and with major involvement by all CTRI staff.
Not long into the process of creating the first guideline, Fiore's national stature in tobacco control took another major step forward. In a commentary in the Journal of the American Medical Association (JAMA), he proposed that clinicians ask every patient at every visit if the patient is a smoker and offer help if the smoker is ready to quit. He argued that such a practice would not only help identify smokers and open the door to a quit attempt, but that failing to raise the issue sent a message that perhaps the healthcare provider did not view smoking as a serious risk to health.
"In the early '90s, I felt we needed to do something significant--even a little dramatic--if we were to get clinicians to pay more attention to tobacco use," Fiore recalls. "As I thought about this challenge, it hit me: half of all smokers will die if they don't quit. If that doesn't warrant designating a 'vital sign,' then what does? Thank goodness JAMA agreed!"
While working diligently to get clinicians to ask routinely about smoking, Fiore's team published findings in 1996 showing that such routine queries doubled the rate of interventions with smokers.
 Promoting the best practices: education and outreach
1999 was a turning point for CTRI in another way as well. That year, the Wisconsin Tobacco Control Board was formed with funds from Wisconsin's share of the master settlement agreement with the tobacco companies. The board set a goal to reduce tobacco use in Wisconsin by 20 percent by 2005. As a partner with the board, CTRI hired six outreach specialists to help clinicians throughout the state learn and adopt the best practices available to reduce patients' tobacco use. From Rhinelander and Eau Claire in northern Wisconsin to Madison and Milwaukee in the south, the outreach group has worked with more than 5,000 healthcare providers in the state thus far.
Two years later, CTRI launched the Wisconsin Tobacco Quit Line, a free telephone counseling service that offers customized help in smoking cessation. The Quit Line logged 18,500 calls in its first eight months of operation, exceeding even the most optimistic projections.
These efforts have been complemented by a partnership with the Wisconsin Women's Health Foundation. The goals are to promote tobacco cessation among women and girls; initiate a "mini-grants" program sponsoring innovative research by local organizations in the state; and conduct the first in-depth survey of behavior, attitudes and perceptions about tobacco use among Wisconsin residents.
As part of the Medical School, CTRI is in a unique position to influence the training of future physicians who will advise and treat tomorrow's smokers. Eight years ago, CTRI recommended smoking-cessation curricula for medical schools, and this year, the clinical elective "Treating Tobacco Use and Dependence" was offered at UW for fourth-year med students. Richard Brown, MD, MPH, who teaches the course, lauds Fiore and Jorenby for their contributions.
"Dr. Fiore is at the forefront of research to enhance the effectiveness of smoking cessation," Brown says. "He is truly a national treasure located right here in Madison."
Keeping the goal in mind
The list of accomplishments, milestones, publications, honors and awards for CTRI in its first decade would easily fill a tome. The staff is now large and diverse enough that CTRI publishes a simple internal newsletter to keep everyone up to date on developments. Fiore's own schedule is intense, especially because he maintains a day-a-week clinical practice in internal medicine. He points ruefully to a growing stack of medical journals in his office and laments that he needs to catch up on his reading. Still, despite all of CTRI's successes, it remains critical to him to remember why it is all being done.
"It's important that we not lose sight of the smokers," he says quietly. "These people have been vilified for so long. We are finally finding ways to help them get free of this addiction they have."
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