David Wetter, PhD, a clinical psychologist and avid cyclist, has been trying to catch the wind for years. Some might say that's pure folly, but he is proving that research, community partnerships, and a lot of personal conviction can result in steady winds of change.
As Director of the Center for Health Outcomes and Population Equity (HOPE), part of Huntsman Cancer Institute and the University of Utah, Wetter is succeeding in helping to curtail tobacco use and its devastating downstream consequences throughout a five-state region. Most recently, Wetter represented the Center for HOPE as the recipient of the C2 Catalyst for Equity Award during the 2022 C2 Cancer Community Awards. Moreover, a bibliographic analysis recently identified his team as the fifth most-active authors in tobacco cessation research.
"I was not a great kid," said Wetter through a self-deprecating chuckle, remembering his younger self who was wholly obsessed with "every sport on the planet." That obsession won him a basketball scholarship to Whitman College in Walla Walla, Wash. But then his career direction stalled.
"I didn't go to graduate school until I was almost 30 as I struggled to figure out what to do with my life. Throughout the years, I would have to share my own story with a number of my team members who were freaking out about their high school senior who got in trouble or didn't know what they wanted to do with their life. Hopefully, they would think I turned out OK and be able to relax just a little.'"
Actually, he turned out better than OK. But more on that later.
From the Beginning
Wetter was born in 1960 "...in a teeny, tiny town called Orofino, Idaho, to an unmarried nurse from the Midwest who came to work at the state mental institution, which is about all that was in Orofino," he told Oncology Times. "Being pregnant and single in 1959 was not OK. So after I was born, I was put up for adoption and adopted by the most spectacular set of parents on the planet."
He and his parents moved about Idaho a bit and the lion's share of his youth was spent in rural communities. "In rural Idaho and most rural communities, there is a lot of tobacco use, a lot of alcohol use, a lot of addiction. It is commonplace. I grew up seeing that," Wetter recalled. In fact, his own beloved father was addicted to tobacco, developed debilitating COPD, and later pancreatic cancer. "My father tried to quit smoking at least 50 times but was just never successful."
After all, it was another world when his father was trying to kick the habit. "The context surrounding smoking was very different. In 1964, 45 percent of the population smoked, including doctors and lawyers. Smokers were at all different levels of occupation and education," he explained. "But when the Surgeon General's report came out that year linking tobacco use and smoking to lung cancer, things started to change. We began to see public health campaigns, laws prohibiting smoking in public places, workplace smoking laws, taxes on tobacco products raising the price of cigarettes-all of these were powerful influences on tobacco use."
But these changes, implemented over time, were a generation too late for his father. It was a tough realization that helped inform Wetter's path once he decided it was time to return to the halls of higher education.
Better Than OK
Wetter went on to earn a master's degree in sport psychology at the University of Oregon and a PhD in clinical psychology with an emphasis on health and addiction at the University of Wisconsin-Madison. From there, he accepted a position at the University of Texas MD Anderson Cancer Center in Houston.
He has witnessed big advancements in treatment, numerous FDA-approved drugs that can help people get off tobacco, and the now widespread availability of behavioral treatment via state "quitlines" everywhere in the country. Yet, despite the fact that the decline in tobacco use is touted as one of the great public health achievements of the 20th century, there's a dirty little footnote: the benefits of that decline were "selective-not inclusive," Wetter noted.
"We drove down the prevalence, but we didn't take care of everybody," he lamented. "We actually concentrated tobacco use into lower socioeconomic and other vulnerable populations. For example, there is very high use among people with mental health issues, people with substance abuse issues, the uninsured, and people living in poverty. So our experience with curtailing tobacco use has become the model for doing wonderful things that have some very bad, though unintended, consequences with respect to health equity. We have to become very thoughtful and purposeful in ensuring that everyone benefits."
That realization was foundational to his decision to pick up stakes from Houston and accept a position at the University of Utah and the Huntsman Cancer Institute. In a conversation with Mary C. Beckerle, PhD, CEO of Huntsman Cancer Institute, whom he had met when the university had tried to recruit him for a different position, he described his ideal job.
"I told her my dream job would be to focus on building programs of research to foster greater health equity by partnering with communities. And you know what? She actually created that position," he said, with a tone of gratitude. "So off I went to Utah with one of my Texas colleagues, Cho Lam, PhD, and we started the Center for Health Outcomes and Population Equity, or the Center for HOPE as we call it. We've just celebrated our sixth anniversary."
Tobacco Use in the Crosshairs
Describing the Center for HOPE, Wetter explained, "We are a research infrastructure with a mission to bring communities and scientists together to create long-term solutions to reduce cancer and chronic disease. In the last 3 years, we've also addressed infectious disease to help with COVID. When we first got here, we met with the Utah Department of Health and Human Services and the Association for Utah Community Health (AUCH), Utah's federally designated primary care association. We asked them about priorities they were trying to address in the state. They said, 'Tobacco use,' and we said, 'We can help you with that.'"
There were other priorities (colon cancer among them) on that initial list that the Center for HOPE addressed later on in their partnership, but understandably tobacco use was one that spoke directly to Wetter's heart.
"Tobacco is still the leading preventable cause of death and disease; approximately 25 percent of all cancers are caused by tobacco," he stated. "So we started designing interventions, programs, and implementation strategies to work with the state of Utah, AUCH, and community health centers throughout the state."
Wetter stressed the importance of community health centers throughout Utah and other states in that fundamental mandate of creating "thoughtful and purposeful" action plans.
"Community health centers are key partners in the Center for HOPE's efforts and achievements. They are the nation's safety net system because they serve people regardless of their ability to pay," he said. "Here in Utah, about two-thirds of the patients live under the poverty line, half are uninsured, half are Latino, and almost 10 percent are Native American. It's a very diverse, low-socioeconomic status population. There are 13 community health center systems and about 60 primary care clinics spread across the state, serving rural frontier populations where you typically will not have any major health care systems or players."
Because the state of Utah did not apply for a Medicaid extension, "We have a higher proportion of uninsured people and, obviously, we also have a high number of rural and frontier folks," Wetter detailed. "So community health center systems step in and are really phenomenal-and essential-partners."
The Work at HOPE
So what actually happens at the Center for HOPE? "We are doing real research," Wetter emphasized. "We are testing different kinds of strategies using multiple different types of study designs to help people get the services they need.
"For example, we have a big tobacco grant for a sequential multiple assignment randomized trial-a very specific kind of innovative study design. We are testing various strategies to connect people to the quitline because the quitline provides treatment regardless of a person's ability to pay. A person can be living in poverty, uninsured, and still get behavioral treatment, still get nicotine replacement therapy."
Wetter said the Center for HOPE is also exploiting electronic health records in the push to connect patients to needed services. "We use a strategy called Ask-Advise-Connect, which uses the EHR to make things easier for clinicians to assess a patient's tobacco use, advise their patients to quit, and directly and electronically connect them to the quitline. More specifically, the EHR prompts providers to assess for tobacco use. If a patient is positive for tobacco use, a script pops up for the clinician to read to the patient, ultimately asking if they're willing to be connected to the quitline. If the answer is yes, the clinician can simply hit a button in the EHR that will send that information to [a person on] the quitline, who will then proactively contact the patient directly.
"It does really, really important things for low-resource health systems," Wetter stressed. "The whole process-assessment, advice, and connection-can be accomplished in 30 seconds. If the patient wants to talk about it more, of course, that is great. But the bottom line is you can do it super, super fast. And it doesn't have to be done by the primary care provider. In fact, it is usually done by the person who rooms with the patient. And of great importance is the fact that it takes the burden of tobacco cessation treatment off of already-overwhelmed low-resource health care systems."
Wetter commented that the Ask-Advise-Connect strategy is an outgrowth of a behavioral economic strategy called "nudges" that earned an economist a Nobel Prize. "There's a lot that we do in the world that tries to take advantage of nudges now," he said.
He further noted it is generally known that "although 70 percent of tobacco users want to quit, when asked, 'Are you ready to quit?' only 10 percent report they are ready. Still, over half of tobacco users attempt to quit every year. Harris Health, the safety net system in the Houston area, has also employed the Ask-Advise-Connect strategy and has reported the effort increased the proportion of tobacco users going into treatment from less than half of a percent to almost 15 percent. So almost a 30-fold difference. That's huge."
Poverty Kills
Looking at the big picture of tobacco use, Wetter said true health equity will be the great equalizer when it comes to cutting smoking rates and increasing survivorship in vulnerable populations.
"In 1989, Samuel Broder, MD, then head of the National Cancer Institute (NCI), said, 'Poverty is a carcinogen,' because it is associated with almost every single kind of cancer," Wetter said. "And if you think of it from a commonsense perspective, who is the last group of people who will benefit from a new surgical technique, a new drug, a new treatment, a new public policy approach, a change in insurance payments? Who is least likely to benefit from any of those? People living in poverty, people who are uninsured, and people living in remote areas. They don't have access or transportation. They don't have anyone to pay for a colonoscopy. They don't have a nearby health care facility. Poverty affects everything from primary prevention, to screening, to diagnosis, to treatment, and right through survivorship."
And, historically, marginalized populations face a very different world in trying to take care of themselves, Wetter mentioned. "For instance, here at the University of Utah, we have a smoke-free campus. But if you go to an agricultural field or a construction site, people can smoke anytime they want," he said.
"We did a paper here that shows that low socioeconomic status individuals face a very different world in terms of smoking-conducive environments compared to people who are well-educated and in higher-level jobs," Wetter continued (Ann Behav Med 2020; doi: 10.1093/abm/kaz034). "They are constantly bombarded with cues to smoke, cigarette availability, etc. And, in addiction, cues like seeing another person smoke or having access to a cigarette can make an addict's brain light up. So it's a much more difficult world to navigate when trying to quit."
Expanding Beyond Utah
With robust community partnerships established throughout Utah, the Center for HOPE has begun to extend its reach to surrounding states.
"About a year and a half ago, Huntsman Cancer Institute expanded our catchment area to include five Mountain West States: Utah, Idaho, Montana, Wyoming, and Nevada. We did that because we are the only NCI-designated cancer center in that entire five-state mountain region," Wetter noted. "It's a big area-17 percent of the continental U.S. land mass with lots of rural and frontier populations. There are a lot of diverse populations-Native American tribes spread out across the Mountain West, concentrations of African Americans in Las Vegas, many Latinos throughout the region, etc. Many people thought we were crazy to tackle such a huge swath of the country-but I have to say I am unbelievably proud that Huntsman Cancer Institute took this on."
The Center for HOPE will again partner with state health departments, state primary care associations, and community health centers in the expanded five-state catchment area. "When we get the right partners, we have a real opportunity to move the needle," said Wetter with enthusiasm for the challenge. "We will use some of the strategies we have already created, but we will also design completely new strategies to meet specific problems and priorities that we've not encountered before. We'll do whatever it takes to address their needs."
As if the five-state region weren't large enough. Wetter said he envisions developing strategies that can effect change throughout the U.S. and beyond. "That's what research is all about. The idea is to find something that works, then get it widely disseminated, in the same way mammography is now used everywhere. Ask-Advise-Connect, for example, or e-referral as it's called generically, is already a CDC best practice for tobacco control. So absolutely our goal is to create solutions we can share across the country."
Valerie Neff Newitt is a contributing writer.