Redefining Tobacco Cessation and Mental Health Care: Inside BHERG’s Mission to Break the Cycle

Director of Training and Mentoring and Senior Psychologist, Sandra Japuntich, PhD, LP, and Senior Psychologist and Director of the Hennepin Healthcare Tobacco Dependence Clinic, Drew Busch, PhD, LP, both have Minnesota roots. However, they met on the other side of the country during their respective clinical internships at Brown University in Providence, Rhode Island. It is indeed a small world after all.

Dr. Drew Busch

Dr. Sandra Japuntich

Family, career opportunities, and their shared friendship brought them back to Minnesota and to Hennepin Healthcare Research Institute, where they formed the Behavioral Health Equity Research Group (BHERG). Dr. Busch and Dr. Japuntich operate as co-directors of BHERG.

The mission of BHERG “is to use behavioral treatments or behavioral interventions to improve health among those who have been disproportionately affected or who have problems accessing care. [Our list of research] values include justice, community, [and growth],” said Dr. Japuntich.

BHERG advances behavioral health by designing clinical trials with a strong focus on increasing access to behavioral health treatments through modalities, care pathways, and settings that increase accessibility for underserved populations. Poor mental health can affect a person’s ability to make healthy choices for themselves, like avoiding tobacco and taking prescribed medications, causing them to experience illness and death earlier than their peers.

The Connection Between Tobacco Use and Mental Health

Currently, the biggest disparity they are addressing is cigarette smoking. Dr. Busch and Dr. Japuntich collaborate as investigators on a number of different smoking cessation studies.

Dr. Busch elaborated, “It’s kind of all tied up in mental health. People with mental illness are more likely to use and smoke at a higher rate than people without mental illness and have a harder time quitting.”

Dr. Busch continued, “A lot of people report that smoking or tobacco use is a tool to get them through stressful moments or to manage their mental health. However, daily smoking becomes a negatively reinforcing process where you’re just trying to avoid feeling bad. They are in withdrawal, and then they smoke and they do feel better in the moment, but then there’s another stressful feeling and craving to smoke half an hour later. So, the pattern of that quick fix, it kind of defines addiction.”

Ongoing Tobacco Cessation Studies

Ongoing BHERG cessation studies include Personal Assistant for Smoking Cessation with Artificial Intelligence and Large Language Models (PASCAL): Culturally Tailored Conversational Agent for Quitting Smoking, Smoking Cessation Outreach for Equity (SCORE), Effectiveness of Nicotine Replacement Therapy Sampling in Dental Practices (FreSH), and the Post-Acute Cardiac Event Smoking (PACES) Study.

Dr. Japuntich explained. “I study cigarette smoking. Smoking is the leading cause of preventable death worldwide. [With smoking], I measure tobacco use in two ways: a combination of self-report via surveys, and then I biochemically verify tobacco use [with] an expired breath carbon monoxide measurement or a saliva cotinine measurement. Cotinine is a byproduct of nicotine.”

The ongoing cessation studies are having real-world effects on patients. In the SCORE study, Dr. Japuntich, Principal Investigator (PI) and Dr. Busch, Co-Investigator, are exploring how to improve smoking outcomes for people of color. The study’s primary outcome is long-term abstinence from combustible tobacco products. As part of SCORE, they are using the framework of “Ask, Advise, Connect.” As part of this framework, they are asking patients if they want to quit smoking, advising them on how, and then sending them a direct referral to the state’s quit smoking line through electronic health record (EHR) systems. In addition, half of the patients receive care coordination from a care coordinator in English and in Spanish. They are testing the additional effect of the care coordination over and above Ask-Advise-Connect.

In addition to the SCORE study, Dr. Japuntich is serving as the PI on the FreSH study. The FreSH study explores whether providing free samples of nicotine replacement therapy at dental appointments will increase quit attempts and long-term abstinence from smoking.

Dr. Japuntich expounded further, “The FreSH study is unique in that it’s conducted in the National Dental Practice-Based Research Network, which is a network across the United States. Recruiting patients into the studies are researchers, actual dentists in really small communities. Our study is tackling the problem that dentists are not as good as primary care providers at providing treatment for tobacco use, even though tobacco use is a leading cause of oral health problems, [such as] oral cancer.”

The study recently concluded with results for both the Midwest and the Northeast. The results found that people who received nicotine replacement therapy samples made more quit attempts than those who did not receive the free samples, and they were more likely to quit in the first month upon receiving the free samples. However, the results were not sustained at six months. This is in contrast to a study in primary care settings, where the effects were sustained in the long term, so researchers are still investigating these differences.

The Future of BHERG

What’s next on the horizon for BHERG? Dr. Japuntich and Dr. Busch are both gearing up for the Center for Chronic Disease Reduction and Engagement Across Minnesota (C2DREAM) grant renewal. They have projects under review for a new center focusing on smoking, alcohol, and cardiovascular disease management. Dr. Japuntich is hopeful about expanding the FreSH study based on the feedback from dentists and dental practices and expanding the PASCAL app.