Black and White adults' perspectives on the genetics of nicotine addiction susceptibility

Genomic medicine to reduce tobacco and related disorders: Translation to precision prevention and treatment

Genomic medicine can enhance prevention and treatment. First, we propose that advances in genomics have the potential to enhance assessment of disease risk, improve prognostic predictions, and guide treatment development and application. Clinical implementation of polygenic risk scores (PRSs) has emerged as an area of active research. The pathway from genomic discovery to implementation is an iterative process. Second, we provide examples on how genomic medicine has the potential to solve problems in prevention and treatment using two examples: Lung cancer screening and evidence-based tobacco treatment are both under-utilized and great opportunities for genomic interventions. Third, we discuss the translational process for developing genomic interventions from evidence to implementation by presenting a model to evaluate genomic evidence for clinical implementation, mechanisms of genomic interventions, and patient desire for genomic interventions. Fourth, we present potential challenges in genomic interventions including a great need for evidence in all diverse populations, little evidence on treatment algorithms, challenges in accommodating a dynamic evidence base, and implementation challenges in real world clinical settings. Finally, we conclude that research to identify genomic markers that are associated with smoking cessation success and the efficacy of smoking cessation treatments is needed to empower people of all diverse ancestry. Importantly, genomic data can be used to help identify patients with elevated risk for nicotine addiction, difficulty quitting smoking, favorable response to specific pharmacotherapy, and tobacco-related health problems.

A Roadmap for conducting psychosocial research in epidemiological studies: perspectives of cohort study principal investigators

BACKGROUND

Psychosocial adversity disproportionately affects racial/ethnic and socioeconomic minorities in the USA, and therefore understanding the mechanisms through which psychosocial stress and resilience influence human health can provide meaningful insights into addressing US health disparities. Despite this promise, psychosocial factors are infrequently and unsystematically collected in the US prospective cohort studies.

METHODS

We sought to understand prospective cohort principal investigators' (PIs') attitudes regarding the importance of psychosocial influences on disease aetiology, in order to identify barriers and opportunities for greater inclusion of these domains in high-quality epidemiological research. One-hour, semi-structured qualitative interviews were conducted with 20 PIs representing 24 US prospective cohort studies funded by the National Institutes of Health (NIH), collectively capturing health data on 1.25 of every 100 American adults. A hypothesis-free, grounded theory approach was used to analyse and interpret interview data.

RESULTS

Most cohort PIs view psychosocial factors as an important research area to further our understanding of disease aetiology and agree that this research will be crucial for future public health innovations. Virtually all PIs emphasised that future psychosocial research will need to elucidate biological and behavioural mechanisms in order to be taken seriously by the epidemiological community more broadly. A lack of pertinent funding mechanisms and a lack of consensus on optimal scales and measures of psychosocial factors were identified as additional barriers to advancing psychosocial research.

CONCLUSIONS

Our interviews emphasised the need for: (1) high-quality, longitudinal studies that investigate biological mechanisms and pathways through which psychosocial factors influence health, (2) effort among epidemiological cohorts to broaden and harmonise the measures they use across cohorts, to facilitate replication of results and (3) the need for targeted funding opportunities from NIH and other grant-making institutions to study these domains.

Building towards common psychosocial measures in U.S. cohort studies: principal investigators' views regarding the role of religiosity and spirituality in human health

BACKGROUND

The goal of this study was to understand prospective cohort study Principal Investigators' (PIs') attitudes regarding the importance of religion and spirituality (R/S) on disease etiology in order to identify barriers and opportunities for greater inclusion of these domains in high-quality epidemiological research.

METHODS

One-hour, semi-structured qualitative interviews were conducted with 20 PIs, who represent 24 different National Institutes of Health (NIH)-funded prospective cohort studies in the U.S. Collectively, these PIs collect detailed health data on approximately 1.25 of every 100 adult Americans. Sample size was calculated to achieve thematic saturation.

RESULTS

The majority of PIs we interviewed viewed R/S as potentially important factors influencing disease etiology, particularly among minority communities that report higher levels of religiosity. Yet nearly all PIs interviewed felt there was not yet a compelling body of evidence elucidating R/S influences on health, and the potential mechanisms through which R/S may be operating to affect health outcomes. PIs identified 5 key areas that would need to be addressed before they would be persuaded to collect more R/S measures in their cohorts: (1) high-quality, prospective studies that include all appropriate covariates for the outcome under study; (2) studies that posit a plausible biological mechanism of effect; (3) well-validated R/S measures, collected in common across multiple cohorts; (4) the need to address bias against R/S research among investigators; and (5) NIH funding for R/S research.

CONCLUSIONS

Results of this study provide a roadmap for future R/S research investigating the impact of R/S influences on disease etiology within the context of U.S. prospective cohort studies. Identifying significant R/S influences on health could inform novel interventions to improve population health. Given the higher levels of religiosity/spirituality among minority communities, R/S research may also provide new leverage points for reducing health disparities.

The Use of the Nicotine Metabolite Ratio as a Biomarker to Personalize Smoking Cessation Treatment: Current Evidence and Future Directions

The nicotine metabolite ratio (NMR), a genetically informed biomarker of rate of nicotine metabolism, has been validated as a tool to select the optimal treatment for individual smokers, thereby improving treatment outcomes. This review summarizes the evidence supporting the development of the NMR as a biomarker of individual differences in nicotine metabolism, the relationship between the NMR and smoking behavior, the clinical utility of using the NMR to personalize treatments for smoking cessation, and the potential mechanisms that underlie the relationship between NMR and smoking cessation. We conclude with a call for additional research necessary to determine the ultimate benefits of using the NMR to personalize treatments for smoking cessation. These future directions include measurement and other methodologic considerations, disseminating this approach to at-risk subpopulations, expanding the NMR to evaluate its efficacy in predicting treatment responses to e-cigarettes and other noncigarette forms of nicotine, and implementation science including cost-effectiveness analyses.See all articles in this Special Collection Honoring Paul F. Engstrom, MD, Champion of Cancer Prevention.

Racial Differences in Smoking-related Disease Risk Perceptions Among Adults Completing Lung Cancer Screening: Follow-up Results from the ACRIN/NLST Ancillary Study

Previous work suggests that, compared to white adults, black adults have lower perceived risk for smoking-related diseases (SRDs), which may influence cessation behavior and health outcomes; however, racial differences in SRD risk perceptions among high-risk patients (i.e., a group that exhibits elevated risk for SRDs) following lung screening remain unknown. This paper thus examined differences in risk perceptions for lung cancer and other SRDs among black and white National Lung Screening Trial (NLST) participants. We administered a 10-item measure of perceived lifetime risk of lung cancer and other SRD (Smoking Risk Perceptions Scale; SRPS) to NLST participants at 1 year following lung screening to (1) establish the internal consistency of the SRPS for both black and white participants, (2) compare smoking-related disease risk perceptions between black and white participants, and (3) identify predictors of risk perceptions for black and white participants using multivariable linear regression models. We determined the SRPS items loaded onto two factors (personal and comparative risks; Cronbach's alpha = 0.93 and 0.95 for 1743 white and 194 black participants, respectively), thus demonstrating high internal consistency for both black and white adults. Compared to white participants, black adults demonstrated lower SRD risk perceptions (SRPS range = 10-50, mean difference = 2.55, SE = 0.50, p < 0.001), even after adjusting for smoking status and sociodemographics. Younger age, female gender, higher education, white race, and current smoking status were independently associated with high risk perceptions. Sociodemographic factors associated with lower risk perceptions resemble factors related to continued smoking. Findings suggest current and former black smokers are at risk of having lower risk perceptions for lung cancer and SRDs than white adults following lung cancer screening; these differences may explain observed racial differences in cessation outcomes. Although similar factors influence black and white adults' beliefs, risk perceptions may differentially impact smoking behavior among these groups. Behavior change models that guide tobacco treatment approaches, particularly for high-risk black smokers, should consider the influence of cultural factors on risk perceptions and cessation efforts.

Do Neurobiological Understandings of Smoking Influence Quitting Self-Efficacy or Treatment Intentions?

Introduction

Addiction is increasingly defined as a "brain disease" caused by changes to neurochemistry. While nicotine addiction has historically been excluded in the brain disease model of addiction (BDMA), it is beginning to be labeled a chronic brain disease. We investigated whether Australian smokers endorse brain-based explanations of smoking, and whether these beliefs are associated with quitting self-efficacy or treatment intentions.

Method

Cross-sectional study of Australian smokers (N = 1538) who completed a survey measuring their agreement with statements on the brain's role in smoking. Logistic regressions tested associations between these items and socio-demographic variables, quitting self-efficacy and intention to use cessation medications.

Results

The majority (57.9%) agreed that smoking changed brain chemistry and 34.4% agreed that smoking was a brain disease. Younger participants and those with more education were more likely to endorse brain-based understandings of smoking. Participants who agreed smoking changed brain chemistry were more likely to report an intention to use cessation medicines (OR 1.5, 95% CI = 1.0-2.2) as were those who agreed that smoking was a brain disease (OR 1.5, 95% CI = 1.1-2.1). Self-efficacy did not differ between those who agreed and disagreed that smoking changed brain chemistry. However, those who agreed that smoking was a brain disease had higher self-efficacy than those who disagreed (OR 1.7, 95% CI = 1.3-2.3).

Conclusion

A neurobiological view of smoking does not dominate public understandings of smoking in Australia. Endorsement of neurobiological explanations of smoking were associated with increased intention to use cessation aids, but were not associated with reduced self-efficacy.

Implications

Explaining tobacco dependence in neurobiological terms is unlikely to induce feelings of fatalism in relation to smoking cessation. Those who endorse biomedical explanations of smoking may be more open to using cessation pharmacotherapies. Describing smoking in terms of alterations in brain chemistry may be more acceptable to smokers than labeling smoking a "brain disease" or "brain disorder."

Patient reported outcomes and patient empowerment in clinical genetics services

Evaluation of clinical genetics services (CGS), including genetic counseling and genetic testing, has been problematic. Patient mortality and morbidity are unlikely to be directly improved by interventions offered in CGS. Patient-reported outcomes (PROs) are not routinely measured in CGS evaluation, but this may change as patient-reported outcome measures (PROMs) become a key part of how healthcare services are managed and funded across the world. However, there is no clear consensus about which PROMs are most useful for CGS evaluation. This review summarizes the published research on how PROs from CGS have been measured and how patients may benefit from using those services, with a focus on patient empowerment. Many patient benefits (PROs) identified repeatedly in the research literature can be re-interpreted within a patient empowerment framework. Other important PROs identified include family functioning, social functioning, altruism, sense of purpose, enabling development of future research and treatment/participating in research. Well-validated measures are available to capture (dimensions of) patient empowerment. Although generic measures of family functioning are available, suitable measures capturing social functioning, development of future treatments, and altruism were not identified in this review. Patient empowerment provides one useful approach to measuring PROs from CGS.

Smokers' beliefs about the tobacco control potential of "a gene for smoking": a focus group study

Background

Several genetic variations associated with nicotine dependence and lung cancer exist. Translating this knowledge into tobacco control policy relies on smokers’ perceptions of the implications of the research. This study explored smokers’ beliefs about the tobacco control uses for research examining genomics, smoking, and addiction.

Method

Smokers (N = 85) participated in one of thirteen focus groups and one interview, stratified by race (eight black, six white) and education (seven < Bachelor’s degree, seven ≥ Bachelor’s degree). Data were analyzed by two independent coders using standard analysis and validation techniques.

Results

Nearly all groups suggested using genetic information for youth-oriented tobacco prevention education. Beliefs about the effectiveness of such actions varied. Many participants believed that providing smokers personalized genetic testing results or informing them about the existence of a gene would not motivate people to quit. All smokers emphasized the need for improved smoking cessation treatment options. Using genomics research to develop gene therapies and personalized drug treatments were also mentioned, yet perceptions of such treatments were mixed. Whereas some participants viewed the possibility positively, others expressed concern about cost and access. Participants who were skeptical of the effectiveness of using genetic information for tobacco control noted that the harms of tobacco use are widely known and genetic information does not add much of a deterrent.

Conclusion

Participants generated several possible tobacco control uses for genomics research findings. Our findings suggest that tobacco control experts should consult with smokers prior to implementing tobacco control measures. The potential public health benefits of genetics and genomics research related to tobacco use cannot be realized until communication strategies that are most likely to encourage and support tobacco avoidance decisions, and minimize mistrust and backlash, are identified.

Anticipated motivation for genetic testing among smokers, nonsmokers, and former smokers: an exploratory qualitative study of decision making

OBJECTIVES

This qualitative study explores the public's interest in genetic testing related to cigarette smoking, comparing the public's motivations with researchers' intentions for this technology.

METHODS

Adult nonsmokers (n=463), former smokers (n=163), and current smokers (n=129) completed an online survey. Within a hypothetical scenario, respondents decided whether they desired genetic testing related to smoking and explained their decision making. A non-parametric Kruskal-Wallis test was used to compare the interest in genetic testing by smoking history group. Inductive content analysis was used to investigate respondents' explanations for their testing decisions.

RESULTS

Most nonsmokers (64%) and former smokers (58%) did not want genetic testing. While most current daily smokers were interested in testing (56%), most current occasional smokers were not (52%). Respondents' decision-making explanations were categorized into 3 major themes: Causality, Relevancy and Utility (e.g. personal benefits or harms). The use of causality, relevancy and utility explanations varied by smoking history. Notable perceived benefits of testing included recreation and altruism. Notable perceived harms included fear of fatalistic thoughts and concern about genetic discrimination.

CONCLUSIONS

Interest in genetic testing was highest among current daily smokers, despite potential utility in other groups. Although respondents' motivations for testing paralleled researchers' intentions of tailoring smoking cessation therapies and increasing motivation to quit or abstain, respondents also raised alternative motivations and fears that healthcare providers would need to address.

Bumps along the translational pathway: anticipating uptake of tailored smoking cessation treatment

AIM

To assess potential barriers to clinical integration of tailored smoking cessation treatment among African American and white smokers in the USA.

METHODS

A total of 392 smokers (203 white and 189 African American) identified within a national random digit dial survey (response rate: 40.1%; 81.2% among households with whom we were able to make contact) of 1200 African Americans and 1200 white Americans. Respondents answered several closed-ended survey items addressing beliefs regarding what influences a smoker's ability to quit, past pharmacotherapy use, and their willingness to undergo genetic assessment in order to be matched to optimal treatment, among other items.

RESULTS

In this first nationally representative survey of US smokers, 77% of respondents expressed willingness to undergo genetic testing in order to be matched to optimal pharmacotherapy, yet only 18% had ever used pharmacotherapy in a previous quit attempt. Smokers who rated 'medications and counseling' as very important in quitting were significantly more likely to endorse genetic testing (odds ratio [OR]: 8.94; 95% CI: 1.86-43.06), while those rating 'having God's help' as very important were significantly less likely to express willingness to undergo testing (OR: 0.11; 95% CI: 0.02-0.71). African American smokers were more likely than white smokers to express willingness to undergo genetic testing (OR: 3.80; 95% CI: 1.09-13.22), despite lower rates of previous pharmacotherapy use.

CONCLUSION

While smokers reported high rates of willingness to undergo genetic testing to be matched to optimal treatment, these results suggest that smokers' willingness to use medications indicated by genetic test results may prove a significant barrier to realizing the promise of tailored smoking cessation treatment. The role of spirituality in smokers' willingness to use medication is an area for further study.

Pharmacogenetic smoking cessation intervention in a health care setting: a pilot feasibility study

INTRODUCTION

There is increasing evidence that response to pharmacological treatment for nicotine dependence may be moderated by genetic polymorphisms. However, the feasibility, acceptability, and impact of genetically tailoring treatment in real-world clinical settings are unknown.

METHODS

We conducted a multiphased, mixed-methods feasibility study with current smokers to develop and evaluate a patient-centered, theoretically grounded personalized medicine treatment protocol. The initial research phase included formative work to develop intervention materials. The second phase included a randomized pilot trial to evaluate the intervention. Trial participants (n = 36) were genotyped for ANKK1 rs1800497 and were randomized to receive genetic feedback (GF) plus standard behavioral counseling (BC) for smoking cessation or BC without GF. All participants received genetically tailored pharmacotherapy (nicotine patch or bupropion).

RESULTS

The intervention was feasible to implement and was acceptable to participants based on satisfaction ratings and objective measures of participation. There was no evidence that the GF resulted in adverse psychological outcomes (e.g., depression, fatalism, reduced perceived control over quitting, differential motivation for quitting) based on quantitative or qualitative outcomes.

CONCLUSIONS

Study results suggest that it is feasible to offer treatment within a health care setting that includes genetically tailored pharmacotherapy and doing so had no apparent adverse psychological impacts. Further evaluation of pharmacogenetically tailored smoking cessation interventions appears warranted.