Smokers’ beliefs about the tobacco control potential of “a gene for smoking”: a focus group study

Extensive research has examined the association of genetic variants with a variety of tobacco use outcomes, including susceptibility to nicotine addiction, smoking-related diseases, and responsiveness to pharmacological smoking cessation aides [1, 2]. The goal of many of the studies is to use research findings to develop biomedical and behavioral interventions that reduce tobacco morbidity and mortality.

The potential utility of using personal genetic testing to motivate smoking cessation has been debated for several years [3‐5]. Early debates have been supplemented by a growing body of research, including meta-analyses and systematic reviews, that suggest that providing smokers with personalized test results for high-risk genetic variants may have limited effectiveness in encouraging cessation [6‐8].

Tailoring smoking cessation therapies according to genotype rather than providing general information about smoking risks may be a viable alternative; smokers and physicians report interest in using genetic testing for this purpose, despite several remaining barriers (e.g., perceived unimportance of medications among some smokers, physicians’ concerns about the ability to counsel patients effectively) [9, 10]. However, research examining the efficacy of tailoring smoking cessation therapies by genotype is nascent. To date there is only one published randomized controlled trial that examined the effects of tailoring nicotine replacement therapy (NRT) dose by genotype [11]. It reported that tailoring NRT dose by genotype resulted in higher 6-month abstinence than tailoring dose by phenotype. A follow-up study reported that participants who received more intensive NRT were more successful quitting, but it did not indicate whether NRT dosage or duration mediated the effect of genetic tailoring on cessation [12]. The paucity of data means that several years will pass before adequate efficacy data are published and tailored smoking cessation interventions are widely used. Thus, alternative uses for tobacco-related genomic research should be identified.

Another complication is that people with limited access to healthcare almost certainly will have limited access to genomics technologies. This raises the possibility that translating genomic technologies from bench to bedside might inadvertently worsen existing cancer disparities [13] by virtue of being unavailable to underserved populations. For example, if smokers cannot afford the genotyping needed for individualized cessation therapies, they may be less likely to quit and therefore at increased risk of morbidity and mortality. Thus, the only exposure to genomic information for smokers with limited access to healthcare may be via media outlets and social networks [14].

This paper explores smokers’ beliefs about the potential for genomics research to inform effective tobacco control policies and programs. We solicited smokers’ ideas because the translation of research from basic genomics to policy implementation requires the involvement of key stakeholders [15, 16]. Lack of involvement can impair an intervention’s effectiveness by ignoring critical factors that might otherwise impede implementation. The data presented are a subset of data collected for a study aimed at understanding smokers’ opinions about the discovery of a genetic variation associated with increased risk of severe nicotine addiction and lung cancer [1]. We examined possible differences in beliefs according to race and educational attainment because these variables are strongly related to smoking prevalence and cessation success [17]. This study focused on understanding the dissemination of genomics research findings via mass media rather than through clinics based on the premise that access to clinical genetic testing will likely be limited for many individuals.

Study participants discussed multiple uses for information about the genetic basis for nicotine addiction and lung cancer, despite widespread skepticism about the validity of the research itself. These uses included encouraging smoking cessation and discouraging smoking initiation by providing people with their personal genetic test results, implementing mass media or other health education campaigns, and developing novel biomedical therapeutics.

The perceived effectiveness of the tobacco control strategies varied. Consistent with other research [22], biomedical therapies were seen as potentially highly effective, yet expensive. These concerns were reasonable; adolescent primary care providers reported less willingness to offer testing for genetic variations associated with nicotine addiction if patients had no health insurance [23]. In contrast, beliefs about the potential effectiveness of genomics-based health education were mixed. Some participants thought that providing personalized genomic test results—or even informing people of the discovery of the genetic variant—might encourage some smokers to make a quit attempt and possibly discourage some young people from starting to smoke. Others were more skeptical, explaining that the overwhelming majority of smokers know that smoking harms health and know that they should quit. These findings are consistent with other research, [24‐26] although [24] did not report that participants were skeptical about the ability of the information to motivate cessation. Participants who were more open to the potential ability of genetic testing to motivate cessation may have had a stronger focus on personal agency than those who were more skeptical. This is consistent with research indicating that quitting self-efficacy is important for cessation success [27]. Nevertheless, this specific finding needs to be replicated because the relevant focus group data were relatively sparse. Concerns about potential discrimination as a result of testing were also raised in a way similar to prior research (forthcoming manuscript) [22, 26, 28].

Prior studies examined the feasibility and effectiveness of using personalized genetic testing to encourage smoking cessation [10, 22, 24, 25]. We extend this research by examining opinions about a broader array of possible tobacco control measures, including approaches not requiring medical testing (i.e., mass media dissemination). However, formal mass media campaigns may have limited effectiveness, and may not communicate this type of information effectively [28].

Another novel finding is that skepticism about the effectiveness of genetic-based prevention efforts may stem from the belief that, thanks to current tobacco control efforts, people think they already understand smoking risks. In that context, the incremental threat of providing genetic information is insufficient to motivate change. However, although smokers know that smoking is “bad for them” in a general way, they are likely unaware of the extent to which tobacco use harms the entire body [17, 29]. Emphasizing lesser-known consequences of smoking in conjunction with genetic counseling might be beneficial. Paying special attention to appearance-based consequences in campaigns oriented towards younger smokers might increase the relevance for that important subgroup [30]. One reason the information may be insufficiently motivating is because genetic information may be less emotionally impactful than the graphic and visceral images and stories included in many smoking prevention and cessation campaigns, such as the Tips from Former Smokers campaign sponsored by the U.S. Centers for Disease Control (http://​www.​cdc.​gov/​tobacco/​campaign/​tips/​).

This paper advances the effective translation of basic genomics research into tobacco control interventions, programs, and policies by beginning to understand the perspectives of current cigarette smokers, a key stakeholder group. We found that, for reasons discussed previously, broad mass media-based dissemination associating nicotine addiction and lung cancer with certain genetic variants is unlikely to motivate large numbers of smokers to quit, or to discourage young people from starting. Interpersonal-based dissemination of the information incorporated into school-based tobacco prevention might be effective for some students, but is likely to be met with considerable skepticism and may backfire.

Despite research indicating that personalized genetic testing is ineffective in promoting cessation [6], it might be more effective for a subset of the population. However, this subset needs to be identified and characterized. The effectiveness of genetic testing would likely be maximized if testing is used to target specific biomedical therapies to specific individuals, rather than simply informing patients that they “have the gene.” However, populations with the highest use of tobacco and/or the most difficulty quitting are medically underserved [17]. Unless the genetic testing process and accompanying therapies are inexpensive and easily accessible to medically underserved populations, individuals at highest risk of tobacco-related morbidity and mortality may be those for whom beneficial therapies are inaccessible. This raises the possibility of genetic testing inadvertently exacerbating existing tobacco-related health disparities.

These findings also highlight the fact that genomic risk information does not exist in a vacuum. Rather, it exists in a living context that allows people to reject both the information (see also [32]) and its potential uses. This context is informed by a multitude of factors including, but certainly not limited to, preexisting knowledge about the topic, prior personal experiences, and attitudes about the healthcare system, economics, human development, and in some cases the importance of personal agency for action. Complicating matters further is that these factors are steeped in emotion, as suggested by the statements illustrating the “We Know” theme. Attempting to communicate genomic risk information without attending to at least some of these factors is unlikely to achieve widespread success [33, 34]. This may be especially true for tobacco use, which is highly addictive and has been the subject of health education campaigns for the last 50 years [17].