Gene-based risk test for lung cancer risk motivates
smoking cessation in randomly selected smokers.
Raewyn J Hopkins BN, MPH1, Robert P Young, MD, PhD1,2, Bryan Hay, BSc1,
Greg D Gamble, MSc1. 1Department of Medicine and Biological Sciences,
University of Auckland, Synergenz Biosciences Ltd, PO Box 37-971,
Auckland, NZ
Dr Robert Young
BMedSc, MBChB, DPhil, FRACP, FRCP
Associate Professor of Medicine and Molecular Genetics
Department of Medicine, University of Auckland, Auckland, New Zealand
Which do you respond to?
Speed
Limit
Speed
Camera
2
Which do you respond to?
“Public Health Approach”
•Non-personalised
•Health warning
•Recommendation
Speed
Limit
“What people read and
ignore”
“Personalised Approach”
Speed
Camera
3
?
Danger and fear
changes risky
behaviour
•Smoker specific risk
•Personal engagement
•Outcome specific
“What people are told
and what will happen
if they don’t act”
Which do you respond to?
“Public Health Approach”
•Non-personalised
•Health warning
•Recommendation
Speed
Limit
“What people read and
ignore”
“Personalised Approach”
•Smoker specific risk
•Personal engagement
•Outcome specific
Speed
Camera
4
“What people are told
and what will happen
if they don’t listen”
Lung cancer risk test
Respiragene test - motivational tension and quitting
TM
•Personalised tests of risk - change behaviour by
increasing motivational tension (fear)
•Respiragene is a gene based personalised test of lung
cancer susceptibility
•Respiragene is a test to engage smokers in the risks of
smoking and a trigger to quitting
•Respiragene does not de-motivate smokers and
reminds them all that they are at risk of lung cancer
5
Smoking cessation rate following
treatment or event
70
•Most smokers quit using cold turkey
•For older smokers, future poor health
is the most cited reason for quitting
60
50
% quit
Smoking cessation: triggers
•Developing lung cancer and COPD
are the most feared complications
40
30
•Most smokers continue to smoke on
the basis the benefits outweigh the
harms
20
10
Un
as
si
st
ed
Ad
vic
e
N
Bu R T
pr
Va opi
re on
ni
cli
ne
CO
He
C
PD
ad T
/N no
ec d u
l
k
ca e
He
n
ar cer
t
Lu a tta
ng
ck
ca
nc
er
0
Treatment or event
Nothing
Treatment
•Most smokers overestimate the
general risk of lung cancer but
underestimate their own risk (below
average risk = optimistic bias)
•Smokers quit when the motivational
tension favour quitting (trigger)
Events
Young RP, et al. 2009 (PMJ)
The main thrust of this paper is that smokers are looking for better
reasons to quit than just non-personalised public health messages
Smokers are motivated to quit by triggers that raise motivational tension
and that these triggers include tests indicating future ill health.
Genetic risk of lung cancer and quitting
Smoking cessation in usual care
vs genetic testing groups
Usual care
Genetic testing
30
Smokers who underwent
genetic testing (blue bars) in
a randomized trial had higher
quit rates than those in a
smoking cessation
programme alone (yellow
bars)
25
20
%
Genetic testing for risk of lung
cancer helps to personalize
the risk from continued
smoking
15
10
5
A
T
IT
s
ab
C
on
on
C
1
yr
ab
s
A
T
IT
yr
1
s
on
th
m
6
6
m
on
th
s
A
T
IT
0
Smoking cessation rates
McBride,C.M., et al: Incorporating genetic susceptibility feedback into a smoking cessation
program for African-American smokers with low income. Cancer Epidemiol Biomarkers
Prev.2002, 11:521-528
Personalising the risks of
smoking helps people choose
healthier lifestyle options (eg
quitting smoking and
preventing relapse)
8
Smoking cessation rate following
treatment or event
70
60
Genetic testing for lung cancer risk
% quit
50
•Most smokers quit using cold turkey
•For older smokers, future poor
health is the most cited reason for
quitting
•Developing lung cancer and COPD
are the most feared complications
40
30
20
•Most smokers continue to smoke
on the basis the benefits outweigh
the harms
10
Un
as
si
st
ed
Ad
vic
e
N
Bu R T
pr
Va opi
re on
ni
cli
ne
CO
He
C
PD
ad T
/N no
ec d u
l
k
ca e
He
n
ar cer
t
Lu a tta
ng
ck
ca
nc
er
0
Treatment or event
Nothing
Smoking cessation
Treatment
Events
•Most smokers overestimate the
general risk of lung cancer but
underestimate their own risk (below
average risk = optimistic bias)
•Smokers quit when the motivational
tension favour quitting (trigger)
3Ts – Robert West- How fear triggers quitting
BMJ 2006; 332:458-460
Tension = motivational tension is the level of fear and anxiety
a smoker experiences that arises from the combined feeling from beliefs,
past experiences and the balance of benefit over harms from continued
smoking.
Trigger = “events” that alter the motivational tension to a point a smoker
acts on their fears and initiates a quit attempt.
Treatment = the provision of smoking cessation services such as
pharmacotherapy, counselling or referral to a specialised smoking
cessation service
10
Smoking cessation: Tension
Tension
Trigger
Treatment
Smoker = Benefits outweigh the harms
Motivational tension low
•fear/anxiety about smoking
•promotes quitting
Optimistic bias high
•denial about smoking risks
•promotes smoking
Smoker
11
West R et al. BMJ 2006; 332: 458-60
Smoking cessation: the 3 Ts
Tension
Trigger
Treatment
Quitter = Harms outweigh the benefits Tip the balance
to achieve quitting
Optimistic bias low
•denial about smoking risks
•promotes smoking
Motivational tension high
•fear/anxiety about smoking
•promotes quitting
Personalised test of vulnerability
ie. Respiragene Test
Ex-smoker
12
Trigger = “Teachable moment”
“Fear is a powerful motivator” but it must be personalised
Lung cancer Risk Test - Respiragene
Tool of engagement
Smoker’s feedback
•Smokers wanted information that caught
their attention
Risk Level
200x
•Current public health campaigns are not
engaging
• Smokers don’t read packet warnings
20x
•TV adds reminded smokers to light up
•Smokers want information personally
relevant (and honest) not “a lecture”
Score
No smoker is lower than “moderate” (elevated) risk
for lung cancer vs non smokers
Test to engage, educate and empower smokers
Lung cancer susceptibility score
•All smokers at some risk for lung cancer
above that of non-smokers
Risk Level
•Factors increasing that risk
•Increasing age
•Family history
•COPD (smoker’s lung)
•“Bad genes”
200x
20x
•Shows risk reduction with quitting
Score
No smoker is lower than “moderate” (elevated) risk
for lung cancer vs nonsmokers
•Educational tool to promote behaviour
change (quitting)
Respiragene test and smoking cessation –
feasibility study in smokers not seeking quit support
• Identified and randomly recruited current smokers over
40 yo.
• Telephone survey to assess smoking habits and
attitudes to quitting
• Offered genetic test (optional), arranged testing (V1)
and then gave results + info (V2)
• Telephone survey to assess smoking habits and
attitudes to quitting at 6 months after testing.
Changes in smoking before and after genetic testing
6 months before testing
(n=38 smokers)
6 months after testing
(n=38 smokers)
Quit
12 Quit
2 6 4
Abstained 3+ days 1
11 Abstained 3+ days
4 5
Abstained 1-2 days 1
3
Abstained 1-2 days
4
Abstained up to 1 day
5
Have cut down cigs/day
3
No change in smoking
2
Abstained up to 1 day 5
2
Have cut down cigs/day 11
3
No change in smoking 10
N=38
2
P<0.05
N=38
After genetic testing changes in smoking;
32 (84%) greater abstinence (blue) vs 3 (8%) less abstinence (red)
(3 unchanged (orange)
Changes in smoking before and after genetic testing
6 months before testing
(n=38 smokers)
6 months after testing
(n=38 smokers)
32% Quit rate
at 6months
Quit
12 Quit
2 6 4
Abstained 3+ days 1
11 Abstained 3+ days
4 5
Abstained 1-2 days 1
3
Abstained 1-2 days
4
Abstained up to 1 day
5
Have cut down cigs/day
3
No change in smoking
2
Abstained up to 1 day 5
2
Have cut down cigs/day 11
3
No change in smoking 10
N=38
2
P<0.05
N=38
After genetic testing changes in smoking;
32 (84%) greater abstinence (blue) vs 3 (8%) less abstinence (red)
(3 unchanged (orange)
Daily cigarette consumption pre- and post genetic testing
6 months after testing
(n=38 smokers)
6 months before testing
(n=38 smokers)
Quit
5
0
12
Quit
6
5 cigs/day
11
10 cigs/day
3
15 cigs/day
5
20 cigs/day
6
5 cigs/day
0
10 cigs/day
9
2
3
3
2
82% reduced
cigarette consumption
6
15 cigs/day
2
20 cigs/day
12
25 cigs/day
0
1
25 cigs/day
30+ cigs/day
2
0
30+ cigs/day
* diagnosed Prostate
3
3
P<0.05
*
cancer after testing)
After genetic testing changes in cigs/day;
12 (32%) Quit smoking, 12 (32%) halved consumption, overall 82% decreased cigs/day (blue),
while 6 (16%) unchanged (orange) and 1 (2%) increased (red) consumption *
Respiragene Test results in smokers
•
•
•
•
84% accepted offer of Respiragene testing
96% stated helpful in motivating quitting
32% quit at 6 months
a further 32% had decreased cigarette
consumption (82% decrease in smoking overall)
• 63% had purchased NRT as part of their effort to
quit
• 8% appeared “demotivated” by testing
D
Ask
Brief advice
Use tests of risk or organ damage
to engage smokers
and “personalise” advice
Cessation
Do testing
Spirometry to assess lung age
(sign of generalised susceptibility
to cardiopulmonary complications)
Take Respiragene Test for lung cancer
risk score
Cost: $150 or $75 via GP
Smoker taking the Respiragene Test: feedback
Female, 61 yo, 20 cigs/day for 46 years with no previous quit attempts, June 2010.
She says…
“We are talking about an addiction here, one of the strongest known to mankind and
perpetuated for years and years by the Tobacco companies as safe and glamorous.
When I took the Respiragene Test I was a long term smoker and I was horrified at the results
and it made me more determined to quit so I cannot see where people think this is a test to
give a ‘green light’ for smoking. There is no level of cigarette smoking that is good for you.
The test itself is very easy and quick but the results are really shocking and certainly affected
me in a positive way to quit. I have been smoke free for 6 months now and intend never to
pick up another cigarette for the rest of my life and in fact have no desire to do so.
This test should be mandatory to anyone who smokes and is admitted to hospital for any
reason or made available to General Practitioners for use with patients who smoke. It’s a
way to see what is happening inside your body and to prevent more damage”.
Respiratory Genetics Group
University of Auckland, New Zealand
Respiratory Genetics Team
University of Auckland, New Zealand
Robert Young DPhil, FRACP
Raewyn Hopkins BN, MPH
Greg Gamble MSc
Bryan Hay BSc
Chris Whittington MSc
Synergenz BioScience Ltd
www.Respiragene.com (US) or
www.Synergenz.com (non-US)
Collaborators
Dr Kyle Hogarth - University of Chicago
Dr John Field – University of Liverpool
Dr Javier Zulueta – University of Navarra
NZ Collaborators
Mike Epton MD FRACP
Peter Black FRACP
Tim Christmas MD FRACP
Which do you respond to?
“Public Health Approach”
•Non-personalised
•Health warning
•Recommendation
Speed
Limit
“What people read and
ignore”
“Personalised Approach”
Speed
Camera
25
SMOKING WILL
KILL YOU
•Smoker specific risk
•Personal engagement
•Outcome specific
“What people are told
and what will happen
if they don’t listen”
Engaging smokers in smoking cessation: role of Respiragene
Ask
Advise
Assess*
Assist
Relevance *
Respiragene testing…….
Risks *
Rewards *
•increase motivation in
favour of quitting
• facilitates follow-up visit for
a consultation focussed
on……
- Respiragene result, and
- cessation options
Reminder of result on
subsequent visits
Roadblocks
5As and 5Rs
Arrange *
Respiragene testing…….
• to engage smokers
in smoking cessation
•assess risk of lung cancer
and benefits of quitting
*
Repetition *
Update of risk according to
spirometry
Smokers response to Respiragene testing
Smokers want a reason to quit and help with
quitting
• Over 80% said they would take a test assessing risk of
lung cancer if offered.
• 6 months after testing with the lung cancer test
– 48% used smoking cessation products
– 32% quit – same proportion from all 3 risk groups
– 28% halved their cigarette consumption
– 100% would recommend to family
– 96% would recommend to smoking friends