Dr Robert Young BMedSc, MBChB, DPhil, FRACP, FRCP

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?

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“Public Health Approach”

•Non-personalised•Health warning•Recommendation

“What people read and ignore”

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“Personalised Approach”

•Smoker specific risk•Personal engagement•Outcome specific

“What people are toldand what will happen if they don’t act”

?Danger and fear changes risky

behaviour


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“What people are toldand what will happen if they don’t listen”

Lung cancer risk test




RespirageneTM test - motivational tension and quitting

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•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

Smoking cessation rate following treatment or event

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Unassis

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Advice NRT

Bupro

pion

Varenic

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COPD

CT nod

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Head/N

eck c

ance

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Heart a

ttack

Lung

cance

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Treatment or event

% q

uit

Smoking cessation: triggers

•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

•Most smokers continue to smoke on the basis the benefits outweigh the harms

•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)

Young RP, et al. 2009 (PMJ)Nothing Treatment Events

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

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20

25

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Smoking cessation rates

%

Usual care Genetic testing

Genetic testing for risk of lung cancer helps to personalize

the risk from continued smoking

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)

Personalising the risks of smoking helps people choose healthier lifestyle options (eg

quitting smoking and preventing relapse)

McBride,C.M., et al: Incorporating genetic susceptibility feedback into a smoking cessationprogram for African-American smokers with low income. Cancer Epidemiol Biomarkers

Prev.2002, 11:521-528

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Smoking cessation rate following treatment or event

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20

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Unassis

ted

Advice NRT

Bupro

pion

Varenic

line

COPD

CT nod

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eck c

ance

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Heart a

ttack

Lung

cance

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Treatment or event

% q

uit

Smoking cessation

•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

•Most smokers continue to smoke on the basis the benefits outweigh the harms

•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)Nothing Treatment Events

Genetic testing for lung cancer risk

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3Ts – Robert West- How fear triggers quitting

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

BMJ 2006; 332:458-460

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Smoking cessation: Tension

TensionTriggerTreatment

Motivational tension low •fear/anxiety about smoking•promotes quitting

Optimistic bias high •denial about smoking risks•promotes smoking

Smoker

Smoker = Benefits outweigh the harms

West R et al. BMJ 2006; 332: 458-60

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Motivational tension high •fear/anxiety about smoking•promotes quitting

Optimistic bias low •denial about smoking risks•promotes smoking

Personalised test of vulnerabilityie. Respiragene Test

Tip the balanceto achieve quitting

“Fear is a powerful motivator” but it must be personalised

Ex-smoker

Smoking cessation: the 3 Ts

Quitter = Harms outweigh the benefitsTensionTriggerTreatment

Trigger = “Teachable moment”

Lung cancer Risk Test - Respiragene

Risk Level

Score

Smoker’s feedback

•Smokers wanted information that caught their attention

•Current public health campaigns are not engaging

• Smokers don’t read packet warnings

•TV adds reminded smokers to light up

•Smokers want information personally relevant (and honest) not “a lecture”

20x

200x

No smoker is lower than “moderate” (elevated) risk for lung cancer vs non smokers

Tool of engagement

Risk Level

Score

Lung cancer susceptibility score

•All smokers at some risk for lung cancer above that of non-smokers

•Factors increasing that risk•Increasing age•Family history•COPD (smoker’s lung)•“Bad genes”

•Shows risk reduction with quitting

•Educational tool to promote behaviour change (quitting)

20x

200x

No smoker is lower than “moderate” (elevated) risk for lung cancer vs nonsmokers

Test to engage, educate and empower smokers

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)

Quit

Abstained 3+ days

Abstained 1-2 days

Abstained up to 1 day

Have cut down cigs/day

No change in smoking

6 months after testing (n=38 smokers)

After genetic testing changes in smoking; 32 (84%) greater abstinence (blue) vs 3 (8%) less abstinence (red)

(3 unchanged (orange)

P<0.05

Quit

Abstained 3+ days

Abstained 1-2 days




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54

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2N=38 N=38

Changes in smoking before and after genetic testing

Quit

Abstained 3+ days

Abstained 1-2 days





After genetic testing changes in smoking; 32 (84%) greater abstinence (blue) vs 3 (8%) less abstinence (red)

(3 unchanged (orange)

P<0.05

Quit

Abstained 3+ days

Abstained 1-2 days




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2N=38 N=38

32% Quit rateat 6months


Daily cigarette consumption pre- and post genetic testing

Quit

5 cigs/day

10 cigs/day

15 cigs/day

20 cigs/day

25 cigs/day

30+ cigs/day

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 *

P<0.05

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Quit

5 cigs/day

10 cigs/day

15 cigs/day

20 cigs/day

25 cigs/day

30+ cigs/day

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63

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3 *

* diagnosed Prostate cancer after testing)

82% reduced cigarette consumption



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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

Ask

Brief advice

Cessation

Do testing

Spirometry to assess lung age (sign of generalised susceptibility to cardiopulmonary complications)

Take Respiragene Test for lung cancer risk score

D Use tests of risk or organ damage to engage smokers

and “personalise” advice

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 GroupUniversity of Auckland, New Zealand

Respiratory Genetics TeamUniversity of Auckland, New Zealand

Robert Young DPhil, FRACPRaewyn Hopkins BN, MPHGreg Gamble MScBryan Hay BScChris Whittington MSc

Synergenz BioScience Ltdwww.Respiragene.com (US) orwww.Synergenz.com (non-US)

CollaboratorsDr Kyle Hogarth - University of ChicagoDr John Field – University of LiverpoolDr Javier Zulueta – University of Navarra

NZ CollaboratorsMike Epton MD FRACP

Peter Black FRACPTim Christmas MD FRACP

http://www.respiragene.com/

http://www.synergenz.com/


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“What people are toldand what will happen if they don’t listen”

SMOKING WILLKILL YOU

Engaging smokers in smoking cessation: role of Respiragene *

Ask Advise Assess* Assist Arrange *

Relevance *

Risks * Rewards *

Roadblocks Repetition *

Respiragene testing…….

• to engage smokers in smoking cessation

•assess risk of lung cancer and benefits of quitting

•increase motivation in favour of quitting

Respiragene testing…….

• facilitates follow-up visit for a consultation focussed on…… - Respiragene result, and- cessation options

Reminder of result on subsequent visits

Update of risk according to spirometry

5As and 5Rs

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

Dr Robert Young BMedSc, MBChB, DPhil, FRACP, FRCP

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