Recently Completed Projects: Ethical Issues
Ethical Issues in Smoking and Genetics
Project Leader: Alexandra Shields, Ph.D.
PROJECT DESCRIPTION:
Despite decades of research aimed at improving the effectiveness of smoking treatment, available treatments are only modestly effective and smoking remains the leading cause of preventable deaths in the United States. Some of the most promising recent directions of nicotine and tobacco research have focused on gaining a better understanding of how genetic factors may affect smoking behavior and response to treatment. It is possible that ongoing research will eventually identify a set of genes whose measurable variants predispose an individual to adverse behavioral phenotypes such as a high likelihood of persisting to smoke despite attempts at cessation. An anticipated result of this work is “individualized medicine”; in this case, attempting to improve clinical outcomes by matching individual patients to optimal therapy by genotype. The case of new research on genetic factors related to smoking behavior offers insight into the complex ethical concerns that must be addressed prior to the consideration of integrating genetically-tailored treatment into routine clinical practice, particularly with respect to complex traits. Concerns related to genetic testing in the context of smoking cessation treatment include potential harm (stigmatization, discrimination) to patients due to inappropriate use of genetic information, differential prevalence of risk-conferring genotypes among racially defined sub-populations, readiness of primary care physicians to incorporate genetic testing for behavioral traits into primary care, and unique challenges associated with providing adequate informed consent. It is critical that these concerns be identified and addressed prior to integrating new knowledge about the role of genetic factors in smoking behavior and treatment into clinical practice.
LATEST FINDINGS:
OBJECTIVE: Smoking remains the leading cause of preventable death nationally. Emerging research may lead to improved smoking cessation treatment options, including tailoring treatment by genotype. Our objective was to assess primary care physicians' attitudes toward new genetic-based approaches to smoking treatment. DESIGN AND SETTING: A 2002 national survey of primary care physicians. Respondents were randomly assigned a survey including 1 of 2 scenarios: a scenario in which a new test to tailor smoking treatment was described as a "genetic" test or one in which the new test was described as a "serum protein" test. PARTICIPANTS: The study sample was randomly drawn from all U.S. primary care physicians in the American Medical Association Masterfile (e.g., those with a primary specialty of internal medicine, family practice, or general practice). Of 2,000 sampled physicians, 1,120 responded, yielding a response rate of 62.3%. MEASUREMENTS AND MAIN RESULTS: Controlling for physician and practice characteristics, describing a new test as "genetic" resulted in a regression-adjusted mean adoption score of 73.5, compared to a score of 82.5 for a nongenetic test, reflecting an 11% reduction in physicians' likelihood of offering such a test to their patients. CONCLUSIONS: Merely describing a new test to tailor smoking treatment as "genetic" poses a significant barrier to physician adoption. Considering national estimates of those who smoke on a daily basis, this 11% reduction in adoption scores would translate into 3.9 million smokers who would not be offered a new genetic-based treatment for smoking. While emerging genetic research may lead to improved smoking treatment, the potential of novel interventions will likely go unrealized unless barriers to clinical integration are addressed.
Shields AE, Blumenthal D, Weiss KB, Comstock CB, Currivan D, Lerman C. Barriers to translating emerging genetic research on smoking into clinical practice: Perspectives of primary care physicians. Journal of General Internal Medicine, 2005; 20(2):131-138.
ADDITIONAL CITATIONS:
Shields AE, Fortun M, Hammonds E, King PA, Lerman C, Rapp R, Sullivan PF. The use of race variables in genetic studies of complex traits and the goal of reducing health disparities. American Psychologist, 2005; 60(1):77-103.
Shields AE, Lerman C, Sullivan P. Translating emerging research on the genetics of smoking into clinical practice: ethical and social considerations. Nicotine and Tobacco Research, 2004; 6(4): 675-688.
Wilfond BS, Geller G, Lerman C, Audrain-McGovern J, Shields AE. Ethical issues in conducting behavioral genetics research: The case of smoking prevention trials among adolescents . Journal of Health Care Law & Policy. 2002; 6(1):73-88