Genome-wide single nucleotide polymorphism heritability of nicotine dependence as a multidimensional phenotype

Genetic Associations with Smoking Relapse and Proportion of Follow-up in Smoking Relapse throughout Adulthood in Pre- and Postmenopausal Women

PREVENTION RELEVANCE

This study is the first to quantify genetic associations with smoking relapse among female smokers throughout adulthood. These findings could inform precision medicine approaches to improve long-term smoking relapse prevention to reduce smoking attributable cancer morbidity and mortality.

Validity of the DSM-5 tobacco use disorder diagnostics in adults with problematic substance use

BACKGROUND

DSM-5 tobacco use disorder (TUD) nosology differs from DSM-IV nicotine dependence (ND) by including craving and DSM-IV abuse criteria, a lower threshold (≥ 2 criteria), and severity levels (mild; moderate; severe). We assessed concurrent and prospective validity of the DSM-5 TUD diagnosis and severity and compared validity with DSM-IV ND diagnosis.

METHODS

The sample included U.S. adults with current problematic substance use and past year cigarette smoking (N = 396). Baseline assessment collected information on DSM-IV ND and DSM-5 TUD criteria, smoking-related variables, and psychopathology. Over the following 90 days, electronic daily assessments queried smoking and cigarette craving. Variables expected to be related to TUD were validators: cigarette consumption, cigarette craving scale, Fagerström Test for Nicotine Dependence, and psychiatric disorders. Regression models estimated the association of each validator with DSM-5 TUD and severity levels, and differential association between DSM-5 TUD and DSM-IV ND diagnoses.

RESULTS

DSM-5 TUD and DSM-IV ND were associated with most baseline validators (p-values < 0.05), with significantly stronger associations with DSM-5 TUD for number of days smoked (p = 0.023) and cigarette craving scale (p = 0.007). Baseline DSM-5 TUD and DSM-IV ND predicted smoking and craving on any given day during follow-up, with stronger associations for DSM-5 TUD (association difference [95% CI%]: any smoking, 0.53 [0.27, 0.77]; number of cigarettes smoked, 1.36 [0.89, 1.78]; craving scale, 0.19 [0.09, 0.28]). Validators were associated with TUD severity in a dose-dependent manner.

CONCLUSION

DSM-5 TUD diagnostic measures as operationalized here demonstrated concurrent and prospective validity. Inclusion of new criteria, particularly craving, improved validity and clinical relevance.

Genetic predispositions moderate the effectiveness of tobacco excise taxes

BACKGROUND

Tobacco consumption is one of the leading causes of preventable death. In this study, we analyze whether someone's genetic predisposition to smoking moderates the response to tobacco excise taxes.

METHODS

We interact polygenic scores for smoking behavior with state-level tobacco excise taxes in longitudinal data (1992-2016) from the US Health and Retirement Study (N = 12,058).

RESULTS

Someone's genetic propensity to smoking moderates the effect of tobacco excise taxes on smoking behavior along the extensive margin (smoking vs. not smoking) and the intensive margin (the amount of tobacco consumed). In our analysis sample, we do not find a significant gene-environment interaction effect on smoking cessation.

CONCLUSIONS

When tobacco excise taxes are relatively high, those with a high genetic predisposition to smoking are less likely (i) to smoke, and (ii) to smoke heavily. While tobacco excise taxes have been effective in reducing smoking, the gene-environment interaction effects we observe in our sample suggest that policy makers could benefit from taking into account the moderating role of genes in the design of future tobacco control policies.

Nicotine metabolism predicted by CYP2A6 genotypes in relation to smoking cessation: A systematic review

INTRODUCTION

Identifying genetic factors associated with smoking cessation could inform precision cessation interventions. Of major interest is genetic variation in nicotine metabolism, largely predicted by CYP2A6 variations.

METHODS

We conducted a systematic literature review to summarize the population-based evidence of the association between CYP2A6 and smoking cessation.In the 12 studies meeting the inclusion criteria, the known functional metabolic effect of CYP2A6 variants was used to classify nicotine metabolism as normal (>75% metabolic activity), intermediate (50.1 - 75% activity), slow (25 - 50% activity), and poor (<25% activity). Summary odds ratios of smoking cessation were calculated across metabolic groups, stratified by ancestry and whether participants received pharmacotherapy or placebo/no treatment.

RESULTS

Among untreated people of European ancestry (n = 4 studies), those with CYP2A6 reduced metabolism were more likely to quit smoking than those with normal metabolism [Summary OR = 2.05, 95% CI 1.23 - 3.42] and the likelihood of cessation increased as nicotine metabolism decreased. Nicotine replacement therapy attenuated the association at end-of-treatment, while bupropion modified the association such that intermediate/slow metabolizers were less likely to quit than normal metabolizers [Summary OR = 0.86, 95% CI 0.79 - 0.94]. Among untreated Asian people (n = 3 studies), results differed compared to those with European ancestry: those with slow metabolism were less likely to have quit smoking than normal metabolizers [Summary OR = 0.52, 95% CI 0.38 - 0.71]. Evidence for people of African ancestry (n = 1 study) suggested the CYP2A6 association with cessation may differ compared to those of European ancestry.

IMPLICATIONS

Most studies included in this review were of European ancestry populations; these showed slower nicotine metabolism was associated with increased likelihood of smoking cessation in a dose-related manner. Pharmacotherapy appeared to attenuate or modify this association among people of European ancestry, but it is unclear whether the change in the association remains consistent after treatment ceases. This finding has implications for precision medicine cessation interventions. Based on only a few studies of people of Asian or African ancestry, the association between CYP2A6 variants and cessation may differ from that observed among those of European ancestry, but more evidence is needed.

Association of the Uncoupling Protein 2-866 G/A Polymorphism with Family History and Duration of Tobacco Use Disorder in a Turkish Population

Background

A variety of substances cause neurotoxicity by increasing intracellular oxidative stress, followed by mitochondrial dysfunction. Uncoupling proteins (UCPs) act as membrane transport proteins and reduce reactive oxygen products and mitochondrial calcium influx. We aimed to study UCP2-866 G/A gene polymorphism in tobacco use disorder (TUD) by comparing genotype distributions between TUD patients and healthy controls considering clinical parameters.

Methods

One hundred eighteen patients with TUD and 96 healthy volunteers were included in the study. The diagnosis of the patients were then confirmed, based on the DSM-5 criteria. Polymerase chain reaction and restriction fragment length polymorphism (PCR-RFLP) were used to determine UCP2 gene polymorphism.

Results

Our results demonstrated that the UCP2 genotype distribution and allele frequencies of the TUD patient group were significantly different from those of the control group. When the UCP2 genotype and the allele frequency distributions were compared between the two groups according to the family history of TUD in the patient group, the UCP2 genotype and allele frequency distributions were significantly different. The GG genotype or G allele percentage was significantly higher in patients with a family history of TUD, than the patients without a family history of TUD. Comparing clinical parameters based on the UCP2 genotype, the disorder's duration was significantly different between the groups of UCP2 genotype. The duration of TUD was significantly shorter in patients with GG genotype than other genotypes.

Conclusions

In summary, the UCP2-866 G/A gene polymorphism might be associated with family history and duration of TUD in Turkish patients.

Association of NRG3 and ERBB4 gene polymorphism with nicotine dependence in Turkish population

BACKGROUND

Nicotine dependence (ND) is characterized by regular smoking, anxiety, irritation, difficulty concentrating, impatience, restlessness, tremor, dizziness, hunger, nicotine demand, and the individual's reluctance to quit despite knowing the health risks of smoking. Recently, it has been reported that the Neuregulin 3 (NRG3)/Erb-B2 receptor tyrosine kinase 4 (ERBB4) signaling pathway plays a role in ND. NRG3, which is activated after nicotine intake, binds to ERBB4 and causes GABA release. GABA reduces anxiety and tension, which are one of the nicotine withdrawal symptoms. Therefore we aimed to investigate the relationship between NRG3 and ERBB4 gene polymorphisms and ND.

MATERIALS AND METHODS

The study population was comprised of patients with ND (n = 200) and healthy non-smoker control subjects (n = 200) who were matched for age, sex, and compared for comorbidity factors such as alcohol, smoking, duration, and education (age range 18-60). Genotypes were detected by Real-Time PCR using TaqMan technology. The Fagerström Nicotine Dependence Test (FTND) score was 5 and above for the patient group and 0 for the control group. DNA was obtained from whole peripheral blood and six polymorphisms of Neuregulin 3 (NRG3) (rs1836724, rs7562566, and rs10048757) and Erb-B2 Receptor Tyrosine Kinase 4 (ERBB4) (rs1764072, rs6584400, and rs10883934) genes were analyzed by real-time PCR method.

RESULTS

Our findings show that the six selected SNPs are not significantly associated with ND in the Turkish population and no correlation with dependence levels (p > 0.05).

CONCLUSION

Although our findings do not show a relationship between ND and these polymorphisms, it is the first study to investigate these single nucleotide polymorphisms (SNPs) for the first time in ND and to find some genotypes in the Turkish population when compared to other populations. Also, our findings are important in terms of their contribution to the literature and forensic genetics.

Multi-polygenic Analysis of Nicotine Dependence in Individuals of European Ancestry

INTRODUCTION

Heritability estimates of nicotine dependence (ND) range from 40-70%, but discovery GWAS of ND are underpowered and have limited predictive utility. In this work, we leverage genetically correlated traits and diseases to increase the accuracy of polygenic risk prediction.

METHODS

We employed a multi-trait model using summary statistic-based best linear unbiased predictors (SBLUP) of genetic correlates of DSM-IV diagnosis of ND in 6,394 individuals of European Ancestry (prevalence = 45.3%, %female = 46.8%, µage = 40.08 [s.d. = 10.43]) and 3,061 individuals from a nationally-representative sample with Fagerström Test for Nicotine Dependence symptom count (FTND; 51.32% female, mean age = 28.9 [s.d. = 1.70]). Polygenic predictors were derived from GWASs known to be phenotypically and genetically correlated with ND (i.e., Cigarettes per Day (CPD), the Alcohol Use Disorders Identification Test (AUDIT-Consumption and AUDIT-Problems), Neuroticism, Depression, Schizophrenia, Educational Attainment, Body Mass Index (BMI), and Self-Perceived Risk-Taking); including Height as a negative control. Analyses controlled for age, gender, study site, and the first 10 ancestral principal components.

RESULTS

The multi-trait model accounted for 3.6% of the total trait variance in DSM-IV ND. Educational Attainment (β=-0.125; 95% confidence interval (CI): [-0.149,-0.101]), CPD (0.071 [0.047,0.095]), and Self-Perceived Risk-Taking (0.051 [0.026,0.075]) were the most robust predictors. PGS effects on FTND were limited.

CONCLUSIONS

Risk for ND is not only polygenic, but also pleiotropic. Polygenic effects on ND that are accessible by these traits are limited in size and act additively to explain risk.

Clarifying the Genetic Influences on Nicotine Dependence and Quantity of Use in Cigarette Smokers

Nicotine dependence and smoking quantity are both robustly associated with the CHRNA5-A3-B4 gene cluster in the 15q25 region, and SNP rs16969968 in particular. The purpose of this paper is to use structural equation modeling techniques (SEM) to disentangle the complex pattern of relationships between rs16969968, nicotine quantity (as measured by the number of cigarettes an individual smokes per day; CPD) and nicotine dependence (as measured by the Fagerström Test for Nicotine Dependence; FTND). CPD is an indicator, but also a potential cause, of FTND, complicating the interpretation of associations between these constructs and requires a more detailed investigation than standard GWAS or general linear regression models can provide. FTND items and genotypes were collected in four samples, with a combined sample size of 5,373 respondents. A mega-analysis was conducted using a multiple group SEM approach to test competing hypotheses regarding the relationships between the SNP rs16969968, FTND and CPD. In the best fitting model, the FTND items loaded onto two correlated factors. The first, labeled "maintenance," assesses the motivation to maintain constant levels of nicotine through out the day. The second was labeled "urgency" as its items concern the urgency to restore nicotine levels after abstinence. We focus our attention on the "maintenance" factor, of which CPD was an indicator. The best fitting model included a negative feedback loop between the Maintenance factor and CPD. Accordingly, the motivation to maintain higher levels of nicotine increased the quantity of nicotine consumed, which subsequently decreases the maintenance motivation. The fact that the Maintenance-CPD feedback model fits the data best implies that there are at least two biological pathways that lead from rs16969968 to smoking behaviors. The model is consistent with a supply and demand system, which allows individuals to achieve a homeostatic equilibrium for their nicotine concentration.

APOE genotype influences P3b amplitude and response to smoking abstinence in young adults

RATIONALE

There is strong evidence that nicotine can enhance cognitive functions and growing evidence that this effect may be larger in young healthy APOE ε4 carriers. However, the moderating effects of the APOE ε4 allele on cognitive impairments caused by nicotine deprivation in chronic smokers have not yet been studied with brain indices.

OBJECTIVE

We sought to determine whether young female carriers of the APOE ε4 allele, relative to noncarriers, would exhibit larger abstinence-induced decreases in P3b amplitude during a two-stimulus auditory oddball task.

METHODS

We compared parietal P3bs in female chronic smokers with either APOE ε3/ε3 (n = 54) or ε3/ε4 (n = 20) genotype under nicotine-sated conditions and after 12-17-h nicotine deprivation.

RESULTS

Nicotine deprivation significantly reduced P3b amplitudes in APOE ε4 carriers, but not in APOE-ε3/ε3 individuals, such that the difference seen prior to nicotine deprivation was eliminated.

CONCLUSIONS

The results suggest that subjects with the APOE ε4 allele are more sensitive to nicotine, which could influence smoking patterns, the risk for nicotine dependence, and the cognitive effects of nicotine use in these individuals.

Evaluation of COMT (rs4680), CNR2 (rs2501432), CNR2 (rs2229579), UCP2 (rs659366), and IL-17 (rs763780) gene variants in synthetic cannabinoid use disorder patients

Synthetic cannabinoids (SC) are psychoactive drugs that generally produce more severe clinical outcomes compared to Δ9-tetrahydrocannabinol. This study aimed to evaluate the relationship between clinical features of synthetic cannabinoid use disorder (SCUD) and COMT (rs4680), CNR2 (rs2501432), CNR2 (rs2229579), UCP2 (rs659366), and IL-17 (rs763780) gene variants in SCUD patients by comparing the genotype distributions of gene variants between patients and healthy controls. Based on the DSM-5 criteria, 94 patients with SCUD, confirmed with a positive urine test, and 95 healthy volunteers were included in the study. Self-mutilation, suicidal behavior, psychotic symptoms, drug-induced psychosis, tobacco use disorder (TUD) or alcohol use disorder (AUD) comorbidity, and family history of TUD or AUD were evaluated in all patients. PCR-RFLP was used to identify gene variants from DNA material. The distributions of CNR2 (rs2229579) and UCP2 (rs659366) variants were significantly different in patients diagnosed with SCUD compared to the control group. SC-related psychotic symptoms were associated with the IL-17 (rs763780) variant in SCUD patients who had an onset of SC usage under 18 years of age. While the COMT Val108Met gene variant was related to self-mutilation, the COMT Val158Met variant was associated with attempted suicide. In addition, in SCUD patients, the UCP2 (rs659366) variant was associated with a family history of AUD or TUD. In summary, CNR2 (rs2229579) and UCP2 (rs659366) variants were associated with SCUD. While SC-related psychotic symptoms were related to the IL-17 (rs763780) variant, the COMT variants were associated with self-mutilation or attempted suicide in SCUD patients.

Genome-Wide Meta-Analyses of FTND and TTFC Phenotypes

INTRODUCTION

FTND (Fagerstrӧm test for nicotine dependence) and TTFC (time to smoke first cigarette in the morning) are common measures of nicotine dependence (ND). However, genome-wide meta-analysis for these phenotypes has not been reported.

METHODS

Genome-wide meta-analyses for FTND (N = 19,431) and TTFC (N = 18,567) phenotypes were conducted for adult smokers of European ancestry from 14 independent cohorts.

RESULTS

We found that SORBS2 on 4q35 (p = 4.05 × 10-8), BG182718 on 11q22 (p = 1.02 × 10-8), and AA333164 on 14q21 (p = 4.11 × 10-9) were associated with TTFC phenotype. We attempted replication of leading candidates with independent samples (FTND, N = 7010 and TTFC, N = 10 061), however, due to limited power of the replication samples, the replication of these new loci did not reach significance. In gene-based analyses, COPB2 was found associated with FTND phenotype, and TFCP2L1, RELN, and INO80C were associated with TTFC phenotype. In pathway and network analyses, we found that the interconnected interactions among the endocytosis, regulation of actin cytoskeleton, axon guidance, MAPK signaling, and chemokine signaling pathways were involved in ND.

CONCLUSIONS

Our analyses identified several promising candidates for both FTND and TTFC phenotypes, and further verification of these candidates was necessary. Candidates supported by both FTND and TTFC (CHRNA4, THSD7B, RBFOX1, and ZNF804A) were associated with addiction to alcohol, cocaine, and heroin, and were associated with autism and schizophrenia. We also identified novel pathways involved in cigarette smoking. The pathway interactions highlighted the importance of receptor recycling and internalization in ND.

IMPLICATIONS

Understanding the genetic architecture of cigarette smoking and ND is critical to develop effective prevention and treatment. Our study identified novel candidates and biological pathways involved in FTND and TTFC phenotypes, and this will facilitate further investigation of these candidates and pathways.

Habenular and striatal activity during performance feedback are differentially linked with state-like and trait-like aspects of tobacco use disorder

The habenula, an epithalamic nucleus involved in reward and aversive processing, may contribute to negative reinforcement mechanisms maintaining nicotine use. We used a performance feedback task that differentially activates the striatum and habenula and administered nicotine and varenicline (versus placebos) to overnight-abstinent smokers and nonsmokers to delineate feedback-related functional brain alterations both as a function of smoking trait (smokers versus nonsmokers) and drug administration state (drug versus placebo). Smokers showed less striatal responsivity to positive feedback, an alteration not mitigated by drug administration, but rather correlated with trait-level addiction severity. Conversely, nicotine administration reduced habenula activity following both positive and negative feedback among abstinent smokers, but not nonsmokers, and increased habenula activity among smokers correlated with elevated state-level tobacco cravings. These outcomes highlight a dissociation between neurobiological processes linked with the dependence severity trait and the nicotine withdrawal state. Interventions simultaneously targeting both aspects may improve currently poor cessation outcomes.

Lack of Association between Opioid-Receptor Genotypes and Smoking Cessation Outcomes in a Randomized, Controlled Naltrexone Trial

AIMS

The present study examined how variation in mu- (OPRM1), kappa- (OPRK), and delta- (OPRD) opioid receptor genes may influence the efficacy of naltrexone in the context of a smoking cessation trial.

METHODS

The study's primary objective was to examine the association of the Asn40Asp OPRM1 single nucleotide polymorphism (SNP) with naltrexone's effects on smoking quit rate, weight gain, and heavy drinking behavior during a double-blind, randomized clinical trial in 280 adult DSM-IV nicotine-dependent participants. The secondary goal of the study was to examine the relationship of 20 additional SNPs of OPRM1, OPRK, and OPRD with the aforementioned outcomes.

RESULTS

Results indicated a null association between any opioid-receptor gene SNP and naltrexone's effects on smoking quit rate, weight gain, and heavy drinking behavior in this sample of nicotine dependent participants.

CONCLUSIONS

In sum, these results do not suggest that genetic variation in opioid-receptors is related to treatment responses to naltrexone in a smoking cessation trial.

Functional Neurocircuits and Neuroimaging Biomarkers of Tobacco Use Disorder

Drug abuse and addiction remain major public health issues, exemplified by the opioid epidemic currently devastating the United States. Treatment outcomes across substance use disorders remain unacceptably poor, wherein drug discovery/development for this multifaceted neuropsychiatric disorder focuses on single molecular-level targets. Rather, our opinion is that a systems-level neuroimaging perspective is crucial for identifying novel therapeutic targets, biomarkers to stratify patients, and individualized treatment strategies. Focusing on tobacco use disorder, we advocate a brain systems-level perspective linking two abuse-related facets (i.e., statelike withdrawal and traitlike addiction severity) with specific neurocircuitry (insula- and striatum-centered networks). To the extent that precise neurocircuits mediate distinct facets of abuse, treatment development must adopt not only a systems-level perspective, but also multi-intervention rather than mono-intervention practices.

Association of opioid receptor mu 1 (OPRM1) A118G polymorphism (rs1799971) with nicotine dependence

Background and Object

Whether opioid-receptor mu 1 (OPRM1) A118G polymorphism (rs1799971) is associated with nicotine dependence is controversial. We analyzed the combined results from published studies of this possibility.

Methods

Literature reviews were performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Web of Science, Chinese National Science Infrastructure (CNKI), PubMed, Embase and Google Scholar database searches using MeSH terms were conducted to find all relevant researches up to October 2016. Odds ratios (ORs) and their 95% confidence intervals (95% CIs) were calculated in allele, homozygote, heterozygote, dominant and recessive models. Ethnicity-specific subgroup meta-analysis, heterogeneity, sensitivity analysis and publication bias were considered.

Results

Seven eligible studies with 3313 patients were included. The ORs in the five genetic models mentioned above were 1.000 (95% CI: 0.906, 1.104; p = 0.999), 1.032 (95% CI: 0.771, 1.381; p = 0.834), 0.963 (95% CI: 0.799, 1.162; p = 0.696), 1.006 (95% CI: 0.916, 1.104; p = 0.907), 0.967 (95% CI: 0.715, 1.309; p = 0.830), respectively. Only in dominant model is the association significant. Upon ethnicity-specific subgroup analysis, there is no statistical significance.

Conclusion

OPRM1-A118G polymorphism (A>G) is not associated with nicotine dependence.

Pharmacotherapy for smoking cessation: effects by subgroup defined by genetically informed biomarkers

BACKGROUND

Smoking cessation therapies are not effective for all smokers, and researchers are interested in identifying those subgroups of individuals (e.g. based on genotype) who respond best to specific treatments.

OBJECTIVES

To assess whether quit rates vary by genetically informed biomarkers within pharmacotherapy treatment arms and as compared with placebo. To assess the effects of pharmacotherapies for smoking cessation in subgroups of smokers defined by genotype for identified genome-wide significant polymorphisms.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group specialised register, clinical trial registries, and genetics databases for trials of pharmacotherapies for smoking cessation from inception until 16 August 2016.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that recruited adult smokers and reported pharmacogenomic analyses from trials of smoking cessation pharmacotherapies versus controls. Eligible trials included those with data on a priori genome-wide significant (P < 5 × 10-8) single-nucleotide polymorphisms (SNPs), replicated non-SNPs, and/or the nicotine metabolite ratio (NMR), hereafter collectively described as biomarkers.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. The primary outcome was smoking abstinence at six months after treatment. The secondary outcome was abstinence at end of treatment (EOT). We conducted two types of meta-analyses- one in which we assessed smoking cessation of active treatment versus placebo within genotype groups, and another in which we compared smoking cessation across genotype groups within treatment arms. We carried out analyses separately in non-Hispanic whites (NHWs) and non-Hispanic blacks (NHBs). We assessed heterogeneity between genotype groups using T², I², and Cochrane Q statistics.

MAIN RESULTS

Analyses included 18 trials including 9017 participants, of whom 6924 were NHW and 2093 NHB participants. Data were available for the following biomarkers: nine SNPs (rs1051730 (CHRNA3); rs16969968, rs588765, and rs2036527 (CHRNA5); rs3733829 and rs7937 (in EGLN2, near CYP2A6); rs1329650 and rs1028936 (LOC100188947); and rs215605 (PDE1C)), two variable number tandem repeats (VNTRs; DRD4 and SLC6A4), and the NMR. Included data produced a total of 40 active versus placebo comparisons, 16 active versus active comparisons, and 64 between-genotype comparisons within treatment arms.For those meta-analyses showing statistically significant heterogeneity between genotype groups, we found the quality of evidence (GRADE) to be generally moderate. We downgraded quality most often because of imprecision or risk of bias due to potential selection bias in genotyping trial participants. Comparisons of relative treatment effects by genotypeFor six-month abstinence, we found statistically significant heterogeneity between genotypes (rs16969968) for nicotine replacement therapy (NRT) versus placebo at six months for NHB participants (P = 0.03; n = 2 trials), but not for other biomarkers or treatment comparisons. Six-month abstinence was increased in the active NRT group as compared to placebo among participants with a GG genotype (risk ratio (RR) 1.47, 95% confidence interval (CI) 1.07 to 2.03), but not in the combined group of participants with a GA or AA genotype (RR 0.43, 95% CI 0.15 to 1.26; ratio of risk ratios (RRR) GG vs GA or AA of 3.51, 95% CI 1.19 to 10.3). Comparisons of treatment effects between genotype groups within pharmacotherapy randomisation armsFor those receiving active NRT, treatment was more effective in achieving six-month abstinence among individuals with a slow NMR than among those with a normal NMR among NHW and NHB combined participants (normal NMR vs slow NMR: RR 0.54, 95% CI 0.37 to 0.78; n = 2 trials). We found no such differences in treatment effects between genotypes at six months for any of the other biomarkers among individuals who received pharmacotherapy or placebo.

AUTHORS' CONCLUSIONS

We did not identify widespread differential treatment effects of pharmacotherapy based on genotype. Some genotype groups within certain ethnic groups may benefit more from NRT or may benefit less from the combination of bupropion with NRT. The reader should interpret these results with caution because none of the statistically significant meta-analyses included more than two trials per genotype comparison, many confidence intervals were wide, and the quality of this evidence (GRADE) was generally moderate. Although we found evidence of superior NRT efficacy for NMR slow versus normal metabolisers, because of the lack of heterogeneity between NMR groups, we cannot conclude that NRT is more effective for slow metabolisers. Access to additional data from multiple trials is needed, particularly for comparisons of different pharmacotherapies.