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Maternal smoking is a recognized risk factor for orofacial clefts. Maternal or fetal pharmacogenetic variants are plausible
modulators of this risk. In this work, we studied 5,427 DNA samples, including 1,244 from subjects in Denmark and
Iowa with facial clefting and 4,183 from parents, siblings, or unrelated population controls. We examined 25 single-
nucleotide polymorphisms in 16 genes in pathways for detoxification of components of cigarette smoke, to look for
evidence of gene-environment interactions. For genes identified as related to oral clefting, we studied gene-expression
profiles in fetal development in the relevant tissues and time intervals. Maternal smoking was a significant risk factor
for clefting and showed dosage effects, in both the Danish and Iowan data. Suggestive effects of variants in the fetal
NAT2 and CYP1A1 genes were observed in both the Iowan and the Danish participants. In an expanded case set, NAT2
continued to show significant overtransmission of an allele to the fetus, with a final P value of .00003. There was an
interaction between maternal smoking and fetal inheritance of a GSTT1-null deletion, seen in both the Danish (P p
.03) and Iowan (P p .002) studies, with a Fisher’s combined P value of !.001, which remained significant after correction
for multiple comparisons. Gene-expression analysis demonstrated expression of GSTT1 in human embryonic craniofacial
tissues during the relevant developmental interval. This study benefited from two large samples, involving independent
populations, that provided substantial power and a framework for future studies that could identify a susceptible pop-
ulation for preventive health care.
Clefts of the upper lip and palate are common birth defects translocator (AHR-ARNT [MIM 600253 and 126110]) path-
whose etiology includes genes, environment, and their in- way as cofactors with maternal smoking, we studied 25
teraction effects. Because they appear to have separate eti- allelic variants in 16 genes, using two large population-
ologies, affected subjects are categorized as having either based OC-affected groups (Iowa and Denmark). Because
cleft lip with or without cleft palate (CL/P) or as having effects of maternal cigarette smoking on embryonic de-
cleft palate only (CPO).1 The prevalence (at birth) of oro- velopment are complex, as is the role of fetal and maternal
facial clefts (OCs) is related to environmental factors, geo- genes involved in detoxification, we performed statistical
graphic origin, and socioeconomic status.2,3 Among the en- tests of several scenarios: (1) detoxification of the risk-
vironmental factors, maternal cigarette smoking is one of relevant component in cigarette smoke is influenced by
the most widely studied,4–9 with some disparities in results fetal genotype, (2) a favorable intrauterine environment
that may be explained by population differences, sampling is determined by the genotype of a smoking mother, and
variation, and the variations in inherited pharmacogenetic (3) the susceptibility detoxification alleles, either of the
susceptibilities to effects of cigarette smoking. Nevertheless, fetus or of the mother, have phenotypic expression only
a recent meta-analysis—of 24 case-control and cohort stud- in the presence of the environmental factors (maternal
ies—of the association between maternal smoking during smoking) or other susceptibility alleles (gene-environment
pregnancy and offspring OC identified statistically signif- or gene-gene interaction effects). We corroborated positive
icant associations between maternal smoking and CL/P results with gene-expression data available for human em-
(relative risk [RR] p 1.34; 95% CI 1.25–1.44) and between bryonic craniofacial tissues.
maternal smoking and CPO (RR p 1.22; 95% CI 1.10–
1.35).10 Investigations of genetic modifiers remain prelim- Material and Methods
inary, with genes involved in the phases I (CYP1A1 [MIM Study Populations
108330] and EPHX1 [MIM 132810]) and II (GSTM1 [MIM DNA samples used in this study came from Iowa and Denmark,
138350], GSTT1 [MIM 600436], and NAT2 [MIM 243400]) as shown in table 1. The study was approved by the institutional
detoxification pathways of special interest.11–13 To inves- review boards in Iowa and Denmark, and written informed con-
tigate genes involved in the detoxification or the aryl sent was obtained from each individual (or the parents of minors)
hydrocarbon receptor–aryl hydrocarbon receptor nuclear included in the study.
From the Departments of Biology (M.S.; J.C.M.), Epidemiology (P.R.; J.C.M.), and Pediatrics (A.L.; J.C.M.), University of Iowa, Iowa City; Center for
the Prevention of Congenital Malformations, Institute of Public Health, University of Southern Denmark, Odense, (K.C.; L.B.); Biostatistics Branch,
National Institute of Environmental Health Sciences (M.S.; C.R.W.) and Department of Anesthesiology, Duke University (R.W.M.), Durham, NC; and
Department of Genetics, Washington University School of Medicine, St. Louis (M.L.)
Received May 26, 2006; accepted for publication October 31, 2006; electronically published December 7, 2006.
Address for correspondence and reprints: Dr. Jeffrey C. Murray, University of Iowa, Department of Pediatrics, South Grand Avenue, 2182 ML, Iowa
City, IA 52242. E-mail: jeff-murray@uiowa.edu
Am. J. Hum. Genet. 2007;80:76–90. 䉷 2006 by The American Society of Human Genetics. All rights reserved. 0002-9297/2007/8001-0009$15.00
Danish samples.—The Danish samples are derived from two in- for some families, grandparents), 375 CEPH samples (phenotype
dependent studies. One set, the Danish case-control (DBS) was unknown),15 and 921 control triads from Iowa.
obtained through a 3-year (December 1991 to August 1994) case-
control study of CL/P and CPO in Denmark. Newborn-screening Genotyping Method
blood spots were used to extract DNA. The 1st-trimester maternal
exposure information, including cigarette smoking, vitamin in-
The studied candidate genes and alleles were selected on the basis
take, alcohol use, and medication, was obtained via interview
of enzymatic activities, expression data during fetal development,
within a few weeks after birth and from birth records. More detail
and sufficient rare-allele frequencies (15%). Samples were geno-
is provided in the work of Christensen et al.6 Because of the lim-
typed either by kinetic PCR16 or by Taqman assays (Applied Bio-
itation of sample quantity, only a subset of the markers was tested
systems).17 For kinetic PCR, each DNA sample was amplified in
on this set of samples. A second set of Danish samples—triads of
two separate reactions, with allele-specific primers in each reac-
an affected individual and parents (DCS), for whom DNA was ex-
tion, and PCR was done in duplicate. Primer sequences are avail-
tracted from cheek swabs—consisted of affected individuals (born
able on request.
1981–1990), their parents, and, in some families, the unaffected
Taqman SNP genotyping assays were obtained through either
sibling(s). These samples were collected between 1995 and 2003,
the Assay-on-Demand or the Assay-by-Design service from Ap-
with no overlap with the DBS samples. Epidemiologic exposure
plied Biosystems. Reactions were performed in duplicate, with
data on smoking and alcohol and vitamin consumption were
use of conditions set forth by the manufacturer. The sequences
available for the DCS samples.
of primers and probes from the Assay-by-Design service are avail-
Iowan population.—Patients with clefts who were born between
able on request.
1987 and 2001 in Iowa were identified through the Iowa Registry
We investigated 25 polymorphisms in 16 genes; information
for Congenital and Inherited Disorders. Control children born
on genes and markers is summarized in table 3, with complete
without major anomalies and matched by birth month, year, and
data listed in table 4. All genotyped families were checked for
sex were also available; for details, see the work of Romitti et al.14
consistency with Mendelian inheritance, and each gene-SNP com-
Most of the families provided complete triads, formed by the
bination was checked for Hardy-Weinberg equilibrium. Allele fre-
index case or control and both biologic birth parents (as deter-
quencies were calculated separately for mothers, fathers, and chil-
mined by parent report and consistency with Mendelian trans-
dren and were stratified by population and OC status (see table
mission, by use of the 25 genotyped SNPs). Data on maternal
5 for details).
cigarette-smoking status were collected by questionnaire, mostly
within 12 mo of the proband’s birth, and were collected for the
3-mo period before conception and for each pregnancy trimester. Embryonic Gene Expression
Data on paternal smoking were available only for a subset of Iowa
data, and preliminary analysis did not identify a paternal smoking Embryonic-expression profiles of the detoxification genes used in
effect, so it was not included in the analysis. Data on a number this study were investigated to confirm that the genes were ex-
of other epidemiologic variables—such as alcohol and vitamin pressed in the relevant tissue during the relevant interval of em-
intake, medication during pregnancy, race/ethnicity, and educa- bryonic development. One source of expression data is the CO-
tion level—were also recorded. Selected demographic character- GENE (Craniofacial and Oral Gene Expression Network) Project,
istics and maternal perinatal exposures are summarized in table which investigates human gene-expression changes that occur
2. during early stages of development, with a focus on craniofacial
Additional sets of samples were used to further investigate the regions. Normal-appearing human embryos from RU-486–in-
apparent overtransmission at the NAT2 590 locus. The samples duced abortions—that were free of autosomal trisomies and for
include 679 Philippine case triads (with children affected with which no parental epidemiologic data were available—were used
OC), 13,000 additional Danish samples from 600 families (con- to generate RNA for micoarray analysis. Affymetrix microarray
sisting of subjects with OC, unaffected sibling, the parents, and, analysis was performed on microdissected, normal human cran-
iofacial structures of 25 target tissues/stages to construct fetal described as “punitively conservative.”19(p505) Here is our approach.
gene-expression profiles.18 We consider that there are three levels of analysis performed here.
Our primary interest is to identify interactions between genetic
Statistical Analysis variants—in either the mother or the fetus—and the exposure:
maternal smoking. For our 25 SNPs, this implies that we must
Statistical analyses were performed separately on samples from include 50 separate tests in our formal hypothesis–testing frame-
Iowa and Denmark, and P values from these two sources were work. There are also two phenotype categories (CPO and CL/P)
combined using Fisher’s method, as described in the “Multiple- and two populations (Iowan and Danish). For the overall formal-
Comparison Considerations” section. We also performed analysis testing framework, we combined the phenotypes and then also
on the basis of aggregated data, to improve estimation of RRs, if combined the P values for the two populations, using Fisher’s
the estimates were compatible in the separate analysis. Since there method.20 We considered an interaction to be significant within
were only a few families (n p 12) with multiple affected offspring, this framework if the P value is !.05/50—that is, 0.001. Another
one affected child was randomly chosen from such families to level of analysis has to do with the main effects for these factors,
be included in the analysis. The data were analyzed under two such as smoking, which are already known or strongly suspected
statistical frameworks: a log-linear model (for case-parents triads) to be related to risk or to the metabolism of xenobiotics. We
and logistic regression analysis (for case-control comparisons). provide an analysis of these, for improved estimation of their
Given that the outcome under study is rare, the RR parameters RRs. A third level should be considered exploratory, rather than
estimated under the former are equivalent to the odds ratio (OR) providing formal-hypothesis tests, and that exploratory category
parameters estimated under the latter. When using the log-linear includes gene-by-gene interactions, differences between the Dan-
model in the analysis, we first used a 2-df test, which places no ish and Iowan populations, and differences between the two sub-
assumptions on the underlying genetic model (see the “Log-Lin- phenotypes. For the second and third sets of analyses, the P values
ear Framework” section below for a detailed description). We then should be taken as an index of strength of evidence rather than
fitted the data in a log-additive model when a significant result as providing formal-hypothesis tests.
was observed.
Log-Linear Framework
Multiple-Comparison Considerations
Interactions between genetic and environmental factors are sta- Major gene effects.—We used the log-linear approach to study
tistically difficult to study; they are second-order effects, and the effects of fetal and maternal genotypes21,22 in family-based
many different combinations must be considered. Therefore, the analyses. The expectation-maximization algorithm was applied,
present analysis faced a multiple-comparison issue. One can sim- for full use of the families with a missing parental genotype.23
ply multiply the P values by the number of tests performed, in The log-linear approach tests fetal genetic effects by comparing
a full Bonferroni correction, but this method has rightly been the distribution of the case genotype after stratification by pa-
rental genotypes with the expected distribution under Mendelian under a dominant or a recessive disease model than with another
inheritance. The unit of analysis is the triad, consisting of an transmission/disequilibrium–based test.25 A limitation of the triad
affected offspring and the two parents. Tests of maternally me- approach is that, unlike the case-control design, it does not pro-
diated genetic effects—that is, effects on the fetus that are due vide a way to detect effects of exposures on risk, although one
to effects of the maternal genotype on the maternal phenotype can assess multiplicative interactions between exposure and
during pregnancy—are based on the symmetry assumption of genotypes.26
allele counts between the mothers and the fathers in the source Effects of gene and maternal-smoking interaction.—For the Iowan
population, as defined by Schaid and Sommer.24 The log-linear samples, smoking status during the critical period between 3 mo
approach provides likelihood-ratio tests (LRTs) of the genetic ef- before and 3 mo after conception served as the indicator variable
fects as well as maximum-likelihood estimators of the genetic for smoking in testing gene–maternal-smoking interaction ef-
RRs for both offspring-mediated and mother-mediated genetic
effects.21 This approach has the advantage of allowing for differ- Table 4. Detailed Marker Information
ent RRs that correspond to carrying one and carrying two copies
of a susceptibility-related allele, relative to no copies. Simulation The table is available in its entirety in the online
edition of The American Journal of Human Genetics.
studies have shown the log-linear approach to be more powerful
the COGENE data showed elevated expression of GSTP1, That study, however, was performed using a case-control
GSTA4, GSTT1, and HIF1A (MIM 603348) at the critical study design, which could be subject to bias due to genetic
regions and time during craniofacial development. In ad- population stratification. Further study of the NAT2 G590A
dition, an association was observed between the fetal ge- locus is required to fully understand the observed over-
notype in GSTA4 and clefting (table A4), although it was transmission. NAT2 is a member of the N-acetyltransfer-
seen in the Danish and not in the Iowan data. Such dif- ases family, which comprises two protein-encoding genes
ferences could suggest that the variant we studied is a (NAT1 and NAT2) and a pseudogene. NAT2 catalyzes the
marker in linkage disequilibrium with a clefting locus in N-acetylation of carcinogens and other xenobiotics such
the Danish but not in the Iowan population. as arylamines, hydrazines, and hydrazides.41 NAT2 G590A
Preferential transmission of the common allele of NAT2 has reduced catalytic activity and protein stability in vi-
G590A was observed in samples from the Iowan and Dan- tro,42 and, whereas the COGENE data did not identify
ish populations (table 7). However, this preferential trans- craniofacial embryonic expression for NAT2, the homo-
mission was also observed, albeit with less transmission log, NAT1, is expressed in mouse fetal liver.43
distortion, in unaffected controls. Accordingly, a supple- GSTT1 is widely studied in the investigations of envi-
mental study was performed using additional control sam- ronmental effects, and the null genotype has been asso-
ples (see the “Danish samples” and “Iowan population” ciated with increased chromosome aberrations and cer-
sections). No preferential transmission was seen in the tain cancers.44 Using a case-control design, Van Rooij et
second (larger) set of controls (P p .63 ), and the apparent al. reported increased risk of OC when mothers carry the
transmission distortion was of only borderline significance GSTT1-null genotype and smoke cigarettes or when both
for all controls combined (P p .056). Several possible ex- mothers and infants carry the null genotype and mothers
planations can be proposed, including sampling variation, smoke.12 We saw increases in risk of OC associated with
systematic genotyping mistakes, actual effects of the var- the GSTT1-null genotypes in the fetus in the Iowan and
iant allele on fetal survival, and segregation distortion. DBS components of our study and similar estimated ORs.
Consistency in genotypes of 1300 samples, through use In a population-based case-control study, Lammer et al.
of kinetic PCR and Taqman assays designed for this marker identified a doubling of risk of cleft lip only (CLO) for fe-
and DNA sequencing of 90 samples, argues against geno- tuses who had both a null genotype for GSTT1 and a mother
typing errors. Zöllner et al. reported evidence of extensive who smoked, and there was a nearly sixfold increased risk
transmission ratio distortion in several regions in the hu- of CL for fetuses with a combination of a mother who
man genome, one of which was located on chromosome smoked and an absence of GSTM1 and GSTT1.45 The CO-
8, coinciding with the chromosomal location of NAT2.40 GENE data show that GSTT1 is highly expressed in de-
In the final, complete data set for the NAT2 G590A marker, veloping fetal craniofacial structures, which suggests that
we observed overtransmission in the OC samples but not its absence in null-genotype individuals could contribute
in the controls, which argues for an etiologic role of this to abnormalities. One possibility is that GSTT1 is present
variant. One other study9 has investigated the associa- in the embryo to metabolize endogenous morphogens, as
tion between variants in the fetal NAT2 gene—including has been suggested for the cytochrome P450 pathway
G590A—and clefting, and the researchers did not detect genes and retinoic acid.34 Absence of GSTT1 in the pres-
a significant association with the NAT2 G590A marker. ence of xenobiotics present in cigarette smoke might result
CYP1B1_snp1:
Alla 1.2 1.2 .53 1.1 .45 .7 .8 .03 1.0 .71 1.0 1.0 .54 1.0 .71
CL/P 1.2 1.2 .60 1.1 .42 .6 .7 .05 .8 .22 .9 1.0 .72 1.0 1.00
CPO 1.0 .9 .93 .9 .70 1.3 2.5 .04 1.7 .02 1.1 1.4 .37 1.2 .23
CYP1A1:
Alla .6 .8 .03 .7 .01 .7 1.1 .20 .8 .17 .7 1.0 .006 .7 .007
No anomaliesb .7 1.0 .11 .7 .068 .6 .8 .09 .7 .05 .7 .9 .01 .7 .008
CYP1A2:
CPO 2.1 .8 .005 1.5 .05 1.4 1.2 .58 1.3 .41 1.7 1.3 .01 1.4 .03
GSTA4_snp2:
No anomaliesb .7 .8 .007 .7 .01 1.0 1.4 .61 1.1 .61 .8 1.0 .04 .9 .11
CLO .6 1.7 .005 .9 .40 .6 .5 .12 .6 .06 .6 1.2 .001 .8 .07
GSTM1_snp1:
CPO 1.3 3.5 .02 1.7 .01 1.1 1.1 .98 1.1 .82 THRRc
GSTP1_snp3:
Alla 1.1 1.0 .47 1.0 .86 1.2 .6 .01 .9 .19 THRRc
CL/P 1.1 1.1 .60 1.0 .70 1.1 .5 .01 .8 .16 THRRc
NAT2_snp2:
Alla .8 .6 .04 .8 .01 .8 .6 .12 .8 .04 .8 .6 .006 .8 .001
No anomaliesb .8 .6 .07 .8 .02 .8 .6 .20 .8 .07 .8 .6 .01 .8 .003
CL/P .8 .4 .01 .7 .01 .9 .6 .43 .8 .24 .8 .5 .007 .7 .002
Control .7 .8 .01 .8 .02 1.0 .8 .67 .9 .43 .8 .8 .03 .8 .02
NOTE.—RR1 is the genetic RR when the child carries one copy of the variant allele; RR2 is that when the child carries two copies of the variant alleles;
R_A is the RR when the child carries one copy of the variant allele, assumed to be a log additive model, a model in which the RR of carrying two copies
of the variant alleles is the square of that of carrying one copy.
a
Includes data from all subjects with nonsyndromic OC.
b
Includes data from subjects without other minor anomalies.
c
For test of heterogeneity in RR (THRR), P ! .05.
Table A6. ORs of Fetal GSTT1 Deletion and Maternal Smoking Effects
in OC
Population,
Fetal GSTT1
No. of OR
Genotypea, and
Maternal Smokingb Cases Controls Total Effectc Value 95% CI
Iowa:
⫺⫺:
Yes 19 9 28 ORge 2.10 .92–4.70
No 30 57 87 ORg .52 .32–.85
⫹⫹/⫹⫺:
Yes 63 54 117 ORe 1.16 .76–1.76
No 180 179 359 Reference
DBS:
⫺⫺-:
Yes 20 14 34 ORge 2.80 1.37–5.61
No 21 49 70 ORg .84 .48–1.46
⫹⫹/⫹⫺:
Yes 78 128 206 ORe 1.20 .84–1.70
No 131 257 388 Reference
Iowa and DBS:
⫺⫺:
Yes 39 23 62 ORge 2.38 1.39–4.01
No 51 106 157 ORg .67 .47–.97
⫹⫹/⫹⫺:
Yes 141 182 323 ORe 1.09 .83–1.41
No 311 436 747 Reference
NOTE.—Data from all subjects with OC are included.
a
⫺⫺ Indicates GSTT1-null genotype; ⫹⫹/⫹⫺ indicates not-null GSTT1 genotype
(either one or two copies of the wild alleles).
b
Yes or no.
c
ORge is the OR of the joint GSTT1 deletion and maternal smoking versus none;
ORg is OR of the GSTT1 deletion alone versus none; ORe is the OR of maternal
smoking alone versus none.
Table A8. Summary of Markers with P ! .05 in Tests for Different Effects in the Sample Sets Studied
Genes Gene-Smoking Interaction
Iowa AhR_snp2, CYP1B1_snp1, CYP1A1, CYP1A2, CYP1A1, GSTM3, and NAT2_snp1 EPHX1_snp1, GSTP1_snp2, HIF1A, EPHX1_snp1 and
GSTP1_snp3, NAT2_snp2, and NQO1 UGT1A7_snp1, and GSTT1_del UGT1A7_snp1
DCS CYP1A1, CYP1A2, GSTA4_SNP2, EPHX1_snp1, GSTP1_snp3, CYP1B1_snp2, CYP1A1, CYP2E1, GSTP1_snp3,
GSTM1_snp1, and NAT2_snp2 NAT2_snp1, and EPHX1_snp2, GSTA4_snp1, HIF1A, NAT2_snp2,
UGT1A7_snp2 GSTA4_snp2, GSTP1_snp3, and UGT1A7_snp1
GSTP1_snp1, and
UGT1A7_snp1
DBSa CYP1A1 NA GSTT1_del NA
NOTE.—SNPs showing statistical significance in more than one population are shown in bold.
a
No maternal samples were available in the DBS sample set, so tests of maternal genotype or maternal genotype and smoking interaction effects were not applicable
(NA). Only 9 (shown in table 3) of the 25 markers were genotyped in Danish case control samples.