Ventromedial Frontoinsular Connectivity is Associated with Long-term Smoking Behavior Change in Aging

A central question in the field of cognitive aging and behavioral neuroscience is what enables some individuals to successfully change their behavior more than others? Smoking is a significant risk factor for cognitive decline, particularly in vulnerable populations, including those who are at an elevated risk for Alzheimers disease (AD). Developing effective smoking reduction strategies is therefore a public health priority. The goal of the current study is to better understand the brain mechanisms underlying long-term smoking behavior change in cognitively normal, but at-risk, older adults. Neuroimaging and human lesional studies have implicated the insula and its functional network in subjective interoceptive awareness of cigarette craving and smoking-cue reactivity. We sought to characterize the extent to which anterior insular resting-state functional connectivity MRI predicted long-term smoking reduction (mean: 2.7 years, range 8 months - 4 years) using a seed-to-voxel approach. Twenty-three (18 women; 26% APOE4 carriers; 61.5 years, SD = 3.7) cognitively unimpaired older individuals who smoked cigarettes at their baseline visit and have a first-degree family history of AD (at least one parent or multiple siblings affected) were included from a prospective longitudinal cohort, PREVENT-AD (Pre-symptomatic Evaluation of Experimental or Novel Treatments for Alzheimer Disease) in the current study. We found that reduced long-term smoking behavior was associated with diminished functional connectivity between bilateral anterior insula and ventromedial prefrontal cortex (vmPFC). In a second pre-registered replication study within a larger, independent sample of one hundred and eighteen cognitively normal older adults who smoked cigarettes at baseline from the UK Biobank (73 women; 27.9 % APOE4 carriers; 60.3 years, SD = 2.7), we found that baseline diminished resting-state functional connectivity between anterior insula and vmPFC predicted long-term smoking reduction (mean 5.2 years; ranging from 3 years to 7 years). To our knowledge, this is the largest study to examine the neural substrates of long-term smoking cessation in human aging. Our results suggest that frontoinsular circuits may be a therapeutic target for smoking reduction and disease prevention in older adults at risk for AD.