Purpose: Approximately 10%-40% of patients with lung cancer report no history of tobacco smoking (never-smokers). We analyzed whole-exome and RNA-sequencing data of 160 tumor and normal lung adenocarcinoma (LUAD) samples from never-smokers to identify clinically actionable alterations and gain insight into the environmental and hereditary risk factors for LUAD among never-smokers., Methods: We performed whole-exome and RNA-sequencing of 88 and 69 never-smoker LUADs. We analyzed these data in conjunction with data from 76 never-smoker and 299 smoker LUAD samples sequenced by The Cancer Genome Atlas and Clinical Proteomic Tumor Analysis Consortium., Results: We observed a high prevalence of clinically actionable driver alterations in never-smoker LUADs compared with smoker LUADs (78%-92% v 49.5%; P < .0001). Although a subset of never-smoker samples demonstrated germline alterations in DNA repair genes, the frequency of samples showing germline variants in cancer predisposing genes was comparable between smokers and never-smokers (6.4% v 6.9%; P = .82). A subset of never-smoker samples (5.9%) showed mutation signatures that were suggestive of passive exposure to cigarette smoke. Finally, analysis of RNA-sequencing data showed distinct immune transcriptional subtypes of never-smoker LUADs that varied in their expression of clinically relevant immune checkpoint molecules and immune cell composition., Conclusion: In this comprehensive genomic and transcriptome analysis of never-smoker LUADs, we observed a potential role for germline variants in DNA repair genes and passive exposure to cigarette smoke in the pathogenesis of a subset of never-smoker LUADs. Our findings also show that clinically actionable driver alterations are highly prevalent in never-smoker LUADs, highlighting the need for obtaining biopsies with adequate cellularity for clinical genomic testing in these patients., Competing Interests: Humam KadaraResearch Funding: Johnson and Johnson Irena LancEmployment: Gyroscope Therapeutics, Arch Oncology (I) Saiama N. WaqarResearch Funding: Spectrum Pharmaceuticals, Lilly, Pfizer, Genentech/Roche, Daiichi Sankyo, Newlink Genetics, EMD Serono, Puma Biotechnology, Novartis, Xcovery, Synermore Biologics, Celgene, Vertex, Bristol Myers Squibb, Stem CentRx, Hengrui Therapeutics, Checkpoint Therapeutics, Ignyta, AstraZeneca, ARIAD, Roche, Merck Daniel MorgenszternConsulting or Advisory Role: Bristol Myers Squibb, AbbVie, Takeda, PharmaMar, Gilead Sciences, G1 Therapeutics, Lilly MedicalResearch Funding: Heat Biologics, Merck, Celgene, AstraZeneca, Baxter, Incyte, AbbVie, Bristol Myers Squibb, EpicentRx, Pfizer, Roche, Lilly, Altum Pharmaceuticals, Array BioPharma, Surface Oncology Jeffrey WardEmployment: MilliporeConsulting or Advisory Role: Novocure, Guidepoint IncTravel, Accommodations, Expenses: Halozyme Ashiq MasoodHonoraria: Bristol Myers Squibb, Boehringer IngelheimSpeakers' Bureau: Bristol-Myers Squibb, Boehringer IngelheimResearch Funding: Boston Biomedical, Ipsen, Seattle Genetics, Novocure, Macrogenics, Merck, Genentech/Roche, Exelixis, Astellas Pharma, Debiopharm Group, PRA Health, CytomX Therapeutics, Calithera Biosciences, Proteus Digital Health, Tempus Shankha SatpathyEmployment: FOGPharmaStock and Other Ownership Interests: FOGPharmaPatents, Royalties, Other Intellectual Property: Proteogenomic Methods for Diagnosing Cancer Steven A. CarrStock and Other Ownership Interests: SEER, KymeraHonoraria: BiogenConsulting or Advisory Role: Kymera, SEER, PTM BiolabsPatents, Royalties, Other Intellectual Property: I have several patents related to use of HLA peptides as vaccine candidates Ignacio WistubaConsulting or Advisory Role: Genentech/Roche, Bristol Myers Squibb, HTG Molecular Diagnostics, Asuragen, Pfizer, AstraZeneca/MedImmune, GlaxoSmithKline, Guardant Health, Merck, MSD Oncology, Bayer, OncoCyte, Flame BiosciencesSpeakers' Bureau: Pfizer, MSD Oncology, Roche, Merck, AstraZenecaResearch Funding: Genentech, Merck, HTG Molecular Diagnostics, Silicon Biosytems, Adaptimmune, EMD Serono. Pfizer, MedImmune, OncoPlex Diagnostics, Takeda, Karus Therapeutics, Amgen, 4D Molecular Therapeutics, Bayer, Novartis, Guardant Health, Adaptive Biotechnologies, Johnson & Johnson, Iovance Biotherapeutics, Akoya Biosciences Harvey PassHonoraria: Genentech/RocheConsulting or Advisory Role: Genentech/Roche, NovartisResearch Funding: Biodesix, Micronoma, NanoString Technologies, Celsius TherapeuticsPatents, Royalties, Other Intellectual Property: Patent Pending, use of fibulin for the diagnosis of mesothelioma; Patent Pending, use of HMGB1 for the diagnosis of mesothelioma, with University of Hawaii; Patent Pending, use of osteopontin for the diagnosis of mesothelioma, with Wayne State UniversityTravel, Accommodations, Expenses: Genentech/Roche Ramaswamy GovindanHonoraria: Genentech/AbbVie, AbbVie, GeneplusConsulting or Advisory Role: Genentech/Roche, AbbVie, AstraZeneca/MedImmune, Pfizer, Bristol Myers Squibb, Nektar, Jounce Therapeutics, Roche, Janssen, Amgen, Achilles TherapeuticsNo other potential conflicts of interest were reported.