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Psychiatric patients and gene-based smoking cessation
packages
Colin O'Gara and Marcus MunafòPsychiatric Bulletin 2006, 30:1-2.
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O’Gara & Munafo' Gene-based smoking cessation packages C O L I N O ’G A R A A N D M A R C U S M U N A F O' Psychiatric patients and gene-based smoking cessationpackages Psychiatric patients are an important consumer body of changes, alternative therapies and other ways to succeed cigarettes worldwide, demonstrating an increased in stopping smoking is also offered.
smoking prevalence (generally greater than 70%)compared with healthy control individuals (around 30%)(Leonard et al, 2001). Schizophrenia (Lohr & Flynn, 1992) and depression (Dierker et al, 2002) are the disorders The main reason a patient is likely to purchase a gene- with the clearest evidence of increased prevalence of based test is to gain personalised scientific information cigarette smoking and tobacco addiction. Smoking in on their likelihood of succeeding in smoking cessation schizophrenia and depression is thought in part to repre- with particular pharmacological treatments (nicotine sent an attempt to self-medicate symptoms of the illness.
replacement therapy and /or Zyban). This information will In particular, troublesome negative symptoms in schizo- not be available as part of a patient’s routine care on a phrenia and low mood in depression. There is also preli- minary evidence to support a relationship between eating Several issues that are relevant to patients disorders and smoking, whereby smoking may be used as purchasing gene-based smoking cessation tests are weight control behaviour (Welch & Fairburn, 1998; Sanchez-Johnsen et al, 2005). As clinicians working witha group of individuals with such high smoking rates, we have a duty of care to protect them from the ill effects oftobacco smoke. Our efforts should include informing Current tests for predisposition to nicotine dependence patients of the best treatments available and directing and response to treatment draw on evidence from them to the appropriate services. The recent arrival of genetic association studies. The difficulty in using such gene-based smoking cessation tests should broaden this data is that they are inconclusive with regard to our best genetic candidates in the smoking cessation field. A goodexample is the dopamine D2 receptor (DRD2) gene, whichhas been reported to be both associated and not asso- ciated with alcoholism and drug dependence phenotypes(including nicotine dependence) in several studies over The mainstays of current smoking cessation treatment many years. There is only at best modest evidence to are nicotine replacement therapy (patches, gum, inhalers, support the role of DRD2 in nicotine dependence.
lozenges, spray) and bupropion (Zyban), although beha- A recent meta-analysis by Munafo' et al (2004) failed to vioural support is also effective. Gene-based tests for demonstrate a statistically significant relationship smoking cessation are currently marketed privately to between DRD2 and nicotine dependence. The only smokers via the internet to help inform them as to studies on UK populations have found no association whether they carry gene variants predisposing them to between variations in this gene and nicotine dependence nicotine addiction. Smokers can buy a genetic test package (retailing around »95), which includes subse- What is needed before a recommendation of the quent advice online, and a kit containing a device to take introduction of genetic tests is a thorough investigation a pin prick of blood which the customer places on an of potential benefit and harm, especially among general absorbent pad and sends to a laboratory for DNA medical and psychiatric patients, including an analysis of analysis. The results are given with a personally tailored specificity and validity. Furthermore, evidence regarding plan for cessation of smoking, including advice on the the efficacy of genetically tailored treatments compared pharmacological treatment most appropriate to an indi- with outcomes associated with currently available vidual’s genetic make-up. Advice about behavioural treatment strategies should be made available.
O’Gara & Munafo' Gene-based smoking cessation packages Psychiatrists’ readiness for gene-based going to be able to give up. Similarly, the information maylead certain individuals to believe that they wil never respond to (for example) Zyban and will avoid it in future.
Psychiatrists are a key point of contact for patientswanting to give up smoking because of the inflated ratesof smoking among individuals suffering from psychiatric illness. Most services wil not have access to medicalgeneticists and the bulk of counselling falls to psychia- It is hoped that targeted therapies based on genotype trists and other members of the mental health team.
will play a key role in the field of smoking cessation.
Findings from studies among general practitioner groups However, our current knowledge of genetic and phar- in the USA indicate that they do not have the knowledge, macogenetic influences in smoking cessation is, at best, willingness or training to take on such a role (Shields et al, modest. The evidence supporting the use of genetic tests 2005). Recent evidence indicates that such concerns are in smoking cessation is preliminary and largely unrepli- greater for new genetic tests than other new tests cated. More studies are needed to verify the usefulness (Freedman et al, 2003). The responsibilities of general of genetic tests for smoking cessation in the clinical adult psychiatrists, substance misuse service professionals setting. Until we have a greater understanding of the and general practitioners are already significant without genetic influences in nicotine addiction, individuals being the additional burden of providing counselling for such cared for in psychiatric services are best advised to avoid tests. The cost implications for the National Health Service of this added duty should also be of concern.
Privacy, genetic discrimination and social Dr Marcus Munafo' has provided consultancy sevices forG-Nostics Ltd.
Current privacy laws within the UK fail to protect patientsfrom the misuse of genetic information. Many Europeancountries (including France, Spain and Germany) have laws preventing insurers and prospective employers fromgaining access to an individual’s genetic profile. These worries are enhanced in the context of smoking because of the pleiotropic nature of the genetic loci that are investigated. Genes that have been associated with smoking behaviour or treatment response have been implicated in many other disorders, such as alcohol and cocaine addiction, compulsive sexual activity, pathological gambling and schizophrenia, among other psychiatric Journal of Psychiatry, 159, 947^953.
conditions. When patients spend money on a genetic test, they are inadvertently generating information about Perspectives of primary care physicians.
their risk for predisposition to developing or possessing a number of other stigmatising conditions.
The majority of individuals who attempt to give up smoking using genetic tests will fail according to accepted LOHR, J. B. & FLYNN, K. (1992) Smokingand schizophrenia. Schizophrenia WELCH, S. L. & FAIRBURN, C. G. (1998) success rates from cessation studies using nicotine repla- cement therapies and bupropion, which are as low as 20% in a year (Department of Health, 2002), even with the best available combination therapies of pharmacolo- gical treatment and behavioural support. A real danger isthat the information provided to patients from the test *Colin O’Gara Medical Officer, Smoking Cessation Clinic, Maudsley Hospitaland Clinical Research Fellow, Institute of Psychiatry, 4 Windsor Walk, London may mislead them into thinking that they have a particu- SE5 8AF, e-mail: c.o’gara@iop. kcl.ac.uk, Marcus Munafo' Lecturer in larly virulent or ‘genetic’ form of addiction and are never Biological Psychiatry, University of Bristol

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