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Psychiatric patients and gene-based smoking cessation packages
Colin O'Gara and Marcus MunafòPsychiatric Bulletin 2006, 30:1-2. References
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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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