The effects of fluoxetine combined with nicotine inhalers in smoking cessation--a randomized trial

Antidepressants for smoking cessation

BACKGROUND

The pharmacological profiles and mechanisms of antidepressants are varied. However, there are common reasons why they might help people to stop smoking tobacco: nicotine withdrawal can produce short-term low mood that antidepressants may relieve; and some antidepressants may have a specific effect on neural pathways or receptors that underlie nicotine addiction.

OBJECTIVES

To assess the evidence for the efficacy, harms, and tolerability of medications with antidepressant properties in assisting long-term tobacco smoking cessation in people who smoke cigarettes.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Specialised Register, most recently on 29 April 2022.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) in people who smoked, comparing antidepressant medications with placebo or no pharmacological treatment, an alternative pharmacotherapy, or the same medication used differently. We excluded trials with fewer than six months of follow-up from efficacy analyses. We included trials with any follow-up length for our analyses of harms.

DATA COLLECTION AND ANALYSIS

We extracted data and assessed risk of bias using standard Cochrane methods. Our primary outcome measure was smoking cessation after at least six months' follow-up. We used the most rigorous definition of abstinence available in each trial, and biochemically validated rates if available. Our secondary outcomes were harms and tolerance outcomes, including adverse events (AEs), serious adverse events (SAEs), psychiatric AEs, seizures, overdoses, suicide attempts, death by suicide, all-cause mortality, and trial dropouts due to treatment. We carried out meta-analyses where appropriate.

MAIN RESULTS

We included a total of 124 studies (48,832 participants) in this review, with 10 new studies added to this update version. Most studies recruited adults from the community or from smoking cessation clinics; four studies focused on adolescents (with participants between 12 and 21 years old). We judged 34 studies to be at high risk of bias; however, restricting analyses only to studies at low or unclear risk of bias did not change clinical interpretation of the results.  There was high-certainty evidence that bupropion increased smoking cessation rates when compared to placebo or no pharmacological treatment (RR 1.60, 95% CI 1.49 to 1.72; I2 = 16%; 50 studies, 18,577 participants). There was moderate-certainty evidence that a combination of bupropion and varenicline may have resulted in superior quit rates to varenicline alone (RR 1.21, 95% CI 0.95 to 1.55; I2 = 15%; 3 studies, 1057 participants). However, there was insufficient evidence to establish whether a combination of bupropion and nicotine replacement therapy (NRT) resulted in superior quit rates to NRT alone (RR 1.17, 95% CI 0.95 to 1.44; I2 = 43%; 15 studies, 4117 participants; low-certainty evidence). There was moderate-certainty evidence that participants taking bupropion were more likely to report SAEs than those taking placebo or no pharmacological treatment. However, results were imprecise and the CI also encompassed no difference (RR 1.16, 95% CI 0.90 to 1.48; I2 = 0%; 23 studies, 10,958 participants). Results were also imprecise when comparing SAEs between people randomised to a combination of bupropion and NRT versus NRT alone (RR 1.52, 95% CI 0.26 to 8.89; I2 = 0%; 4 studies, 657 participants) and randomised to bupropion plus varenicline versus varenicline alone (RR 1.23, 95% CI 0.63 to 2.42; I2 = 0%; 5 studies, 1268 participants). In both cases, we judged evidence to be of low certainty. There was high-certainty evidence that bupropion resulted in more trial dropouts due to AEs than placebo or no pharmacological treatment (RR 1.44, 95% CI 1.27 to 1.65; I2 = 2%; 25 studies, 12,346 participants). However, there was insufficient evidence that bupropion combined with NRT versus NRT alone (RR 1.67, 95% CI 0.95 to 2.92; I2 = 0%; 3 studies, 737 participants) or bupropion combined with varenicline versus varenicline alone (RR 0.80, 95% CI 0.45 to 1.45; I2 = 0%; 4 studies, 1230 participants) had an impact on the number of dropouts due to treatment. In both cases, imprecision was substantial (we judged the evidence to be of low certainty for both comparisons). Bupropion resulted in inferior smoking cessation rates to varenicline (RR 0.73, 95% CI 0.67 to 0.80; I2 = 0%; 9 studies, 7564 participants), and to combination NRT (RR 0.74, 95% CI 0.55 to 0.98; I2 = 0%; 2 studies; 720 participants). However, there was no clear evidence of a difference in efficacy between bupropion and single-form NRT (RR 1.03, 95% CI 0.93 to 1.13; I2 = 0%; 10 studies, 7613 participants). We also found evidence that nortriptyline aided smoking cessation when compared with placebo (RR 2.03, 95% CI 1.48 to 2.78; I2 = 16%; 6 studies, 975 participants), and some evidence that bupropion resulted in superior quit rates to nortriptyline (RR 1.30, 95% CI 0.93 to 1.82; I2 = 0%; 3 studies, 417 participants), although this result was subject to imprecision. Findings were sparse and inconsistent as to whether antidepressants, primarily bupropion and nortriptyline, had a particular benefit for people with current or previous depression.

AUTHORS' CONCLUSIONS

There is high-certainty evidence that bupropion can aid long-term smoking cessation. However, bupropion may increase SAEs (moderate-certainty evidence when compared to placebo/no pharmacological treatment). There is high-certainty evidence that people taking bupropion are more likely to discontinue treatment compared with people receiving placebo or no pharmacological treatment. Nortriptyline also appears to have a beneficial effect on smoking quit rates relative to placebo, although bupropion may be more effective. Evidence also suggests that bupropion may be as successful as single-form NRT in helping people to quit smoking, but less effective than combination NRT and varenicline. In most cases, a paucity of data made it difficult to draw conclusions regarding harms and tolerability. Further studies investigating the efficacy of bupropion versus placebo are unlikely to change our interpretation of the effect, providing no clear justification for pursuing bupropion for smoking cessation over other licensed smoking cessation treatments; namely, NRT and varenicline. However, it is important that future studies of antidepressants for smoking cessation measure and report on harms and tolerability.

Use of Fluoxetine to Reduce Weight in Adults with Overweight or Obesity: Abridged Republication of the Cochrane Systematic Review

INTRODUCTION

Using fluoxetine is one of many weight loss strategies. A serotonin reuptake inhibitor indicated for depression believed to impact weight control by changing an individual's appetite; however, its benefit-risk ratio is unclear. The aim of this review was to assess the efficacy and safety of fluoxetine in reducing weight in adults with overweight or obesity.

METHODS

We searched Cochrane Library, MEDLINE, Embase, and other databases without language restrictions. Cochrane Collaboration tool and GRADE instrument assessed the risk of bias of randomized controlled trials and certainty of their evidence. We conducted random-effects meta-analyses and calculated the risk ratio/mean difference with 95% confidence intervals for the outcomes.

RESULTS

We included 19 trials (2,216 adults) and found that fluoxetine may reduce weight by -2.7 kg (95% CI -4 to -1.4; p < 0.001) and body mass index by -1.1 kg/m2 (95% CI -3.7 to 1.4), compared with placebo; however, it would cause approximately twice as many adverse events, such as dizziness, drowsiness, fatigue, insomnia, or nausea.

CONCLUSIONS

Although low-certainty evidence suggests that off-label fluoxetine may reduce weight, high-certainty research is needed to be conducted in the future to determine its effects exclusively as well as whether it is useful when combined with other agents. This article is based on a Cochrane Review published in the Cochrane Database of Systematic Reviews 2019, Issue 10, DOI: 10.1002/14651858.CD011688.pub2. Cochrane Reviews are regularly updated as new evidence emerges, and in response to feedback, it should be consulted for the most recent version of the review.

Selective serotonin reuptake inhibitors in the treatment of depression, anxiety, and post-traumatic stress disorder in substance use disorders: a Bayesian meta-analysis

PURPOSE

Examine SSRIs' efficacy in treating depression, anxiety, PTSD, and substance use in individuals with addiction.

METHODS

From their inception until August 6, 2021, we searched Google Scholar, PubMed, Scopus, OVID MEDLINE, and Academic Search Complete. We included randomized controlled trials (RCTs) and omitted open-label studies. Bayesian analysis was performed. Bayes factor (BF) established efficacy and tau (τ) statistical heterogeneity. The RoB2 method assessed potential biases. Subgroup analysis was carried out to determine SSRI performance. Treatment duration, SSRI dosage, and attrition rate were all examined in meta-regression.

RESULTS

We investigated 64 RCTs with 6128 participants. SSRIs reduced depressive symptoms in opioid, alcohol, cocaine, cannabis, and nicotine use disorders (d = 0.353, BF > 99); social anxiety symptoms in alcohol use disorder (d = 0.875, BF > 99); and generalized anxiety symptoms in opioid, alcohol, cocaine, marijuana, and nicotine use disorders (d = 0.346, BF = 4.236). Evidence for PTSD was inconclusive. SSRIs facilitated abstinence for opioid, alcohol, cocaine, cannabis, and nicotine use (d = 0.325, BF > 99); reduced craving for alcohol, cocaine, and nicotine use (d = 0.533, BF = 24.129); and reduced alcohol use (d = 0.452, BF > 99) and cocaine use (d = 0.255, BF = 3.87). Fluoxetine showed the highest antidepressant effect. There was no effect of attrition rate, SSRI dosage, or treatment length on SSRI's efficacy.

CONCLUSIONS

Results support the use of SSRIs to treat substance use, depression, and anxiety in individuals with addiction.

PROTOCOL REGISTRATION

PROSPERO registration number: CRD42020164944.

Interventions for preventing weight gain after smoking cessation

BACKGROUND

Most people who stop smoking gain weight. This can discourage some people from making a quit attempt and risks offsetting some, but not all, of the health advantages of quitting. Interventions to prevent weight gain could improve health outcomes, but there is a concern that they may undermine quitting.

OBJECTIVES

To systematically review the effects of: (1) interventions targeting post-cessation weight gain on weight change and smoking cessation (referred to as 'Part 1') and (2) interventions designed to aid smoking cessation that plausibly affect post-cessation weight gain (referred to as 'Part 2').

SEARCH METHODS

Part 1 - We searched the Cochrane Tobacco Addiction Group's Specialized Register and CENTRAL; latest search 16 October 2020. Part 2 - We searched included studies in the following 'parent' Cochrane reviews: nicotine replacement therapy (NRT), antidepressants, nicotine receptor partial agonists, e-cigarettes, and exercise interventions for smoking cessation published in Issue 10, 2020 of the Cochrane Library. We updated register searches for the review of nicotine receptor partial agonists.

SELECTION CRITERIA

Part 1 - trials of interventions that targeted post-cessation weight gain and had measured weight at any follow-up point or smoking cessation, or both, six or more months after quit day. Part 2 - trials included in the selected parent Cochrane reviews reporting weight change at any time point.

DATA COLLECTION AND ANALYSIS

Screening and data extraction followed standard Cochrane methods. Change in weight was expressed as difference in weight change from baseline to follow-up between trial arms and was reported only in people abstinent from smoking. Abstinence from smoking was expressed as a risk ratio (RR). Where appropriate, we performed meta-analysis using the inverse variance method for weight, and Mantel-Haenszel method for smoking.

MAIN RESULTS

Part 1: We include 37 completed studies; 21 are new to this update. We judged five studies to be at low risk of bias, 17 to be at unclear risk and the remainder at high risk.  An intermittent very low calorie diet (VLCD) comprising full meal replacement provided free of charge and accompanied by intensive dietitian support significantly reduced weight gain at end of treatment compared with education on how to avoid weight gain (mean difference (MD) -3.70 kg, 95% confidence interval (CI) -4.82 to -2.58; 1 study, 121 participants), but there was no evidence of benefit at 12 months (MD -1.30 kg, 95% CI -3.49 to 0.89; 1 study, 62 participants). The VLCD increased the chances of abstinence at 12 months (RR 1.73, 95% CI 1.10 to 2.73; 1 study, 287 participants). However, a second study  found that no-one completed the VLCD intervention or achieved abstinence. Interventions aimed at increasing acceptance of weight gain reported mixed effects at end of treatment, 6 months and 12 months with confidence intervals including both increases and decreases in weight gain compared with no advice or health education. Due to high heterogeneity, we did not combine the data. These interventions increased quit rates at 6 months (RR 1.42, 95% CI 1.03 to 1.96; 4 studies, 619 participants; I² = 21%), but there was no evidence at 12 months (RR 1.25, 95% CI 0.76 to 2.06; 2 studies, 496 participants; I² = 26%). Some pharmacological interventions tested for limiting post-cessation weight gain (PCWG) reduced weight gain at the end of treatment (dexfenfluramine, phenylpropanolamine, naltrexone). The effects of ephedrine and caffeine combined, lorcaserin, and chromium were too imprecise to give useful estimates of treatment effects. There was very low-certainty evidence that personalized weight management support reduced weight gain at end of treatment (MD -1.11 kg, 95% CI -1.93 to -0.29; 3 studies, 121 participants; I² = 0%), but no evidence in the longer-term 12 months (MD -0.44 kg, 95% CI -2.34 to 1.46; 4 studies, 530 participants; I² = 41%). There was low to very low-certainty evidence that detailed weight management education without personalized assessment, planning and feedback did not reduce weight gain and may have reduced smoking cessation rates (12 months: MD -0.21 kg, 95% CI -2.28 to 1.86; 2 studies, 61 participants; I² = 0%; RR for smoking cessation 0.66, 95% CI 0.48 to 0.90; 2 studies, 522 participants; I² = 0%). Part 2: We include 83 completed studies, 27 of which are new to this update. There was low certainty that exercise interventions led to minimal or no weight reduction compared with standard care at end of treatment (MD -0.25 kg, 95% CI -0.78 to 0.29; 4 studies, 404 participants; I² = 0%). However, weight was reduced at 12 months (MD -2.07 kg, 95% CI -3.78 to -0.36; 3 studies, 182 participants; I² = 0%). Both bupropion and fluoxetine limited weight gain at end of treatment (bupropion MD -1.01 kg, 95% CI -1.35 to -0.67; 10 studies, 1098 participants; I² = 3%); (fluoxetine MD -1.01 kg, 95% CI -1.49 to -0.53; 2 studies, 144 participants; I² = 38%; low- and very low-certainty evidence, respectively). There was no evidence of benefit at 12 months for bupropion, but estimates were imprecise (bupropion MD -0.26 kg, 95% CI -1.31 to 0.78; 7 studies, 471 participants; I² = 0%). No studies of fluoxetine provided data at 12 months. There was moderate-certainty that NRT reduced weight at end of treatment (MD -0.52 kg, 95% CI -0.99 to -0.05; 21 studies, 2784 participants; I² = 81%) and moderate-certainty that the effect may be similar at 12 months (MD -0.37 kg, 95% CI -0.86 to 0.11; 17 studies, 1463 participants; I² = 0%), although the estimates are too imprecise to assess long-term benefit. There was mixed evidence of the effect of varenicline on weight, with high-certainty evidence that weight change was very modestly lower at the end of treatment (MD -0.23 kg, 95% CI -0.53 to 0.06; 14 studies, 2566 participants; I² = 32%); a low-certainty estimate gave an imprecise estimate of higher weight at 12 months (MD 1.05 kg, 95% CI -0.58 to 2.69; 3 studies, 237 participants; I² = 0%).

AUTHORS' CONCLUSIONS

Overall, there is no intervention for which there is moderate certainty of a clinically useful effect on long-term weight gain. There is also no moderate- or high-certainty evidence that interventions designed to limit weight gain reduce the chances of people achieving abstinence from smoking.

Comparative efficacy and safety of pharmacological interventions for smoking cessation in healthy adults: A network meta-analysis

Smoking is the leading cause of morbidity and mortality in different non-communicable diseases, and cessation leads to immense health benefits. The present network meta-analysis has been conducted to evaluate and compare the effects of available pharmacological interventions for smoking cessation in adults. A standard meta-analysis protocol was developed and after performing a comprehensive literature search on MEDLINE/PubMed, Cochrane databases, and International Clinical Trials Registry Platform, reviewers extracted data from 97 randomized controlled trials. PRISMA guidelines were followed in data extraction, analysis and reporting of findings. Random effects Bayesian network meta-analysis was done to pool the effects across the interventions. Network graph was built, and for closed triangles in the network graph, node splitting analysis was performed. The primary outcome measure was self-reported biochemically verified smoking abstinence at six months. The number of participants achieving continuous abstinence was reported. Data for the number of participants reporting at least one adverse event was also extracted, if available. Combination of nicotine receptor agonist and nicotine replacement therapy had a significant odd of 4.4 (95%CrI:2.2-8.7), bupropion and nicotine receptor agonist 4.0 (95%CrI:2.1-7.7), bupropion and nicotine replacement therapy 3.8 (95%CrI:2.3-6.2), combination nicotine replacement therapy has an odd of 2.6 (95%CrI:1.8-3.8), and nicotine receptor agonist had a significant odd of 2.7 (95%CrI:2.3-3.2) when compared to placebo (moderate quality of evidence) for continuous abstinence at 6 months. When compared with behavioural therapy, the odds ratio of interventions was not statistically significant. Combination of nicotine receptor agonist and nicotine replacement therapy has the highest probability of being the best treatment for abstinence from smoking.

5-HT2A and 5-HT2C receptors as potential targets for the treatment of nicotine use and dependence

Nicotine use and dependence, typically achieved through cigarette smoking, but increasingly through vape products, is the leading cause of preventable death today. Despite a recognition that many current smokers would like to quit, the success rate at doing so is low and indicative of the persistent nature of nicotine dependence and the high urge to relapse. There are currently three main forms of pharmacotherapy approved as aids to treat nicotine dependence: a variety of nicotine replacement products (NRT's), the mixed NA/DA reuptake inhibitor bupropion (Zyban®), and the preferential nicotinic α4β2 receptor agonist drug, varenicline (Chantix®); the latter being generally recognized to be the most effective. However, each of these approaches afford only limited efficacy, and various other pharmacological approaches are being explored. This chapter focusses on approaches targeted to the serotonin (5-HT) system, namely, selective serotonin reuptake inhibitors (SSRI's) which served a pioneer role in the investigation of serotoninergic modulators in human smoking cessation trials; and secondly drugs selectively interacting with the 5-HT2A and 5-HT2C receptor systems. From an efficacy perspective, measured as smoking abstinence, the 5-HT2A agonist psychedelics, namely psilocybin, seem to show the most promise; although as the article highlights, these findings are both preliminary and there are significant challenges to the route to approval, and therapeutic use of this class should they reach approval status. Additional avenues include 5-HT2C receptor agonists, which until recently was pioneered by lorcaserin, and 5-HT2A receptor antagonists represented by pimavanserin. Each of these approaches has distinct profiles across preclinical tests of nicotine dependence, and may have therapeutic potential. It is anticipated as diagnostic and predictive biomarkers emerge, they may provide opportunities for subject stratification and opportunities for personalizing smoking cessation treatment. The clinical assessment of SSRI, 5-HT2A and/or 5-HT2C receptor-based treatments may be best served by this process.

Antidepressants for smoking cessation

BACKGROUND

Whilst the pharmacological profiles and mechanisms of antidepressants are varied, there are common reasons why they might help people to stop smoking tobacco. Firstly, nicotine withdrawal may produce depressive symptoms and antidepressants may relieve these. Additionally, some antidepressants may have a specific effect on neural pathways or receptors that underlie nicotine addiction.

OBJECTIVES

To assess the evidence for the efficacy, safety and tolerability of medications with antidepressant properties in assisting long-term tobacco smoking cessation in people who smoke cigarettes.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Specialized Register, which includes reports of trials indexed in the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and PsycINFO, clinicaltrials.gov, the ICTRP, and other reviews and meeting abstracts, in May 2019.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) that recruited smokers, and compared antidepressant medications with placebo or no treatment, an alternative pharmacotherapy, or the same medication used in a different way. We excluded trials with less than six months follow-up from efficacy analyses. We included trials with any follow-up length in safety analyses.

DATA COLLECTION AND ANALYSIS

We extracted data and assessed risk of bias using standard Cochrane methods. We also used GRADE to assess the certainty of the evidence. The primary outcome measure was smoking cessation after at least six months follow-up, expressed as a risk ratio (RR) and 95% confidence intervals (CIs). We used the most rigorous definition of abstinence available in each trial, and biochemically validated rates if available. Where appropriate, we performed meta-analysis using a fixed-effect model. Similarly, we presented incidence of safety and tolerance outcomes, including adverse events (AEs), serious adverse events (SAEs), psychiatric AEs, seizures, overdoses, suicide attempts, death by suicide, all-cause mortality, and trial dropout due to drug, as RRs (95% CIs).

MAIN RESULTS

We included 115 studies (33 new to this update) in this review; most recruited adult participants from the community or from smoking cessation clinics. We judged 28 of the studies to be at high risk of bias; however, restricting analyses only to studies at low or unclear risk did not change clinical interpretation of the results. There was high-certainty evidence that bupropion increased long-term smoking cessation rates (RR 1.64, 95% CI 1.52 to 1.77; I² = 15%; 45 studies, 17,866 participants). There was insufficient evidence to establish whether participants taking bupropion were more likely to report SAEs compared to those taking placebo. Results were imprecise and CIs encompassed no difference (RR 1.16, 95% CI 0.90 to 1.48; I² = 0%; 21 studies, 10,625 participants; moderate-certainty evidence, downgraded one level due to imprecision). We found high-certainty evidence that use of bupropion resulted in more trial dropouts due to adverse events of the drug than placebo (RR 1.37, 95% CI 1.21 to 1.56; I² = 19%; 25 studies, 12,340 participants). Participants randomized to bupropion were also more likely to report psychiatric AEs compared with those randomized to placebo (RR 1.25, 95% CI 1.15 to 1.37; I² = 15%; 6 studies, 4439 participants). We also looked at the safety and efficacy of bupropion when combined with other non-antidepressant smoking cessation therapies. There was insufficient evidence to establish whether combination bupropion and nicotine replacement therapy (NRT) resulted in superior quit rates to NRT alone (RR 1.19, 95% CI 0.94 to 1.51; I² = 52%; 12 studies, 3487 participants), or whether combination bupropion and varenicline resulted in superior quit rates to varenicline alone (RR 1.21, 95% CI 0.95 to 1.55; I² = 15%; 3 studies, 1057 participants). We judged the certainty of evidence to be low and moderate, respectively; in both cases due to imprecision, and also due to inconsistency in the former. Safety data were sparse for these comparisons, making it difficult to draw clear conclusions. A meta-analysis of six studies provided evidence that bupropion resulted in inferior smoking cessation rates to varenicline (RR 0.71, 95% CI 0.64 to 0.79; I² = 0%; 6 studies, 6286 participants), whilst there was no evidence of a difference in efficacy between bupropion and NRT (RR 0.99, 95% CI 0.91 to 1.09; I² = 18%; 10 studies, 8230 participants). We also found some evidence that nortriptyline aided smoking cessation when compared with placebo (RR 2.03, 95% CI 1.48 to 2.78; I² = 16%; 6 studies, 975 participants), whilst there was insufficient evidence to determine whether bupropion or nortriptyline were more effective when compared with one another (RR 1.30 (favouring bupropion), 95% CI 0.93 to 1.82; I² = 0%; 3 studies, 417 participants). There was no evidence that any of the other antidepressants tested (including St John's Wort, selective serotonin reuptake inhibitors (SSRIs), monoamine oxidase inhibitors (MAOIs)) had a beneficial effect on smoking cessation. Findings were sparse and inconsistent as to whether antidepressants, primarily bupropion and nortriptyline, had a particular benefit for people with current or previous depression.

AUTHORS' CONCLUSIONS

There is high-certainty evidence that bupropion can aid long-term smoking cessation. However, bupropion also increases the number of adverse events, including psychiatric AEs, and there is high-certainty evidence that people taking bupropion are more likely to discontinue treatment compared with placebo. However, there is no clear evidence to suggest whether people taking bupropion experience more or fewer SAEs than those taking placebo (moderate certainty). Nortriptyline also appears to have a beneficial effect on smoking quit rates relative to placebo. Evidence suggests that bupropion may be as successful as NRT and nortriptyline in helping people to quit smoking, but that it is less effective than varenicline. There is insufficient evidence to determine whether the other antidepressants tested, such as SSRIs, aid smoking cessation, and when looking at safety and tolerance outcomes, in most cases, paucity of data made it difficult to draw conclusions. Due to the high-certainty evidence, further studies investigating the efficacy of bupropion versus placebo are unlikely to change our interpretation of the effect, providing no clear justification for pursuing bupropion for smoking cessation over front-line smoking cessation aids already available. However, it is important that where studies of antidepressants for smoking cessation are carried out they measure and report safety and tolerability clearly.

Randomized Clinical Trials Investigating Innovative Interventions for Smoking Cessation in the Last Decade

Every year, billions of dollars are spent treating smoking and related conditions, yet smoking-related morbidity and mortality continue to rise. There are currently only three FDA-approved medications for smoking cessation: nicotine replacement therapy, bupropion, and varenicline. Although these medications increase abstinence rates, most individuals relapse following treatment. This chapter reviews clinical trials published within the past 10 years investigating novel smoking cessation pharmacotherapies. Among these pharmacotherapies, some showed promising results, such as cytisine and endocannabinoid modulators, whereas others failed to produce significant effects. More research is needed to develop drugs that produce higher rates of long-term abstinence and to determine which subgroups of patients benefit from a given treatment.

Fluoxetine for adults who are overweight or obese

BACKGROUND

Fluoxetine is a serotonin reuptake inhibitor indicated for major depression. It is also thought to affect weight control: this seems to happen through appetite changes resulting in decreased food intake and normalisation of unusual eating behaviours. However, the benefit-risk ratio of this off-label medication is unclear.

OBJECTIVES

To assess the effects of fluoxetine for overweight or obese adults.

SEARCH METHODS

We searched the Cochrane Library, MEDLINE, Embase, LILACS, the ICTRP Search Portal and ClinicalTrials.gov and World Health Organization (WHO) ICTRP Search Portal. The last date of the search was December 2018 for all databases, to which we applied no language restrictions .

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing the administration of fluoxetine versus placebo, other anti-obesity agents, non-pharmacological therapy or no treatment in overweight or obese adults without depression, mental illness or abnormal eating patterns.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened abstracts and titles for relevance. Screening for inclusion, data extraction and risk of bias assessment was performed by one author and checked by the second. We assessed trials for the overall certainty of the evidence using the GRADE instrument. For additional information we contacted trial authors by email. We performed random-effects meta-analyses and calculated the risk ratio (RR) with 95% confidence intervals (95% CI) for dichotomous outcomes and the mean difference (MD) with 95% CI for continuous outcomes.

MAIN RESULTS

We identified 1036 records, scrutinized 52 full-text articles and included 19 completed RCTs (one trial is awaiting assessment). A total of 2216 participants entered the trials, 1280 participants were randomly assigned to fluoxetine (60 mg/d, 40 mg/d, 20 mg/d and 10 mg/d) and 936 participants were randomly assigned to various comparison groups (placebo; the anti-obesity agents diethylpropion, fenproporex, mazindol, sibutramine, metformin, fenfluramine, dexfenfluramine, fluvoxamine, 5-hydroxy-tryptophan; no treatment; and omega-3 gel). Within the 19 RCTs there were 56 trial arms. Fifteen trials were parallel RCTs and four were cross-over RCTs. The participants in the included trials were followed up for periods between three weeks and one year. The certainty of the evidence was low or very low: the majority of trials had a high risk of bias in one or more of the risk of bias domains.For our main comparison group - fluoxetine versus placebo - and across all fluoxetine dosages and durations of treatment, the MD was -2.7 kg (95% CI -4 to -1.4; P < 0.001; 10 trials, 956 participants; low-certainty evidence). The 95% prediction interval ranged between -7.1 kg and 1.7 kg. The MD in body mass index (BMI) reduction across all fluoxetine dosages compared with placebo was -1.1 kg/m² (95% CI -3.7 to 1.4; 3 trials, 97 participants; very low certainty evidence). Only nine placebo-controlled trials reported adverse events. A total of 399 out of 627 participants (63.6%) receiving fluoxetine compared with 352 out of 626 participants (56.2%) receiving placebo experienced an adverse event. Random-effects meta-analysis showed an increase in the risk of having at least one adverse event of any type in the fluoxetine groups compared with placebo (RR 1.18, 95% CI 0.99 to 1.42; P = 0.07; 9 trials, 1253 participants; low-certainty evidence). The 95% prediction interval ranged between 0.74 and 1.88. Following fluoxetine treatment the adverse events of dizziness, drowsiness, fatigue, insomnia and nausea were observed approximately twice as often compared to placebo. A total of 15 out of 197 participants (7.6%) receiving fluoxetine compared with 12 out of 196 participants (6.1%) receiving placebo experienced depression. The RR across all fluoxetine doses compared with placebo was 1.20 (95% CI 0.57 to 2.52; P = 0.62; 3 trials, 393 participants; very low certainty evidence). All-cause mortality, health-related quality of life and socioeconomic effects were not reported.The comparisons of fluoxetine with other anti-obesity agents (3 trials, 234 participants), omega-3 gel (1 trial, 48 participants) and no treatment (1 trial, 60 participants) showed inconclusive results (very low certainty evidence).

AUTHORS' CONCLUSIONS

Low-certainty evidence suggests that off-label fluoxetine may decrease weight compared with placebo. However, low-certainty evidence suggests an increase in the risk for dizziness, drowsiness, fatigue, insomnia and nausea following fluoxetine treatment.

Effectiveness of pharmacological or psychological interventions for smoking cessation in smokers with major depression or depressive symptoms: A systematic review of the literature

BACKGROUND

Smokers with major depressive disorder (MDD) or depressive symptoms (DS) represent a subgroup in need of attention, since they have specific clinical features and prognosis.

METHODS

A systematic review of the literature (Cochrane, MEDLINE, ScienceDirect, Web of Science databases from inception to June 2017) of randomized clinical trials assessing the effectiveness of pharmacological, psychological, or combined interventions for smoking cessation in subjects with current or past MDD/DS without medical or comorbid psychiatric disorder(s) was run following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

RESULTS

Twenty-seven studies met the inclusion criteria. Nicotine, varenicline, and staged-care intervention were more effective in smokers with current MDD; nicotine and fluoxetine plus nicotine were more effective in smokers with DS; naltrexone and nicotine plus fluoxetine were more effective in smokers with severe current DS. Cognitive-behavioral therapy and cognitive and behavioral cessation and relapse prevention skills training were superior to placebo in smokers with past MDD.

CONCLUSIONS

More research is needed into effectively addressing smoking in people with concurrent mental disorder. Data currently available need to be confirmed in randomized trials aimed at replicating the results and disentangling the effects of each therapeutic ingredient when a combination therapy is proposed. Studies on tolerability of treatments are warranted, as well as those aimed at identifying factors of vulnerability to adverse effects.

Ecological momentary analysis of the relations among stressful events, affective reactivity, and smoking among smokers with high versus low depressive symptoms during a quit attempt

AIMS

To assess whether individuals trying to quit smoking who have high depressive symptoms (HD), compared with low depressive symptoms (LD): (1) report more frequent stressful events (SEs), (2) are more likely to smoke after SEs, (3) experience greater acute or persistent changes in affect after an SE, and (4) are at greater risk of smoking following affective changes.

DESIGN

Smoking cessation data were analyzed using multi-level path modeling to examine the moderating effects of depressive symptoms on relations among SEs, subsequent affect, and smoking.

SETTING

An academic research center in Central New Jersey, USA.

PARTICIPANTS

Seventy-one adult treatment-seeking daily smokers recruited from 2010 to 2012.

MEASUREMENTS

Baseline depressive symptoms [HD: Center for Epidemiological Studies Depression Scale (CES-D) ≥ 16 versus LD: CES-D < 16]; and real-time ecological momentary assessment (EMA) reports of SEs, affect, and smoking assessed during 21 days post-quit.

FINDINGS

Multi-level models indicated that HD smokers were more likely than LD smokers to report stressful events [odds ratio (OR) = 2.323, P = 0.009], but had similar post-stress acute affective changes (negative affect: b = -0.117, P = 0.137, positive affect: b = 0.020, P = 0.805). Only HD smokers reported increased negative affect (NA) (b = 0.199, P = 0.030) and decreased positive affect (PA) up to 12 hours later (b = -0.217, P = 0.021), and greater lapse risk up to 24 hours after an SE (OR = 3.213, P = 0.017). The persistence of elevated NA and suppressed PA was partially explained by increased odds of subsequent SEs among HD smokers. However, the heightened stress-lapse association over 24 hours found in HD smokers was not fully explained by sustained aversive affect or subsequent SEs.

CONCLUSIONS

Depressed and non-depressed smokers trying to quit appear to experience similar acute affective changes following stress: however, depressed smokers experience higher rates of exposure to stress, longer-lasting post-stress affective disturbance and greater risk of smoking lapse 12-24 hours after a stressful event than non-depressed smokers.

New Pharmacological Agents to Aid Smoking Cessation and Tobacco Harm Reduction: What Has Been Investigated, and What Is in the Pipeline?

A wide range of support is available to help smokers to quit and to aid attempts at harm reduction, including three first-line smoking cessation medications: nicotine replacement therapy, varenicline and bupropion. Despite the efficacy of these, there is a continual need to diversify the range of medications so that the needs of tobacco users are met. This paper compares the first-line smoking cessation medications with (1) two variants of these existing products: new galenic formulations of varenicline and novel nicotine delivery devices; and (2) 24 alternative products: cytisine (novel outside Central and Eastern Europe), nortriptyline, other tricyclic antidepressants, electronic cigarettes, clonidine (an anxiolytic), other anxiolytics (e.g. buspirone), selective serotonin reuptake inhibitors, supplements (e.g. St John's wort), silver acetate, Nicobrevin, modafinil, venlafaxine, monoamine oxidase inhibitors (MAOIs), opioid antagonists, nicotinic acetylcholine receptor (nAChR) antagonists, glucose tablets, selective cannabinoid type 1 receptor antagonists, nicotine vaccines, drugs that affect gamma-aminobutyric acid (GABA) transmission, drugs that affect N-methyl-D-aspartate (NMDA) receptors, dopamine agonists (e.g. levodopa), pioglitazone (Actos; OMS405), noradrenaline reuptake inhibitors and the weight management drug lorcaserin. Six 'ESCUSE' criteria-relative efficacy, relative safety, relative cost, relative use (overall impact of effective medication use), relative scope (ability to serve new groups of patients) and relative ease of use-are used. Many of these products are in the early stages of clinical trials; however, cytisine looks most promising in having established efficacy and safety with low cost. Electronic cigarettes have become very popular, appear to be efficacious and are safer than smoking, but issues of continued dependence and possible harms need to be considered.

Sex differences in attenuation of nicotine reinstatement after individual and combined treatments of progesterone and varenicline

Tobacco use is the largest cause of preventable mortality in the western world. Even after treatment, relapse rates for tobacco are high, and more effective pharmacological treatments are needed. Progesterone (PRO), a female hormone used in contraceptives, reduces stimulant use but its effects on tobacco addiction are unknown. Varenicline (VAR) is a commonly used medication that reduces tobacco use. The present study examined sex differences in the individual vs. combined effects of PRO and VAR on reinstatement of nicotine-seeking behavior in a rat model of relapse. Adult female and male Wistar rats self-administered nicotine (NIC, 0.03mg/kg/infusion) for 14days followed by 21days of extinction when no cues or drug were present. Rats were then divided into 4 treatment groups: control (VEH+SAL), PRO alone (PRO+SAL), VAR alone (VEH+VAR) and the combination (PRO+VAR). Reinstatement of nicotine-seeking behavior induced by priming injections of NIC or caffeine (CAF), presentation of cues (CUES), and the combination of drugs and cues (e.g. NIC+CUES, CAF+CUES) were tested after extinction. Male and female rats did not differ in self-administration of nicotine or extinction responding, and both showed elevated levels of responding to the CAF+CUES condition. However, males, but not females, reinstated active lever-pressing to the NIC+CUES condition, and that was attenuated by both VAR and VAR+PRO treatment. Thus, males were more sensitive to NIC+CUE-induced reinstatement than females, and VAR alone and VAR combined with PRO effectively reduced nicotine relapse.

Effects of sequential fluoxetine and gender on prequit depressive symptoms, affect, craving, and quit day abstinence in smokers with elevated depressive symptoms: a growth curve modeling approach

Although the important roles of postquit affect and withdrawal symptoms in the process of smoking cessation have been well established, little is known about the relations between prequit affective trajectories and cessation outcome on the target quit date (TQD). This study examined whether a 16-week course of fluoxetine initiated 8 weeks prequit ("sequential" fluoxetine) improved TQD abstinence relative to placebo through its effects on prequit depressive symptoms, affect (withdrawal-relevant negative affect, general negative affect, and positive affect), and craving to smoke among 206 smokers with elevated depressed symptoms. The moderating effects of gender were also examined. In total, 83 smokers (40%) failed to achieve abstinence on TQD, with no difference between treatment conditions or gender. Overall structural equation models showed that fluoxetine had significant indirect effects on TQD abstinence through changes in prequit withdrawal-relevant negative affect and craving, but not depressive symptoms. However, multigroup analyses revealed gender differences. Sequential fluoxetine reduced prequit depressive symptoms, withdrawal-relevant negative affect, and craving only among women. Reduction in prequit depressive symptoms and craving among women, and withdrawal-relevant negative affect among men was associated with TQD abstinence. Moreover, exploratory analysis showed negative trend-level indirect effects of fluoxetine on TQD abstinence via increased side effects, regardless of gender. This study demonstrated the importance of considering gender when examining treatment efficacy. Identifying ways to further reduce prequit depressive symptoms and craving for women and withdrawal-relevant negative affect for men whereas alleviating side effects may help smokers with elevated depressed symptoms achieve the first smoking cessation milestone.

Antidepressants for smoking cessation

BACKGROUND

There are at least three reasons to believe antidepressants might help in smoking cessation. Firstly, nicotine withdrawal may produce depressive symptoms or precipitate a major depressive episode and antidepressants may relieve these. Secondly, nicotine may have antidepressant effects that maintain smoking, and antidepressants may substitute for this effect. Finally, some antidepressants may have a specific effect on neural pathways (e.g. inhibiting monoamine oxidase) or receptors (e.g. blockade of nicotinic-cholinergic receptors) underlying nicotine addiction.

OBJECTIVES

The aim of this review is to assess the effect and safety of antidepressant medications to aid long-term smoking cessation. The medications include bupropion; doxepin; fluoxetine; imipramine; lazabemide; moclobemide; nortriptyline; paroxetine; S-Adenosyl-L-Methionine (SAMe); selegiline; sertraline; St. John's wort; tryptophan; venlafaxine; and zimeledine.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Specialised Register which includes reports of trials indexed in the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, and PsycINFO, and other reviews and meeting abstracts, in July 2013.

SELECTION CRITERIA

We considered randomized trials comparing antidepressant medications to placebo or an alternative pharmacotherapy for smoking cessation. We also included trials comparing different doses, using pharmacotherapy to prevent relapse or re-initiate smoking cessation or to help smokers reduce cigarette consumption. We excluded trials with less than six months follow-up.

DATA COLLECTION AND ANALYSIS

We extracted data and assessed risk of bias using standard methodological procedures expected by the Cochrane Collaboration.The main outcome measure was abstinence from smoking after at least six months follow-up in patients smoking at baseline, expressed as a risk ratio (RR). We used the most rigorous definition of abstinence available in each trial, and biochemically validated rates if available. Where appropriate, we performed meta-analysis using a fixed-effect model.

MAIN RESULTS

Twenty-four new trials were identified since the 2009 update, bringing the total number of included trials to 90. There were 65 trials of bupropion and ten trials of nortriptyline, with the majority at low or unclear risk of bias. There was high quality evidence that, when used as the sole pharmacotherapy, bupropion significantly increased long-term cessation (44 trials, N = 13,728, risk ratio [RR] 1.62, 95% confidence interval [CI] 1.49 to 1.76). There was moderate quality evidence, limited by a relatively small number of trials and participants, that nortriptyline also significantly increased long-term cessation when used as the sole pharmacotherapy (six trials, N = 975, RR 2.03, 95% CI 1.48 to 2.78). There is insufficient evidence that adding bupropion (12 trials, N = 3487, RR 1.9, 95% CI 0.94 to 1.51) or nortriptyline (4 trials, N = 1644, RR 1.21, 95% CI 0.94 to 1.55) to nicotine replacement therapy (NRT) provides an additional long-term benefit. Based on a limited amount of data from direct comparisons, bupropion and nortriptyline appear to be equally effective and of similar efficacy to NRT (bupropion versus nortriptyline 3 trials, N = 417, RR 1.30, 95% CI 0.93 to 1.82; bupropion versus NRT 8 trials, N = 4096, RR 0.96, 95% CI 0.85 to 1.09; no direct comparisons between nortriptyline and NRT). Pooled results from four trials comparing bupropion to varenicline showed significantly lower quitting with bupropion than with varenicline (N = 1810, RR 0.68, 95% CI 0.56 to 0.83). Meta-analyses did not detect a significant increase in the rate of serious adverse events amongst participants taking bupropion, though the confidence interval only narrowly missed statistical significance (33 trials, N = 9631, RR 1.30, 95% CI 1.00 to 1.69). There is a risk of about 1 in 1000 of seizures associated with bupropion use. Bupropion has been associated with suicide risk, but whether this is causal is unclear. Nortriptyline has the potential for serious side-effects, but none have been seen in the few small trials for smoking cessation.There was no evidence of a significant effect for selective serotonin reuptake inhibitors on their own (RR 0.93, 95% CI 0.71 to 1.22, N = 1594; 2 trials fluoxetine, 1 paroxetine, 1 sertraline) or as an adjunct to NRT (3 trials of fluoxetine, N = 466, RR 0.70, 95% CI 0.64 to 1.82). Significant effects were also not detected for monoamine oxidase inhibitors (RR 1.29, 95% CI 0.93 to 1.79, N = 827; 1 trial moclobemide, 5 selegiline), the atypical antidepressant venlafaxine (1 trial, N = 147, RR 1.22, 95% CI 0.64 to 2.32), the herbal therapy St John's wort (hypericum) (2 trials, N = 261, RR 0.81, 95% CI 0.26 to 2.53), or the dietary supplement SAMe (1 trial, N = 120, RR 0.70, 95% CI 0.24 to 2.07).

AUTHORS' CONCLUSIONS

The antidepressants bupropion and nortriptyline aid long-term smoking cessation. Adverse events with either medication appear to rarely be serious or lead to stopping medication. Evidence suggests that the mode of action of bupropion and nortriptyline is independent of their antidepressant effect and that they are of similar efficacy to nicotine replacement. Evidence also suggests that bupropion is less effective than varenicline, but further research is needed to confirm this finding. Evidence suggests that neither selective serotonin reuptake inhibitors (e.g. fluoxetine) nor monoamine oxidase inhibitors aid cessation.

Efficacy of sequential use of fluoxetine for smoking cessation in elevated depressive symptom smokers

INTRODUCTION

Fluoxetine, a selective serotonin reuptake inhibitor, was examined in the treatment of smokers with elevated depressive symptoms. Specifically, this randomized, open-label clinical trial was designed to evaluate the efficacy of three logical, real-world alternatives for providing smoking cessation treatment to smokers with elevated depressive symptoms.

METHODS

In a sample of 216 smokers (mean Center for Epidemiological Studies Depression Scale score = 11.41), participants were randomly assigned to (a) transdermal nicotine patch (TNP), beginning on quit date and continuing for 8 weeks thereafter; (b) standard administration of antidepressant pharmacotherapy with fluoxetine (20mg), beginning 2 weeks before quit date and continuing for 8 weeks following quit date + TNP (ST-FLUOX); or (c) sequential administration of fluoxetine (20mg), beginning 8 weeks before quit date and continuing for 8 weeks following quit date + TNP (SEQ-FLUOX). All participants received 5 sessions of brief behavioral smoking cessation treatment.

RESULTS

Findings indicate that SEQ-FLUOX resulted in significantly higher point prevalence abstinence than ST-FLUOX at 6-month follow-up (OR = 2.35; 95% CI = 1.10-5.02, p < .03), a difference that was reduced at the 12-month assessment. Furthermore, sequential fluoxetine treatment, compared with standard fluoxetine treatment, resulted in significantly lower levels of depressive symptoms throughout smoking cessation treatment (p < .025) and significantly lower nicotine withdrawal-related negative affect (p < .004) immediately after quitting.

CONCLUSIONS

Findings suggest that if one is going to prescribe fluoxetine for smoking cessation in smokers with elevated depressive symptoms, it is best to begin prescribing fluoxetine well before the target quit date.

Smoking cessation interventions for smokers with current or past depression

BACKGROUND

Individuals with current or past depression are often smokers who are more nicotine dependent, more likely to suffer from negative mood changes after nicotine withdrawal, and more likely to relapse to smoking after quitting than the general population, which contributes to their higher morbidity and mortality from smoking-related illnesses. It remains unclear what interventions can help them to quit smoking.

OBJECTIVES

To evaluate the effectiveness of smoking cessation interventions, with and without specific mood management components, in smokers with current or past depression.

SEARCH METHODS

In April 2013, we searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, PsycINFO, other reviews, and asked experts for information on trials.

SELECTION CRITERIA

Criteria for including studies in this review were that they had to be randomised controlled trials (RCTs) comparing smoking cessation interventions in adult smokers with current or past depression. Depression was defined as major depression or depressive symptoms. We included studies where subgroups of participants with depression were identified, either pre-stated or post hoc. The outcome was abstinence from smoking after six months or longer follow-up. We preferred prolonged or continuous abstinence and biochemically validated abstinence where available.

DATA COLLECTION AND ANALYSIS

When possible, we estimated pooled risk ratios (RRs) with the Mantel-Haenszel method (fixed-effect model). We also performed subgroup analyses, by length of follow-up, depression measurement, depression group in study, antidepressant use, published or unpublished data, format of intervention, level of behavioural support, additional pharmacotherapy, type of antidepressant medication, and additional nicotine replacement therapy (NRT).

MAIN RESULTS

Forty-nine RCTs were included of which 33 trials investigated smoking cessation interventions with specific mood management components for depression. In smokers with current depression, meta-analysis showed a significant positive effect for adding psychosocial mood management to a standard smoking cessation intervention when compared with standard smoking cessation intervention alone (11 trials, N = 1844, RR 1.47, 95% CI 1.13 to 1.92). In smokers with past depression we found a similar effect (13 trials, N = 1496, RR 1.41, 95% CI 1.13 to 1.77). Meta-analysis resulted in a positive effect, although not significant, for adding bupropion compared with placebo in smokers with current depression (5 trials, N = 410, RR 1.37, 95% CI 0.83 to 2.27). There were not enough trial data to evaluate the effectiveness of fluoxetine and paroxetine for smokers with current depression. Bupropion (4 trials, N = 404, RR 2.04, 95% CI 1.31 to 3.18) might significantly increase long-term cessation among smokers with past depression when compared with placebo, but the evidence for bupropion is relatively weak due to the small number of studies and the post hoc subgroups for all the studies. There were not enough trial data to evaluate the effectiveness of fluoxetine, nortriptyline, paroxetine, selegiline, and sertraline in smokers with past depression.Twenty-three of the 49 trials investigated smoking cessation interventions without specific components for depression. There was heterogeneity between the trials which compared psychosocial interventions with standard smoking cessation counselling for both smokers with current and past depression. Therefore, we did not estimate a pooled effect. One trial compared nicotine replacement therapy (NRT) versus placebo in smokers with current depression and found a positive, although not significant, effect (N = 196, RR 2.64, 95% CI 0.93 to 7.45). Meta-analysis also found a positive, although not significant, effect for NRT versus placebo in smokers with past depression (3 trials, N = 432, RR 1.17, 95% CI 0.85 to 1.60). Three trials compared other pharmacotherapy versus placebo and six trials compared other interventions in smokers with current or past depression. Due to heterogeneity between the interventions of the included trials we did not estimate pooled effects.

AUTHORS' CONCLUSIONS

Evidence suggests that adding a psychosocial mood management component to a standard smoking cessation intervention increases long-term cessation rates in smokers with both current and past depression when compared with the standard intervention alone. Pooled results from four trials suggest that use of bupropion may increase long-term cessation in smokers with past depression. There was no evidence found for the use of bupropion in smokers with current depression. There was not enough evidence to evaluate the effectiveness of the other antidepressants in smokers with current or past depression. There was also not enough evidence to evaluate the group of trials that investigated interventions without specific mood management components for depression, including NRT and psychosocial interventions.

Two decades of smoking cessation treatment research on smokers with depression: 1990-2010

INTRODUCTION

Adults with depression smoke at higher rates than other adults leaving a large segment of this population, who already incur increased health-related risks, vulnerable to the enormous harmful consequences of smoking. Yet, the impact that depression has on smoking cessation is not clear due to the mixed results of past research. The primary aims of this review were to synthesize the research examining the relationship of depression to smoking cessation outcomes over a 20-year period, to examine the gender and racial composition of these studies, and to identify directions for future research.

METHODS

Potential articles published between January 1, 1990 and December 31, 2010 were identified through a MEDLINE search of the terms "clinical trial," "depression," and "smoking cessation." 68 studies used all three terms and met the inclusion criteria.

RESULTS

The majority of studies examined either a past diagnosis of major depression or current depression symptoms. Within the few studies that examined the interaction of gender and depression on smoking cessation, depression had a greater impact on treatment outcomes for women than men. No study reported examining the interactive impact of race and depression on treatment outcomes.

CONCLUSIONS

Although attention to the relationship of depression and smoking cessation outcomes has increased over the past 20 years, little information exists to inform a treatment approach for smokers with Current Major Depressive Disorder, Dysthymia, and Minor Depression and few studies report gender and racial differences in the relationship of depression and smoking cessation outcomes, thus suggesting major areas for targeted research.

Weight gain in smokers after quitting cigarettes: meta-analysis

OBJECTIVE

To describe weight gain and its variation in smokers who achieve prolonged abstinence for up to 12 months and who quit without treatment or use drugs to assist cessation.

DESIGN

Meta-analysis.

DATA SOURCES

We searched the Central Register of Controlled Trials (CENTRAL) and trials listed in Cochrane reviews of smoking cessation interventions (nicotine replacement therapy, nicotinic partial agonists, antidepressants, and exercise) for randomised trials of first line treatments (nicotine replacement therapy, bupropion, and varenicline) and exercise that reported weight change. We also searched CENTRAL for trials of interventions for weight gain after cessation.

REVIEW METHODS

Trials were included if they recorded weight change from baseline to follow-up in abstinent smokers. We used a random effects inverse variance model to calculate the mean and 95% confidence intervals and the mean of the standard deviation for weight change from baseline to one, two, three, six, and 12 months after quitting. We explored subgroup differences using random effects meta-regression.

RESULTS

62 studies were included. In untreated quitters, mean weight gain was 1.12 kg (95% confidence interval 0.76 to 1.47), 2.26 kg (1.98 to 2.54), 2.85 kg (2.42 to 3.28), 4.23 kg (3.69 to 4.77), and 4.67 kg (3.96 to 5.38) at one, two, three, six, and 12 months after quitting, respectively. Using the means and weighted standard deviations, we calculated that at 12 months after cessation, 16%, 37%, 34%, and 13% of untreated quitters lost weight, and gained less than 5 kg, gained 5-10 kg, and gained more than 10 kg, respectively. Estimates of weight gain were similar for people using different pharmacotherapies to support cessation. Estimates were also similar between people especially concerned about weight gain and those not concerned.

CONCLUSION

Smoking cessation is associated with a mean increase of 4-5 kg in body weight after 12 months of abstinence, and most weight gain occurs within three months of quitting. Variation in weight change is large, with about 16% of quitters losing weight and 13% gaining more than 10 kg.

Interventions for preventing weight gain after smoking cessation

BACKGROUND

Most people who stop smoking gain weight. There are some interventions that have been designed to reduce weight gain when stopping smoking. Some smoking cessation interventions may also limit weight gain although their effect on weight has not been reviewed.

OBJECTIVES

To systematically review the effect of: (1) Interventions targeting post-cessation weight gain on weight change and smoking cessation.(2) Interventions designed to aid smoking cessation that may also plausibly affect weight on post-cessation weight change.

SEARCH METHODS

Part 1 - We searched the Cochrane Tobacco Addiction Group's Specialized Register and CENTRAL in September 2011.Part 2 - In addition we searched the included studies in the following "parent" Cochrane reviews: nicotine replacement therapy (NRT), antidepressants, nicotine receptor partial agonists, cannabinoid type 1 receptor antagonists and exercise interventions for smoking cessation published in Issue 9, 2011 of the Cochrane Library.

SELECTION CRITERIA

Part 1 - We included trials of interventions that were targeted at post-cessation weight gain and had measured weight at any follow up point and/or smoking cessation six or more months after quit day.Part 2 - We included trials that had been included in the selected parent Cochrane reviews if they had reported weight gain at any time point.

DATA COLLECTION AND ANALYSIS

We extracted data on baseline characteristics of the study population, intervention, outcome and study quality. Change in weight was expressed as difference in weight change from baseline to follow up between trial arms and was reported in abstinent smokers only. Abstinence from smoking was expressed as a risk ratio (RR). We used the most rigorous definition of abstinence available in each trial. Where appropriate, we performed meta-analysis using the inverse variance method for weight and Mantel-Haenszel method for smoking using a fixed-effect model.

MAIN RESULTS

Part 1: Some pharmacological interventions tested for limiting post cessation weight gain (PCWG) resulted in a significant reduction in WG at the end of treatment (dexfenfluramine (Mean difference (MD) -2.50 kg, 95% confidence interval (CI) -2.98 to -2.02, 1 study), phenylpropanolamine (MD -0.50 kg, 95% CI -0.80 to -0.20, N=3), naltrexone (MD -0.78 kg, 95% CI -1.52 to -0.05, N=2). There was no evidence that treatment reduced weight at 6 or 12 months (m). No pharmacological intervention significantly affected smoking cessation rates.Weight management education only was associated with no reduction in PCWG at end of treatment (6 or 12m). However these interventions significantly reduced abstinence at 12m (Risk ratio (RR) 0.66, 95% CI 0.48 to 0.90, N=2). Personalised weight management support reduced PCWG at 12m (MD -2.58 kg, 95% CI -5.11 to -0.05, N=2) and was not associated with a significant reduction of abstinence at 12m (RR 0.74, 95% CI 0.39 to 1.43, N=2). A very low calorie diet (VLCD) significantly reduced PCWG at end of treatment (MD -3.70 kg, 95% CI -4.82 to -2.58, N=1), but not significantly so at 12m (MD -1.30 kg, 95% CI -3.49 to 0.89, N=1). The VLCD increased chances of abstinence at 12m (RR 1.73, 95% CI 1.10 to 2.73, N=1). There was no evidence that cognitive behavioural therapy to allay concern about weight gain (CBT) reduced PCWG, but there was some evidence of increased PCWG at 6m (MD 0.74, 95% CI 0.24 to 1.24). It was associated with improved abstinence at 6m (RR 1.83, 95% CI 1.07 to 3.13, N=2) but not at 12m (RR 1.25, 95% CI 0.83 to 1.86, N=2). However, there was significant statistical heterogeneity.Part 2: We found no evidence that exercise interventions significantly reduced PCWG at end of treatment (MD -0.25 kg, 95% CI -0.78 to 0.29, N=4) however a significant reduction was found at 12m (MD -2.07 kg, 95% CI -3.78 to -0.36, N=3).Both bupropion and fluoxetine limited PCWG at the end of treatment (bupropion MD -1.12 kg, 95% CI -1.47 to -0.77, N=7) (fluoxetine MD -0.99 kg, 95% CI -1.36 to -0.61, N=2). There was no evidence that the effect persisted at 6m (bupropion MD -0.58 kg, 95% CI -2.16 to 1.00, N=4), (fluoxetine MD -0.01 kg, 95% CI -1.11 to 1.10, N=2) or 12m (bupropion MD -0.38 kg, 95% CI -2.00 to 1.24, N=4). There were no data on WG at 12m for fluoxetine.Overall, treatment with NRT attenuated PCWG at the end of treatment (MD -0.69 kg, 95% CI -0.88 to -0.51, N=19), with no strong evidence that the effect differed for the different forms of NRT. There was evidence of significant statistical heterogeneity caused by one study which reported a 4.3 kg reduction in PCWG due to NRT. With this study removed, the difference in weight change at end of treatment was -0.45 kg (95% CI -0.66 to -0.27, N=18). There was no evidence of an effect on PCWG at 12m (MD -0.42 kg, 95% CI -0.92 to 0.08, N=15).We found evidence that varenicline significantly reduced PCWG at end of treatment (MD -0.41 kg, 95% CI -0.63 to -0.19, N=11), but this effect was not maintained at 6 or 12m. Three studies compared the effect of bupropion to varenicline. Participants taking bupropion gained significantly less weight at the end of treatment (-0.51 kg (95% CI -0.93 to -0.09 kg), N=3). Direct comparison showed no significant difference in PCWG between varenicline and NRT.

AUTHORS' CONCLUSIONS

Although some pharmacotherapies tested to limit PCWG show evidence of short-term success, other problems with them and the lack of data on long-term efficacy limits their use. Weight management education only, is not effective and may reduce abstinence. Personalised weight management support may be effective and not reduce abstinence, but there are too few data to be sure. One study showed a VLCD increased abstinence but did not prevent WG in the longer term. CBT to accept WG did not limit PCWG and may not promote abstinence in the long term. Exercise interventions significantly reduced weight in the long term, but not the short term. More studies are needed to clarify whether this is an effect of treatment or a chance finding. Bupropion, fluoxetine, NRT and varenicline reduce PCWG while using the medication. Although this effect was not maintained one year after stopping smoking, the evidence is insufficient to exclude a modest long-term effect. The data are not sufficient to make strong clinical recommendations for effective programmes to prevent weight gain after cessation.

Predictors of persistent nicotine dependence among adults in the United States

BACKGROUND

Evidence suggests that nicotine dependence is the key barrier to successful smoking cessation. No previous study has documented predictors of persistent nicotine dependence among adults in the community. The goal of this study is to prospectively identify predictors of continued nicotine dependence over a 3-year period among adults.

METHODS

Data were drawn from Waves I and II of the National Epidemiologic Survey of Alcohol and Related Conditions (NESARC), a nationally representative sample of 34,653 adults in the United States. Logistic regression analyses were used to estimate the odds of persistent nicotine dependence at Wave 2 given the presence of various sociodemographic and psychiatric predictors at Wave 1.

RESULTS

Mood, anxiety, personality and illicit substance use disorders were associated with significantly increased risk of persistent nicotine dependence. The strength of these relationships was attenuated slightly after adjusting for demographic differences, but remained statistically significant. Persistent nicotine dependence was more common among unmarried, younger females with lower income levels and lower educational attainment.

CONCLUSIONS

To our knowledge, this study is the first to prospectively identify predictors of persistent nicotine dependence among adults. Our results suggest that the incorporation of mental health treatment into alternative smoking cessation approaches may help to increase the effectiveness of these programs and that a greater focus of these services on vulnerable segments of the population is needed in order to reduce continued disparities in smoking in the general population.

Depressive mood, suicide ideation and anxiety in smokers who do and smokers who do not manage to stop smoking after a target quit day

AIMS

The effect of successful and unsuccessful smoking cessation on depressive mood, anxiety- and suicide-related outcomes is unclear. The aim of this secondary analysis was to explore the relationship between abstinence status and these outcomes.

DESIGN

Cohort of adult smokers attempting to stop smoking. Smoking status was assessed by a daily diary; depressed mood, anxiety and suicidal tendencies by the Hamilton Depression Rating Scale (HDRS). The association of complete and point-prevalence abstinence with the HDRS variables was assessed using multi-level linear regression models.

SETTING

Randomized trial of sertraline versus placebo for smoking cessation with weekly behavioural support provided in a clinic.

PARTICIPANTS

A total of 133 adult smokers with past major depression.

FINDINGS

Pre-quit mood scores did not predict smoking status post-quit day. Both continuous and point-prevalence abstainers had significantly lower total HDRS, suicide and anxiety scores, adjusted for all potential confounders, during the period following quit day than did non-abstainers who experienced a significant mood deterioration. There was a significant effect of sertraline on post-quit HDRS scores but not on abstinence.

CONCLUSIONS

Contrary to expectation, smoking abstinence among smokers with a history of major depression did not lead to increase in depression, anxiety or suicide ideation; however, failed quit attempts did. Persisting with a quit attempt while unable to achieve abstinence may be associated with mood deterioration.

Treatment of smokers with co-occurring disorders: emphasis on integration in mental health and addiction treatment settings

This article reviews the research on the treatment of cigarette smoking in individuals who have comorbid mental illnesses or non-nicotinic addictions. The prevalence of smoking in mentally ill and substance-abusing populations is presented, as well as reasons for this high prevalence. The historical role of cigarettes and tobacco in mental illness and addiction is reviewed to help the reader better understand the pervasiveness of smoking in these disorders and the relative absence of intervention efforts in mental heath and addiction treatment settings. The article then discusses the several reasons for integrating smoking treatment into mental health and addiction settings. The outcome research for adult and adolescent comorbid smokers is reviewed, and barriers to treatment are discussed. The review closes with a brief discussion of models of integration and thoughts about prevention.

Smoking cessation pharmacotherapy

Cigarette smoking remains an important risk factor for premature cardiovascular disease and its many complications. There are clear benefits from treating tobacco dependence on the rate of clinical outcomes. In addition to behavioral therapies, various pharmacologic strategies have been developed to help achieve this goal. First-line therapies include nicotine replacement, bupropion and varenicline, a partial nicotine antagonist. Second-line treatments include clonidine and nortriptyline. Additional treatment strategies with less proven efficacy include monoamine oxidase inhibitors, selective serotonin reuptake inhibitors, opioid receptor antagonists, bromocriptine, anti-anxiety drugs, nicotinic receptor antagonists (e.g. mecamylamine) and glucose tablets. Various approaches under investigation include inhibitors of the hepatic P450 enzyme (e.g. methoxsalen), cannabinoid-1 receptor antagonists (e.g. rimonabant), and nicotine vaccines.

Systematic review and meta-analysis of combination therapy for smoking cessation

OBJECTIVES

To review published clinical trials on combination therapy for smoking cessation and determine the role of this regimen for treating tobacco dependence.

DATA SOURCES

Search terms included in this systematic review were nicotine replacement patch, nicotine replacement therapy, nicotine replacement gum, nicotine replacement inhaler, nicotine replacement nasal spray, nicotine replacement lozenge, bupropion SR (for sustained release), combination therapy, smoking cessation, and varenicline. Trials conducted from 1994 through October 10, 2007, were identified using EBM Reviews: Cochrane Central Register of Controlled Trials and Medline.

STUDY SELECTION

Clinical trials of various regimens for smoking cessation were included based on a large sample size (n > or = 200); use of first-line smoking cessation therapies; double-blind, randomized, placebo-controlled design; and study duration of 1 year or more. The primary objective of the included clinical trials was to assess the efficacy of combination therapy. Studies that involved medications other than first-line therapies, adolescents, and post hoc analyses and that were not written in English were excluded.

DATA SYNTHESIS

Five clinical trials meeting the inclusion criteria were reviewed. All of the studies included the use of the nicotine replacement patch along with one other agent. A total of 2,204 patients were treated. Combination therapy was significantly better than monotherapy at all pooled comparisons (P < 0.05). The aggregated relative risk of abstinence comparing combination with single treatment groups was 1.42 (95% CI 1.21-1.67), 1.54 (1.19-2.00), and 1.58 (1.25-1.99) at 3, 6, and 12 months, respectively. Adverse effects with combination nicotine replacement therapy were minimal and similar to placebo or monotherapy.

CONCLUSION

Current literature indicates that combination therapy is statistically better than monotherapy in smoking cessation treatment as assessed by 3-, 6-, and 12-month abstinence rates. Adverse effects and adherence to combination therapy are similar to monotherapy and placebo.

The role of negative affect in risk for early lapse among low distress tolerance smokers

Individual differences in the ability to tolerate negative affect due to psychological and/or physical discomfort (e.g., distress tolerance) are emerging as an important predictor of smoking cessation outcomes. The purpose of this study was to build on existing evidence by exploring the relationship between levels of distress tolerance (DT) and negative affect on quit date in relation to risk for early lapse. Eighty-one smokers (48% female; M age=42.6 years) who completed laboratory-based, behavioral distress tolerance tasks prior to an unaided quit attempt were categorized into low, average, and high persistence on the tasks. Low persistence smokers were significantly more likely to lapse on the assigned quit day. Among smokers able to achieve abstinence on quit day, low persistence smokers demonstrated higher levels of negative affect and urges compared to high persistence smokers. Further, negative affect-related risk for early lapse was strongest among those with low persistence. These findings suggest that smokers low in distress tolerance may be particularly vulnerable to very early lapse to smoking and that increases in negative affect may contribute to the risk for early lapse in this high-risk group of smokers.

An evaluation of the Italian version of the Fagerström Test for Nicotine Dependence

This study examined the psychometric properties of an Italian version of the Fagerström Test for Nicotine Dependence in a sample of 593 smokers who were enrolled in a randomized Phase IV clinical trial to compare bupropion to placebo. This version was administered at baseline, and from each participant an expired air carbon monoxide (CO) measure was taken. Spearman correlations between the Total score and CO concentration were .27 in the combined sample and .27 and .25 among men and women. With respect to the internal consistency reliability, the coefficient alpha was low (alpha= .55) in the combined sample and among men (.59) and women (.50). While the Total score predicted abstinence at 7 wk., it was not significantly related to continuous abstinence at 12 mo. postrandomization. The properties of the Italian version of the Fagerström Test for Nicotine Dependence appear to be consistent with other versions described in the literature.

Smoking behavior postmyocardial infarction among ENRICHD trial participants: cognitive behavior therapy intervention for depression and low perceived social support compared with care as usual

INTRODUCTION

Patients with cardiovascular disease who stop smoking lower their risk of subsequent morbidity and mortality. However, patients who have suffered a myocardial infarction (MI) are more likely to be depressed than the general population, which may make smoking cessation more difficult. Poor social support may also make smoking cessation more difficult for some patients. This study examines the effect of cognitive behavior therapy (CBT) for depression, low perceived social support or both on smoking behavior in post-MI patients.

METHODS

Participants were 1233 patients with a history of smoking enrolled in the Enhancing Recovery in Coronary Heart Disease Patients (ENRICHD) trial who provided 7-day point-prevalence smoking behavior information at baseline and at two or more follow-up assessments. The ENRICHD trial enrolled post-MI patients with depression, low perceived social support or both. Participants were randomly assigned to either CBT intervention or usual care. We used mixed effects models to accommodate data from multiple smoking point-prevalence measures for each individual participant.

RESULTS

CBT did not significantly reduce post-MI smoking across all intervention patients with a history of smoking. However, CBT did reduce post-MI smoking among the subgroup of depressed patients with adequate perceived social support (OR, 0.68; 95% CI, 0.47-0.98).

CONCLUSION

CBT for depression without more specific attention to smoking cessation may have little overall value as a strategy for helping post-MI patients refrain from smoking. However, use of CBT to treat depression may have the gratuitous benefit of reducing smoking among some post-MI patients.

Novel pharmacological approaches for treating tobacco dependence and withdrawal: current status

Increasing the diversity and availability of medications for the treatment of tobacco dependence and/or withdrawal, to aid in the achievement of smoking cessation, is crucial to meet the diverse needs of tobacco users. Despite a general awareness that smoking is harmful and widespread interest in smoking cessation, nearly 50 million adults in the US and 1.3 billion worldwide continue to smoke. Nicotine replacement therapies are effective in the treatment of tobacco dependence and withdrawal, but do not meet the needs of all tobacco users. Improvement of tobacco dependence and/or withdrawal treatments is likely to rely on novel pharmacological approaches that include new chemical entities and new formulations of current drugs. In addition, new indications for treating tobacco dependence and withdrawal show promise for reducing tobacco use and associated disease. This article focuses on a range of novel pharmacological approaches for the treatment of tobacco dependence and/or withdrawal, including oral and pulmonary nicotine delivery and the following non-nicotinic medications: antidepressants, an alpha4beta2 nicotine partial agonist, an alpha2-noradrenergic agonist, cytochrome P450 (CYP) 2A6 inhibitors, opioid antagonists and GABAergic medications. In addition to existing medications, this article addresses novel medications in the clinical development stage and those that have been evaluated previously. Novel medications in the clinical development stage include at least three nicotine vaccines and the cannabinoid receptor acting drug rimonabant. Medications evaluated previously include lobeline, mecamylamine and an anticholinergic drug regimen comprising atropine, scopolamine and chlorpromazine. Having not been approved by major drug regulatory authorities for the treatment of tobacco dependence and/or withdrawal, these medications have been evaluated in an experimental capacity.

Change in perceived stress, partner support, decisional balance, and self-efficacy following residential nicotine dependence treatment

The primary aim was to examine the effect of an eight day residential treatment for nicotine dependence on perceived stress, partner support, decisional balance, and self-efficacy for stopping smoking. Whether these variables predicted six months post treatment abstinence following residential treatment was also examined. Participants included 170 adult cigarette smokers. Perceived stress, partner support, decisional balance, and self-efficacy for stopping smoking were assessed on the first and last day of treatment. In addition, six month continuous tobacco abstinence was evaluated. Residential treatment was found to produce significant (p < 0.001) treatment changes in all psychosocial factors except one aspect of decisional balance (i.e., cons of smoking). Psychosocial factors did not predict six month tobacco abstinence. Only age (p = 0.014) and history of mental illness (p = 0.012) were found to predict six month continuous abstinence following residential treatment. This study provides new information about how residential treatment impacts psychosocial factors considered to be important predictors of tobacco abstinence in outpatient settings.

Pharmacotherapy of dual substance abuse and dependence

The US FDA has approved a limited number of treatments for alcohol, nicotine and opioid dependence; however, no treatments for other abused drugs such as marijuana, cocaine or methamphetamine are approved. This review focuses on research into drug pharmacotherapies, particularly single-drug therapies, for substance abuse and dependence contributing to the most important dual substance use disorders (SUDs). Given the implications of poly-substance abuse, it is essential that clinicians and researchers be aware of potential pharmacotherapies for the treatment of dual SUDs.A substantial number of patients abuse more than one drug concurrently, complicating the treatment of SUD and leaving clinicians with few FDA-approved drug options for their patients. In this era of evidence-based medicine, such patients are typically treated with therapeutically proven medications, but in ways that are outside the scope of a drug's original indication by the FDA. Such 'off-label' prescribing has become an important therapeutic strategy for practitioners seeking treatments for other diseases in subpopulations such as paediatrics and gerontology or for medical conditions such as oncology or mental illness. Similarly, the information that most clinicians use to make their decisions for treating patients abusing multiple drugs stems from trials treating a single SUD, anecdotal experiences from their own practice or that of their colleagues, or single-case studies reported in the literature. The existing evidence suggests there are few treatments for SUDs that confer significant reductions in substance use across a broad patient population. Moreover, even fewer clinical efficacy trials have been conducted that provide evidence of therapeutic benefit for these drugs. Recognising the difficulty in making the proper drug choice for facilitating maximum treatment success, this review highlights the single drugs or drug combinations that show some potential for treating dual SUDs. This review finds strongest support for the use of disulfiram for treatment of alcohol and cocaine dependence (with or without concomitant methadone maintenance), baclofen for alcohol and cocaine dependence (but not opioid-dependent cocaine users), tiagabine for cocaine dependence in methadone-maintained patients, and topiramate for alcohol, nicotine and cocaine dependence. While ondansetron and olanzapine show some efficacy in treating alcohol and cocaine dependence, more research is needed to better delineate the subpopulation in which these drugs may provide their maximum effect.

Fluoxetine, smoking, and history of major depression: A randomized controlled trial

The study was a randomized placebo-controlled trial testing whether fluoxetine selectively enhances cessation for smokers with a history of depression. Euthymic smokers with (H+, n = 109) or without (H-, n = 138) a history of major depression received 60 mg fluoxetine or placebo plus group behavioral quit-smoking treatment for 12 weeks. Fluoxetine initially enhanced cessation for H+ smokers (p = .02) but subsequently impaired cessation regardless of depressive history. Six months after quit date, fluoxetine-treated participants were 3.3 times more likely to be smoking (p = .02). Further research is warranted to determine why high-dose fluoxetine produces continuing effects that oppose tobacco abstinence.

Smoking Cessation Pharmacotherapy?Nicotine and Non-Nicotine Preparations

Cigarette smokers tend to die prematurely from a number of diseases. Cigarette smoking is an important modifiable risk factor for cardiovascular morbidity and mortality. Despite the clear health benefits of smoking cessation, smokers usually find it difficult to stop and behavioral therapies often prove insufficient. Pharmacologic intervention may aid the process because of the addictive nature of nicotine. Nicotine replacement therapy, which is regarded as first-line therapy, was developed to overcome the symptoms of nicotine withdrawal that many patients find distressing. Different modes of administration include inhalation and buccal or transdermal absorption. The orally administered non-nicotine drugs varenicline and bupropion are also regarded as first-line treatments, either used alone or as an adjunct to nicotine replacement therapy. Second-line treatments include clonidine and nortriptyline. Other treatment strategies that have been examined include monoamine oxidase inhibitors and selective serotonin reuptake inhibitors; efficacy has yet to be proven definitively. A novel approach to treatment using the cannabinoid-1 receptor antagonist rimonabant is also under investigation.

Antidepressants for smoking cessation

BACKGROUND

There are at least two theoretical reasons to believe antidepressants might help in smoking cessation. Nicotine withdrawal may produce depressive symptoms or precipitate a major depressive episode and antidepressants may relieve these. Nicotine may have antidepressant effects that maintain smoking, and antidepressants may substitute for this effect. Alternatively, some antidepressants may have a specific effect on neural pathways underlying nicotine addiction, (e.g. blocking nicotine receptors) independent of their antidepressant effects.

OBJECTIVES

The aim of this review is to assess the effect of antidepressant medications in aiding long-term smoking cessation. The medications include bupropion; doxepin; fluoxetine; imipramine; moclobemide; nortriptyline; paroxetine; sertraline, tryptophan and venlafaxine.

SEARCH STRATEGY

We searched the Cochrane Tobacco Addiction Group trials register which includes trials indexed in MEDLINE, EMBASE, SciSearch and PsycINFO, and other reviews and meeting abstracts, in September 2006.

SELECTION CRITERIA

We considered randomized trials comparing antidepressant medications to placebo or an alternative pharmacotherapy for smoking cessation. We also included trials comparing different doses, using pharmacotherapy to prevent relapse or re-initiate smoking cessation or to help smokers reduce cigarette consumption. We excluded trials with less than six months follow up.

DATA COLLECTION AND ANALYSIS

We extracted data in duplicate on the type of study population, the nature of the pharmacotherapy, the outcome measures, method of randomization, and completeness of follow up. The main outcome measure was abstinence from smoking after at least six months follow up in patients smoking at baseline, expressed as an odds ratio (OR). We used the most rigorous definition of abstinence available in each trial, and biochemically validated rates if available. Where appropriate, we performed meta-analysis using a fixed-effect model.

MAIN RESULTS

Seventeen new trials were identified since the last update in 2004 bringing the total number of included trials to 53. There were 40 trials of bupropion and eight trials of nortriptyline. When used as the sole pharmacotherapy, bupropion (31 trials, odds ratio [OR] 1.94, 95% confidence interval [CI] 1.72 to 2.19) and nortriptyline (four trials, OR 2.34, 95% CI 1.61 to 3.41) both doubled the odds of cessation. There is insufficient evidence that adding bupropion or nortriptyline to nicotine replacement therapy provides an additional long-term benefit. Three trials of extended therapy with bupropion to prevent relapse after initial cessation did not find evidence of a significant long-term benefit. From the available data bupropion and nortriptyline appear to be equally effective and of similar efficacy to nicotine replacement therapy. Pooling three trials comparing bupropion to varenicline showed a lower odds of quitting with bupropion (OR 0.60, 95% CI 0.46 to 0.78). There is a risk of about 1 in 1000 of seizures associated with bupropion use. Concerns that bupropion may increase suicide risk are currently unproven. Nortriptyline has the potential for serious side-effects, but none have been seen in the few small trials for smoking cessation. There were six trials of selective serotonin reuptake inhibitors; four of fluoxetine, one of sertraline and one of paroxetine. None of these detected significant long-term effects, and there was no evidence of a significant benefit when results were pooled. There was one trial of the monoamine oxidase inhibitor moclobemide, and one of the atypical antidepressant venlafaxine. Neither of these detected a significant long-term benefit.

AUTHORS' CONCLUSIONS

The antidepressants bupropion and nortriptyline aid long-term smoking cessation but selective serotonin reuptake inhibitors (e.g. fluoxetine) do not. Evidence suggests that the mode of action of bupropion and nortriptyline is independent of their antidepressant effect and that they are of similar efficacy to nicotine replacement. Adverse events with both medications are rarely serious or lead to stopping medication.

Pre-cessation depressive mood predicts failure to quit smoking: the role of coping and personality traits

AIMS

To examine whether mood, personality and coping predict smoking cessation and whether the associations of personality and coping are mediated through depressed mood.

SETTING

Multicenter (n = 8) smoking cessation trial.

PARTICIPANTS

A total of 600 smokers (> or = 15 cigarettes/day) without current depression who participated in a smoking cessation study.

MEASUREMENTS

The outcome was continuous abstinence during the last 4 weeks of the 3-month trial: depressed mood was measured by the Beck Depression Inventory (BDI), personality by the Revised NEO Personality Inventory (NEO-PI-R) and coping by the Revised Ways of Coping Checklist (RWCC).

FINDINGS

A total of 14.7% (88/600) were abstainers. Controlling for potential confounders, baseline BDI independently predicted smoking cessation. Smokers with BDI > or = 10 were less likely to quit than those with BDI < 10 (odds ratio: 6.39, 95% CI: 1.44-28.3, P = 0.01). Compared to BDI < 10 smokers, BDI > or = 10 smokers had significantly higher scores for neuroticism and lower scores for extraversion and conscientiousness (NEO-PI-R). On the RWCC, BDI > or = 10 smokers scored higher for blame self, wishful thinking and problem avoidance and they scored lower on problem focus than smokers with BDI < 10. A mediational analysis showed that neither personality traits nor coping skills predicted directly smoking cessation. However, low level of problem focusing and social support seeking predicted a negative outcome via depressed mood.

CONCLUSION

A BDI score > or = 10, even in smokers who do not meet a current diagnosis of major depression, directly predicts inability to quit. This suggests the utility of assessing depression symptoms in routine smoking cessation care.

Current and emerging pharmacotherapies for treating tobacco dependence

Tobacco dependence remains the leading cause of death and disease in the US and a major cause of mortality around the world, yet 1 out of 5 American adults smoke and 1.3 billion adults smoke worldwide. Nicotine replacement therapies (NRTs), bupropion and varenicline, are approved by the US FDA as first-line treatments for nicotine dependence. Clonidine and nortriptyline are recommended as second-line treatments by the Agency for Healthcare Research and Quality. Although recent data suggest that varenicline is superior to bupropion for treating nicotine dependence, a majority of smokers fail to maintain long-term abstinence from smoking using FDA-approved pharmacotherapies. Thus, continued investigation of novel medications for nicotine dependence remains a critical priority. Guided by research on multiple neurobiological mechanisms of nicotine dependence, several novel medications that mimic and/or attenuate nicotine's rewarding effects, or reduce nicotine withdrawal, are under investigation. Although existing data are limited or conflicting, there is some evidence for the efficacy of selegiline, fluoxetine, naltrexone and mecamylamine in certain subgroups of smokers. New research directions, such as fast-acting NRTs, the tailored use of NRTs for subtypes of smokers, and pharmacogenetics, hold promise for new treatment approaches and, ultimately, for reducing rates of tobacco use in the US and worldwide.

Risk factors and their effects on the dynamic process of smoking relapse among veteran smokers

Smoking cessation programs can help smokers make a successful attempt at quitting, but many initial quitters relapse over time. This study aims to identify risk factors for smoking relapse and examine the influence of these factors on the dynamic relapse process in an outpatient smoking cessation program for veterans. Baseline information included socio-demographic description, medical and psychiatric comorbidities, smoking history and behavior, nicotine dependence, smoking motives, and confidence in the ability to quit. The intervention involved a 4-session group therapy consisting of cognitive and pharmacological treatments. The 189 initial quitters by program completion were followed via a telephone interview 6 months later. We identified six risk factors associated with relapse within the first 6 months post quit. Furthermore, we described characteristics of the dynamic process of smoking relapse and studied the influence of the identified risk factors on the relapse curve. The effects of these risk factors can be categorized into two patterns. Annual income and age at smoking initiation showed a delayed action that influenced the relapse curve after several weeks post quit, whereas age, number of smoking coworkers, history of schizophrenia, and number of sessions attended modified the relapse process soon after quitting. The information will be useful in targeting veteran smokers who are at high risk for relapse, choosing the optimal time for post-cessation services, and developing strategies accordingly.

Nicotine and non-nicotine smoking cessation pharmacotherapies

Cigarette smoking remains an important risk factor for premature cardiovascular disease and its complications. There are clear benefits of cigarette smoking cessation on the rate of clinical outcomes, and in addition to behavioral therapies, various pharmacologic strategies have been developed to help achieve this goal. First-line therapies include nicotine replacement and/or bupropion. Second-line treatments include clonidine and nortriptyline. Additional treatment strategies, with less proven efficacy, include monoamine oxidase inhibitors, selective serotonin reuptake inhibitors, opioid receptor antagonists, bromocriptine, antianxiety drugs, nicotinic receptor antagonists (eg, mecamylamine), and glucose tablets. Various approaches under investigation include the use of partial nicotine agonists (eg, varenicline), inhibitors of the hepatic P-450 enzyme (eg, methoxsalen), cannaboid-1 receptor antagonists (eg, rimonabant), and nicotine vaccines.

Distress tolerance and early smoking lapse

A significant percentage of smokers attempting cessation lapse to smoking within a matter of days and very few of these individuals recover to achieve abstinence. Current models of relapse devote insufficient attention to this phenomenon of early smoking lapse. Furthermore, studies attempting to relate severity of nicotine withdrawal symptoms to short-term smoking cessation outcomes have yielded equivocal results. The authors argue that how one reacts to the discomfort of nicotine withdrawal is a more promising avenue of investigation than severity of withdrawal and that inability to tolerate the distress of nicotine withdrawal and associated negative affect is a key factor in early smoking lapse and subsequent relapse. Theoretical and clinical implications of distress tolerance in smoking cessation are discussed and the development of a specialized and novel behavioral distress tolerance treatment for early smoking lapsers is proposed.

Novel pharmacotherapeutic targets for the management of drug addiction

Despite individual variation in the liability to the abuse of psychoactive substances, there is substantial commonality shared by drugs of abuse. The knowledge of these common mechanisms together with the continued elucidation of the neurobiological underpinnings of withdrawal symptoms, drug intake, craving, relapse, and co-morbid psychiatric associations are critically important for the development of new therapeutic strategies. The present review will focus on recent advances in the development of innovative pharmacotherapeutic agents, which should promote higher efficacy (abstinence, prevention of relapse, long-term recovery) and patient compliance, as well as improved safety profiles.

Efficacy of antidepressants in substance use disorders with and without comorbid depression. A systematic review and meta-analysis

Antidepressants are commonly used in substance abusers due to the potential effect on some underlying mechanisms involved in drug use disorders and to treat comorbid depression. A systematic review of the literature of the efficacy of antidepressant drugs in subjects with drug abuse disorders, including alcohol, cocaine, nicotine and opioid, with and without comorbid depression was performed. Only randomised, double-blind, controlled trials have been evaluated. A meta-analysis was done with the included studies that used common evaluation procedures in alcohol, cocaine and opioid dependence. Based on the present review some recommendations may be proposed. The prescription of antidepressants for drug abuse seems only clear for nicotine dependence with or without previous comorbid depression (bupropion and nortryptiline). In alcohol dependence without comorbid depression, the use of any antidepressant seems not justified, while in cocaine dependence has to be clarified. The use of antidepressants in alcohol, cocaine or opioid dependence with comorbid depression needs more studies in well-defined samples, adequate doses and duration of treatment to be really conclusive. Interestingly, SSRIs do not seem to offer significant advantages compared with tricyclic drugs in substance abuse disorders. Differences both related to individual characteristics and specific antidepressant drugs need to be clarified in future studies.

Treating Tobacco Dependence: State of the Science and New Directions

Despite almost two decades of intensive tobacco control efforts, nearly one quarter of Americans continue to smoke. The two United States Food and Drug Administration–approved medications used to treat tobacco dependence, bupropion and nicotine replacement therapy, are effective for only a fraction of smokers. Investigations of medications approved for affective disorders and other forms of substance abuse, such as fluoxetine and naltrexone, have yielded mixed results as tobacco dependence treatments. A particular challenge in tobacco dependence treatment is the development of effective approaches for smokers with unique needs, such as cancer patients and pregnant women. Despite new developments in these areas, significant gaps in knowledge and practice remain. Basic research in the neurobiologic and genetic basis of nicotine dependence offers promise for the development of novel and more effective treatment approaches. For example, emerging research in pharmacogenetics explores how genetic variation in drug-metabolizing enzymes and drug targets modifies response to pharmacotherapy. These discoveries could someday help practitioners to individualize the type, dosage, and duration of tobacco dependence treatment based on genotype, and maximize the efficacy.

Combination treatment for nicotine dependence: state of the science

Both nicotine replacement and sustained-release buproprion double the odds of achieving short- and moderate-term abstinence from nicotine. However, questions remain about the efficacy of combining pharmacotherapies. Our purposes were to review the evidence for (1) combined pharmacotherapy and (2) multimodal treatment combining pharmacotherapy and behavioral treatment and to recommend combinations of treatments to reduce nicotine dependence. Combining first-line pharmacotherapies with each other or with investigational drugs shows little benefit. In contrast, trials combining specific behavioral treatments with first-line pharmacotherapies show enhanced smoking cessation rates, but benefits are not seen in all populations. We recommend future directions for research, including better specification of behavioral components and further examination of the length and timing of treatment.

Antidepressants for smoking cessation

BACKGROUND

There are at least two theoretical reasons to believe antidepressants might help in smoking cessation. Nicotine withdrawal may produce depressive symptoms or precipitate a major depressive episode and antidepressants may relieve these. Nicotine may have antidepressant effects that maintain smoking, and antidepressants may substitute for this effect. Alternatively, some antidepressants may have a specific effect on neural pathways underlying nicotine addiction, independent of their antidepressant effects.

OBJECTIVES

The aim of this review is to assess the effect of antidepressant medications in aiding long-term smoking cessation. The medications include bupropion; doxepin; fluoxetine; imipramine; moclobemide; nortriptyline; paroxetine; sertraline, tryptophan and venlafaxine.

SEARCH STRATEGY

We searched the Cochrane Tobacco Addiction Group trials register which includes trials indexed in MEDLINE, EMBASE, SciSearch and PsycINFO, and other reviews and meeting abstracts, in March 2004.

SELECTION CRITERIA

We considered randomized trials comparing antidepressant medications to placebo or an alternative therapy for smoking cessation. We also included trials comparing different doses, using pharmacotherapy to prevent relapse or re-initiate smoking cessation and using pharmacotherapy to help smokers reduce cigarette consumption. We excluded trials with less than six months follow up.

DATA COLLECTION AND ANALYSIS

We extracted data in duplicate on the type of study population, the nature of the pharmacotherapy, the outcome measures, method of randomization, and completeness of follow up. The main outcome measure was abstinence from smoking after at least six months follow up in patients smoking at baseline, expressed as an odds ratio (OR). We used the most rigorous definition of abstinence for each trial, and biochemically validated rates if available. Where appropriate, we performed meta-analysis using a fixed effect model.

MAIN RESULTS

There was one trial of the monoamine oxidase inhibitor moclobemide, and one of the atypical antidepressant venlafaxine. Neither of these detected a significant long-term benefit. There were five trials of selective serotonin reuptake inhibitors; three of fluoxetine, one of sertraline and one of paroxetine. None of these detected significant effects, and there was no evidence of a significant benefit when results were pooled. There were 24 trials of bupropion and six trials of nortriptyline. When used as the sole pharmacotherapy, bupropion (19 trials, OR 2.06, 95% confidence intervals [CI] 1.77 to 2.40) and nortriptyline (four trials, OR 2.79, 95% CI 1.70 to 4.59) both doubled the odds of cessation. In one trial the combination of bupropion and nicotine patch produced slightly higher quit rates than patch alone, but this was not replicated in a second study. Two trials of extended therapy with bupropion to prevent relapse after initial cessation did not show a significant long-term benefit. There is a risk of about 1 in 1000 of seizures associated with bupropion use. Concerns that bupropion may increase suicide risk are currently unproven.

REVIEWERS' CONCLUSIONS

The antidepressants bupropion and nortriptyline aid long term smoking cessation but selective serotonin reuptake inhibitors (e.g. fluoxetine) do not. The fact that only some forms of antidepressants aid cessation and that they do so regardless of depressive symptoms strongly suggests that their mode of action is independent of their antidepressant effect.