Bupropion for the treatment of tobacco dependence: guidelines for balancing risks and benefits

Documento de consenso sobre tabaquismo y riesgo vascular

Consensus statement on smoking and vascular risk About 22% of the Spanish population are daily smokers. Men are more likely to smoke than women. In Spain, women between 15-25 years of age smoke as much or more than men. Every smoker should be assessed for: physical dependence on nicotine (Fagerström test), social and psychological dependence (Glover Nilsson test), level of motivation to quit (Richmond test), probability of therapy success (Henri-Mondor and Michael-Fiore tests), and stage of behavioral change development (Prochaska and DiClementi). Advice on smoking cessation is highly cost-effective and should always be provided. Smoking is an enhancer of cardiovascular risk because it acts as a pathogen agent in the development of arteriosclerosis and is associated with ischemic heart disease, stroke, and peripheral artery disease. Smoking increases the risk of chronic lung diseases (COPD) and is related to cancers of the lung, female genitalia, larynx, oropharynx, bladder, mouth, esophagus, liver and biliary tract, and stomach, among others. Combined oral contraceptives should be avoided in women smokers older than 35 years of age due to the risk of thromboembolism. In smoking cessation, the involvement of physicians, nurses, psychologists, etc. is important, and their multidisciplinary collaboration is needed. Effective pharmacological treatments for smoking cessation are available. Combined treatments are recommended when smoker's dependence is high. For individuals who are unable to quit smoking, a strategy based on tobacco damage management with a total switch to smokeless products could be a less dangerous alternative for their health than continuing to smoke.

Gabapentin for cessation of smoking and non-smoking tobacco habits in Indian population

BACKGROUND

The effectiveness of gabapentin in tobacco dependence has been evaluated by many researchers. The randomized control trials, testing the efficacy of gabapentin in quitting the habit in smokers and users of smokeless tobacco, have not been published yet. We attempted to address this lacuna in knowledge in reducing dependence on tobacco use by gabapentin.

METHODS

Our study involves 150 study subjects, 75 of whom were identified as chronic users of tobacco and assigned randomly to one of the three groups consisting of 25 subjects each. Gabapentin in tablet form was prescribed thrice a day for 8 weeks wherein group 1 received a dose of 300mg, group 2 received 600 mg, and group 3 was prescribed 900 mg. An age and sex matched control group have received calcium tablets as placebo in three times daily dose for a period of 8 weeks.

RESULTS

Among the three doses of gabapentin, stoppage of habit was reported to be highest in the group-2 followed by group 1 and group 3 respectively. In our study, we found differences in response to quitting tobacco use between duration of habit prior to pharmacologic intervention amongst both smokers and the users of smokeless tobacco.

CONCLUSIONS

Gabapentin at dose of 600 mg TDS has optimum effect. Smokers having smoking for more than ten years showed notable benefit with gabapentin. Among smokeless tobacco users who quit tobacco dependence was better having history of habit less than 2 years.

Evidence for the Confluence of Cigarette Smoking, Other Substance Use, and Psychosocial and Mental Health in a Sample of Urban Sexual Minority Young Adults: The P18 Cohort Study

BACKGROUND

Sexual minority men (SMM) and transgender women (TW) are more likely to smoke cigarettes than heterosexual and cisgender peers, which may exacerbate existing disparities in mental and psychosocial health and substance use.

PURPOSE

As few existing studies have examined the confluence of these factors, we sought to examine tobacco use in a diverse sample of SMM and TW and describe its relationship with other substance use and health.

METHODS

Data were drawn from a study of syndemic conditions among SMM and TW, which included measures assessing tobacco use, substance use, and mental, psychosocial, and general health.

RESULTS

A majority of the racially/ethnically and socioeconomically diverse sample (n = 665) reported ever smoking a cigarette, and more than half of them were current smokers. Current smoking was associated with more frequent recent substance use and poorer mental, psychosocial, and general health. In multivariable analyses, current smoking was predicted by more frequent substance use and more severe anxiety, when adjusting for demographic, substance use, and health factors.

CONCLUSIONS

A syndemic approach to health conditions such as substance use, mental health, and psychosocial burden dictates a framework of interrelation and mutual exacerbation. In doing so, we found that current cigarette use was associated with more frequent alcohol and marijuana use and more severe anxiety, suggesting a confluence of cigarette smoking, other substance use, and mental health burden. We recommend a holistic approach to treating tobacco use in sexual and gender minority populations that addresses both substance use and the myriad psychosocial burdens that sexual and gender minority communities experience.

Effect of a Smoking Cessation Program on Inpatients in the Largest Hospital in Southern Iran

Background:

There is evidence that cessation programs can be effective for hospital inpatients. Hence, the aim of this study was to investigate the effects of such programs and factors that may affect success.

Methods:

This study was carried out on in-patient users of tobacco in Shiraz Hospital, Iran in 2015. After implementing the inclusion criteria, a study population was selected using a convenience sampling method. Participants were contacted monthly by study personnel concerning certain aspects of their tobacco cessation program. The study lasted 6 months. Data analyses involved survival analysis using Kaplan–Meier analysis, log-rank test, and multivariate Cox regression modeling.

Results:

The study included 425 in-patient smokers of which 328 (77.2%) were male. Median follow-up time was 96 days (interquartile range: 20–150). Cessation survival rates were 76% at 1 month, 63% at 2 months, and 61% at 3 months. From the 4^th month onward rates remained unchanged at 60%. Univariate analyses with variables such as time since last smoking, consumption type, interval between wake-up and consumption, the severity of dependence and interest in smoking cessation were statistically significant as to cessation survival rate (P < 0.05). After adjusting the confounding variables based on multivariable analyses, results indicated that consumption type, the severity of dependence and interest in smoking cessation were the most important predictors of cessation survival rates among in-patient smokers.

Conclusions:

Findings indicated that application of the cessation program among our group of inpatients appears to have been an effective intervention that produced an extended period of no smoking.

Postnatal Cardiovascular Consequences in the Offspring of Pregnant Rats Exposed to Smoking and Smoking Cessation Pharmacotherapies

Approximately 20% of pregnant women smoke despite intentions to quit. Smoking cessation drugs, such as nicotine replacement therapy (NRT) and bupropion, are recommended treatments. Adverse cardiovascular outcomes in offspring have raised concerns about NRT's safety during pregnancy. However, the effect of bupropion is unknown. Using a rat model, we determined whether NRT and bupropion interventions during pregnancy are safer than continued smoking on offspring's cardiovascular function. Male offspring of controls and dams exposed to cigarette smoke (1.6 packs/day, inhalation), nicotine (2 mg/kg/d subcutaneously), and bupropion (13 mg/kg twice daily orally) were assessed for fetoplacental weight, cardiac function, blood pressure, and vascular reactivity. Fetoplacental weights were decreased and spontaneous beating and intracellular calcium in neonatal cardiomyocytes were increased in smoking, nicotine, and bupropion offspring; however, these effects were more accentuated in smoking followed by nicotine and bupropion offspring. Increased heart rate and decreased cardiac output, stroke volume, and left ventricular percent posterior wall thickening were observed in smoking, nicotine, and bupropion offspring. The left ventricular mass was reduced in smoking and nicotine but not in bupropion offspring. Blood pressure was higher with decreased endothelium-dependent relaxation and exaggerated vascular contraction to angiotensin II in smoking and nicotine offspring, with more pronounced dysfunctions in smoking than nicotine offspring. Maternal bupropion did not impact offspring's blood pressure, endothelium-dependent relaxation, and vascular contraction. In conclusion, maternal nicotine intervention adversely affects offspring's cardiovascular outcomes, albeit less severely than continued smoking. However, bupropion causes cardiac derangement in offspring but does not adversely affect blood pressure and vascular function.

Bupropion sustained release for pregnant smokers: a randomized, placebo-controlled trial

BACKGROUND

Bupropion is used to treat depression during pregnancy. However, its usefulness as a smoking cessation aid for pregnant women is not fully known.

OBJECTIVE

The objective of the study was to evaluate the preliminary efficacy of bupropion sustained release for smoking cessation during pregnancy.

STUDY DESIGN

We conducted a randomized, prospective, double-blind, placebo-controlled, pilot trial. Pregnant women who smoked daily received individualized behavior counseling and were randomly assigned to a 12 week, twice-a-day treatment with 150 mg bupropion sustained release or placebo. The primary study objectives were to determine whether bupropion sustained release reduces nicotine withdrawal symptoms on the quit date and during the treatment period compared with placebo and whether it increases 7 day point prevalence abstinence at the end of the treatment period and at the end of pregnancy.

RESULTS

Subjects in the bupropion (n = 30) and placebo (n = 35) groups were comparable in age, smoking history, number of daily smoked cigarettes, and nicotine dependence. After controlling for maternal age and race, bupropion sustained release reduced cigarette cravings (1.5 ± 1.1 vs 2.1 ± 1.2, P = .02) and total nicotine withdrawal symptoms (3.8 ± 4.3 vs 5.4 ± 5.1, P = .028) during the treatment period. Administration of bupropion sustained release reduced tobacco exposure, as determined by levels of carbon monoxide in exhaled air (7.4 ± 6.4 vs 9.1 ± 5.8, P = .053) and concentrations of cotinine in urine (348 ± 384 ng/mL vs 831 ± 727 ng/mL, P = .007) and increased overall abstinence rates during treatment (19% vs 2%, P = .003). However, there was no significant difference in 7 day point prevalence abstinence rates between the 2 groups at the end of medication treatment (17% vs 3%, P = .087) and at the end of pregnancy (10% vs 3%, P = .328).

CONCLUSION

Individual smoking cessation counseling along with the twice-daily use of 150 mg bupropion sustained release increased smoking cessation rates and reduced cravings and total nicotine withdrawal symptoms during the treatment period. However, there was no significant difference in abstinence rates between groups at the end of medication treatment and at the end of pregnancy, likely because of the small sample size. A larger study is needed to confirm these findings and to examine the potential benefit/ risk ratio of bupropion sustained release for smoking cessation during pregnancy.

Cardiovascular stimulant actions of bupropion in comparison to cocaine in the rat

Stimulants are banned in competition by the World Anti-Doping Agency, except for a small number of therapeutic agents subject to monitoring, including bupropion. We have examined the potency of bupropion in comparison with two agents banned in competition, adrafinil and modafinil, and with cocaine and desipramine as blockers of the noradrenaline re-uptake transporter in peripheral tissues of the rat. For studies in vivo, the pressor response to noradrenaline in the anaesthetized rat was studied. Cocaine, desipramine and bupropion at doses of 0.1, 0.3 and 1mg/kg, respectively, significantly increased the pressor response to noradrenaline. Overall, cocaine and desipramine were approximately 2-5 times more potent than bupropion in vivo in the rat. Adrafinil and modafinil (both 3mg/kg) did not significantly affect the pressor response. Bupropion was chosen for further study. In 1Hz paced rat right ventricular strips, bupropion (30μM) significantly increased the potency of noradrenaline at increasing the force of contraction. In rat vas deferens, bupropion and cocaine produced concentration-dependent increases in the contractile response to nerve stimulation, and cocaine was 11 times more potent than bupropion. Since bupropion is used clinically in doses of up to 300mg, it is likely that bupropion has actions at the noradrenaline transporter, and thus cardiovascular stimulant actions, in clinical doses. This may explain findings of increased exercise performance with bupropion.

Sensitivity and specificity of a procedure for early human screening of novel smoking cessation medications

BACKGROUND AND AIM

It is important to find economical methods in early Phase 2 studies to screen drugs potentially useful to aid smoking cessation. A method has been developed that detects efficacy of varenicline and nicotine patch. This study aimed to evaluate whether the method would detect the efficacy of bupropion and identify correctly the lack of efficacy of modafinil.

DESIGN

Using a within-subject double cross-over design, smokers attempted to quit during each treatment, with bupropion (150 mg b.i.d.), modafinil [100 mg twice daily (b.i.d.)] or placebo (double-blind, counterbalanced order). In each of three medication periods, all smoked with no drug on week 1 (baseline or washout), began dose run-up on week 2, and tried to quit every day during week 3.

SETTING

A university research center in the United States.

PARTICIPANTS

Forty-five adult smokers high in quit interest.

MEASUREMENTS

Abstinence was verified daily each quit week by self-report of no smoking over the prior 24 hours and carbon monoxide (CO) < 5 parts per million.

FINDINGS

Compared with placebo, bupropion did (F(1,44)  = 6.98, P = 0.01), but modafinil did not (F(1,44)  = 0.29, P = 0.60), increase the number of abstinent days. Also, bupropion (versus placebo) significantly increased the number of those able to maintain continuous abstinence on all 5 days throughout the quit week (11 versus four), Z = 2.11, P < 0.05, while modafinil did not (six).

CONCLUSIONS

Assessing days abstinent during 1 week of use of medication versus placebo in a cross-over design could be a useful early Phase 2 study design for discriminating between medications useful versus not useful in aiding smoking cessation.

Naltrexone/Bupropion combination therapy in overweight or obese patients with major depressive disorder: results of a pilot study

OBJECTIVE

To evaluate the effect of 32-mg/d naltrexone sustained release and 360-mg/d bupropion sustained release (NB32) in overweight and obese patients with major depressive disorder (MDD).

METHOD

Twenty-five female patients with a DSM-IV diagnosis of MDD, an Inventory of Depressive Symptomatology-Self-Report score > 26, and a body mass index ≥ 27 and ≤ 43 kg/m(2) received up to 24 weeks of open-label treatment with NB32 with dietary and behavioral counseling (data collection: March 2008-July 2009). The primary endpoint was change from baseline in the Montgomery-Asberg Depression Rating Scale (MADRS) total score at 12 weeks; secondary endpoints included MADRS total score at week 24, change in weight, and Clinical Global Impressions-Improvement scale responder status (CGI-I score ≤ 2) at weeks 12 and 24 (modified intent-to-treat [mITT]: patients with ≥ 1 postbaseline MADRS total score on study drug; N = 23).

RESULTS

MADRS scores showed significant reductions at weeks 12 and 24 (mITT-last observation carried forward [LOCF]: -13.1 ± 7.1 and -15.3 ± 8.1, respectively, P < .001 vs baseline for all). Mean ± SD weight loss was -4.0% ± 4.6% (mITT-LOCF) and -6.1% ± 4.7% (observed cases) at week 12 and -5.3% ± 6.5% (mITT-LOCF) and -9.2% ± 6.2% (observed cases) at week 24 (P < .001 vs baseline for all). By week 24, 95% of patients (mITT-LOCF) were responders (CGI-I score ≤ 2) and 70% were in remission (CGI-I score = 1). The safety/tolerability profile of NB32 was consistent with its individual components; the most common adverse events were nausea, constipation, headache, and insomnia, with no serious adverse events attributed to NB32.

CONCLUSION

Twenty-four weeks of open-label NB32 therapy with dietary and behavioral counseling was associated with improvement in depressive symptoms and reduced body weight in overweight/obese women with MDD.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT00624858.

Memory-related effects of cholinergic receptor ligands in mice as measured by the elevated plus maze test

The purpose of our experiments was to examine the influence of cholinergic receptor ligands on memory-related behavior in mice using the elevated plus maze (EPM) test. The EPM test allows the exploration of different memory processes (acquisition and consolidation), depending on the time of drug treatment. The time necessary for mice to move from the opened arm to the enclosed arm (i.e., transfer latency, TL) was used as an index of memory. Our findings reveal that for both the processes of acquisition and consolidation, treatment with nicotine (0.035 or 0.175 mg/kg, free base, sc) shortened TL on the second day of the experiments (TL2), thus improving memory processes. Treatment with scopolamine (0.3 or 1.0 mg/kg, ip) significantly increased TL2 values, thus impairing cognitive processes. Moreover, we found that treatment with nicotine, at the non-effective doses used during testing, prevented scopolamine-induced memory impairment by inducing a decrease in TL2 values. Next, we evaluated the influence of bupropion (10 or 20 mg/kg, ip), a drug currently used for smoking cessation in humans, on memory-related behavior induced by treatment with nicotine and scopolamine. An acute injection of bupropion (10 or 20 mg/kg) prior to injection with either nicotine (0.035 mg/kg) or scopolamine (1.0 mg/kg) significantly prevented nicotine-induced memory improvement or scopolamine-induced memory impairment. Bupropion treatment can diminish the rewarding (dependence-producing) effects of nicotine and also the cognitive effects that are related to addiction. Our studies further indicate the great involvement of the cholinergic system in memory processes and the potential for the development of more effective pharmacotherapies for memory impairment-like human disorders in which the cholinergic pathways have been implicated.

Comparisons of high-dose and combination nicotine replacement therapy, varenicline, and bupropion for smoking cessation: a systematic review and multiple treatment meta-analysis

AIM

This review compared the effect of high-dose nicotine replacement therapy (NRT) and combinations of NRT for increasing smoking abstinence rates compared to standard-dose NRT patch, varenicline, and bupropion on smoking abstinence.

METHODS

Ten electronic databases were searched (up to January 2012) for randomized controlled trials (RCT) of standard-dose (≤ 22 mg) or high-dose nicotine patch therapy (> 22 mg), combination NRT (e.g. nicotine patch + nicotine inhaler), bupropion, and varenicline. Analysis consisted of random-effects pairwise meta-analysis and a Bayesian multiple treatment comparison (MTC).

RESULTS

We identified 146 RCTs (65 standard-doses of the nicotine patch (≤ 22 mg); 6 high-dose NRT patch (> 22 mg); 5 high versus standard-dose NRT patch; 5 combination NRT versus inert controls; 6 combination versus single NRT patch; 48 bupropion; and 11 varenicline). The MTC found that all therapies offered treatment benefits at most time points over controls. Combination NRT and higher-dose NRT did not demonstrate consistent effects over other interventions. With the exception of varenicline, the benefits of treatments over standard-dose NRT were not retained in the long term.

CONCLUSIONS

All pharmacologic treatments were significantly more effective than inert controls. Varenicline was the only treatment demonstrating effects over other options. These results should be considered in the development of clinical practice guidelines.

A brief review of pharmacotherapeutic treatment options in smoking cessation: bupropion versus varenicline

PURPOSE

The purpose of this article is to compare the efficacy of two prominent medications utilized in smoking cessation: bupropion and varenicline.

DATA SOURCES

Comprehensive review of the literature on bupropion and varenicline including randomized control trials, government reports, journal reviews, and pharmaceutical inserts.

CONCLUSIONS

In all studies comparing varenicline to bupropion and/or placebo, varenicline yielded a greater cessation rate at both 3 and 12 months. Additionally, varenicline 1 mg indicated an increased potential for long-term cessation success when compared with varenicline 0.5 mg. When compared with only placebo, bupropion demonstrated a higher efficacy for cessation both at 3 and 12 months.

IMPLICATIONS FOR PRACTICE

Only 6% of the 20 million smokers who attempt to quit will succeed in long term. Clinicians must assess their patient's willingness to quit and educate them about cessation options. Knowing the efficacy of various treatment options for patients will potentially increase their success at quitting smoking. Understanding the treatment options available, allows for clinicians to provide the best possible method for smoking cessation for their patient population.

Smoking cessation intervention: an evidence-based approach

Cigarette smoking represents the most important source of preventable morbidity and premature mortality worldwide. Approximately 100 million deaths were caused by tobacco use in the 20th century. There are >1 billion smokers worldwide, and globally the use of tobacco products is increasing, with the epidemic shifting to the developing world. Tobacco dependence is a chronic condition that often requires repeated intervention for success. Just informing a patient about health risks, although necessary, is usually not sufficient for a decision to change. Smokers should be provided with counseling when attempting to quit. Pharmacologic smoking cessation aids are recommended for all smokers who are trying to quit, unless contraindicated. Evidence-based guidelines recommend nicotine replacement therapy, bupropion SR, and varenicline as effective alternatives for smoking cessation therapy, especially when combined with behavioral interventions. Combination pharmacotherapy is indicated for highly nicotine-dependent smokers, patients who have failed with monotherapy, and patients with breakthrough cravings. An additional form of nicotine replacement therapy or an addition of a non-nicotine replacement therapy oral medication (bupropion or varenicline) may be helpful. The rate of successful smoking cessation at 1 year is 3% to 5% when the patient simply tries to stop, 7% to 16% if the smoker undergoes behavioral intervention, and up to 24% when receiving pharmacological treatment and behavioral support.

Gabapentin for smoking cessation

INTRODUCTION

We conducted a preliminary proof-of-concept study evaluating gabapentin for the treatment of tobacco dependence.

METHODS

Subjects (N = 80) were randomized to gabapentin (600 mg three times per day or 900 mg three times per day) or placebo. After a 2-week dose titration, the target dose was maintained for 9 weeks and then tapered over 1 week. Follow-up was for 12 weeks after the medication phase.

RESULTS

The study had high dropout rates with more than one half of participants in each arm discontinuing study. Gabapentin-treated participants exhibited lower abstinence rates than placebo-treated participants; however, this difference was not significant. Smoking reduction was observed across all treatment arms compared with baseline (p < .01) but did not differ across treatment groups.

DISCUSSION

Although not definitive, our findings suggest that gabapentin administered at these doses with this dosing regimen holds little promise for the treatment of tobacco dependence in a population of smokers seeking treatment.

Treating tobacco dependence in light of the 2008 US Department of Health and Human Services clinical practice guideline

Cigarette smoking is the most important preventable cause of morbidity, mortality, and excess health care costs in the United States. From 2000 through 2004, cigarette smoking caused an estimated annual average of 443,595 deaths and cost $193 billion per year in smoking-attributable productivity losses and smoking-related health care expenditures. Preventing smoking and providing effective treatment to help smokers quit will remain a public health priority for the foreseeable future. In support of this goal, the US Department of Health and Human Services recently published the clinical practice guideline entitled Treating Tobacco Use and Dependence: 2008 Update. The new guideline updates the previous guidelines published in 1996 and 2000 and presents many new research findings to provide a broader evidence base for effective intervention. This article briefly reviews the major updates and recommendations from the new guideline and highlights its practical clinical applications.

Treating tobacco dependence in light of the 2008 US Department of Health and Human Services clinical practice guideline

Cigarette smoking is the most important preventable cause of morbidity, mortality, and excess health care costs in the United States. From 2000 through 2004, cigarette smoking caused an estimated annual average of 443,595 deaths and cost $193 billion per year in smoking-attributable productivity losses and smoking-related health care expenditures. Preventing smoking and providing effective treatment to help smokers quit will remain a public health priority for the foreseeable future. In support of this goal, the US Department of Health and Human Services recently published the clinical practice guideline entitled Treating Tobacco Use and Dependence: 2008 Update. The new guideline updates the previous guidelines published in 1996 and 2000 and presents many new research findings to provide a broader evidence base for effective intervention. This article briefly reviews the major updates and recommendations from the new guideline and highlights its practical clinical applications.

Smoking and chronic obstructive pulmonary disease (COPD). Parallel epidemics of the 21 century

One hundred million deaths were caused by tobacco in the 20(th) century, and it is estimated that there will be up to one billion deaths attributed to tobacco use in the 21(st) century. Chronic obstructive pulmonary disease (COPD) is rapidly becoming a global public health crisis with smoking being recognized as its most important causative factor. The most effective available treatment for COPD is smoking cessation. There is mounting evidence that the rate of progression of COPD can be reduced when patients at risk of developing the disease stop smoking, while lifelong smokers have a 50% probability of developing COPD during their lifetime. More significantly, there is also evidence that the risk of developing COPD falls by about half with smoking cessation. Several pharmacological interventions now exist to aid smokers in cessation; these include nicotine replacement therapy, bupropion, and varenicline. All pharmacotherapies for smoking cessation are more efficacious than placebo, with odds ratios of about 2. Pharmacologic therapy should be combined with nonpharmacologic (behavioral) therapy. Unfortunately, despite the documented efficacy of these agents, the absolute number of patients who are abstinent from smoking at 12 months of follow-up is low.

Pharmacology of stimulants prohibited by the World Anti-Doping Agency (WADA)

This review examines the pharmacology of stimulants prohibited by the World Anti-Doping Agency (WADA). Stimulants that increase alertness/reduce fatigue or activate the cardiovascular system can include drugs like ephedrine available in many over-the-counter medicines. Others such as amphetamines, cocaine and hallucinogenic drugs, available on prescription or illegally, can modify mood. A total of 62 stimulants (61 chemical entities) are listed in the WADA List, prohibited in competition. Athletes may have stimulants in their body for one of three main reasons: inadvertent consumption in a propriety medicine; deliberate consumption for misuse as a recreational drug and deliberate consumption to enhance performance. The majority of stimulants on the list act on the monoaminergic systems: adrenergic (sympathetic, transmitter noradrenaline), dopaminergic (transmitter dopamine) and serotonergic (transmitter serotonin, 5-HT). Sympathomimetic describes agents, which mimic sympathetic responses, and dopaminomimetic and serotoninomimetic can be used to describe actions on the dopamine and serotonin systems. However, many agents act to mimic more than one of these monoamines, so that a collective term of monoaminomimetic may be useful. Monoaminomimietic actions of stimulants can include blockade of re-uptake of neurotransmitter, indirect release of neurotransmitter, direct activation of monoaminergic receptors. Many of the stimulants are amphetamines or amphetamine derivatives, including agents with abuse potential as recreational drugs. A number of agents are metabolized to amphetamine or metamphetamine. In addition to the monoaminomimetic agents, a small number of agents with different modes of action are on the list. A number of commonly used stimulants are not considered as Prohibited Substances.

Bupropion extended-release for depressive disorders

Bupropion is an antidepressant thought to work through effects on norepinephrine and dopamine. It was first marketed in the USA in 1989 as a thrice-daily immediate-release preparation. This was followed in 1996 by twice-daily sustained-release and, most recently in 2003, by once-daily extended-release preparations. Its clinical efficacy for treating depression is equivalent to that of other antidepressants. In addition, the extended-release preparation has been shown to be effective for treating geriatric depression and depression characterized by reduced energy, pleasure and interest, and for preventing recurrence of seasonal affective disorder. Favorable aspects of its side-effect profile include low likelihood of somnolence, sexual dysfunction and weight gain. This review provides a history of the evolution of bupropion in its three formulations, with an emphasis on the efficacy and tolerability of the extended-release preparation.

Bupropion and cognitive-behavioral treatment for depression in smoking cessation

This study is a randomized, double-blind, placebo-controlled clinical trial examining the effects of an intensive cognitive-behavioral mood management treatment (CBTD) and of bupropion, both singularly and in combination, on smoking cessation in adult smokers. As an extension of our previous work, we planned to examine the synergistic effects of CBTD and bupropion on smoking cessation outcomes in general and among smokers with depression vulnerability factors. Participants were 524 smokers (47.5% female, M (age) = 44.27 years) who were randomized to one of four 12-week treatments: (a) standard, cognitive-behavioral smoking cessation treatment (ST) plus bupropion (BUP), (b) ST plus placebo (PLAC), (c) standard cessation treatment combined with cognitive-behavioral treatment for depression (CBTD) plus BUP, and (d) CBTD plus PLAC. Follow-up assessments were conducted 2, 6, and 12 months after treatment, and self-reported abstinence was verified biochemically. Consistent with previous studies, bupropion, in comparison with placebo, resulted in better smoking outcomes in both intensive group treatments. Adding CBTD to standard intensive group treatment did not result in improved smoking cessation outcomes. In addition, neither CBTD nor bupropion, either alone or in combination, was differentially effective for smokers with single-past-episode major depressive disorder (MDD), recurrent MDD, or elevated depressive symptoms. However, findings with regard to recurrent MDD and elevated depressive symptoms should be interpreted with caution given the low rate of recurrent MDD and the low level of depressive symptoms in our sample. An a priori test of treatment effects in smokers with these depression vulnerability factors is warranted in future clinical trials.

Pharmacological approaches to smoking cessation

Smoking, the most prominent nongenetic factor contributing to mortality, remains the major public health problem throughout the world. There are nearly 1.1 billion users of nicotine and tobacco products worldwide while approximately one third to half of them will die from smoking-related disease. The habit of smoking is mainly propelled by nicotine, a strongly addictive substance, to which the vast majority of smokers fall victim. Except for the general and specific support and counseling strategies there are now effective treatments for nicotine addiction. Two types of pharmacological therapies have been approved and are now licensed for smoking cessation. The first therapy consists of nicotine replacement, substituting the nicotine from cigarettes with safer nicotine formulations. The second therapy is bupropion, an antidepressant of the aminoketone class, which has been demonstrated to be effective in smoking cessation. However, although some cigarette smokers are able to quit, many are not, and standard medications to assist smoking cessation are ineffective. Several agents used for other indications (e.g. neurological diseases, depression, alcoholism) might be used to treat this subgroup. In conclusion, new more effective drugs are needed in order to fight the panepidemic of smoking globally.

Treating tobacco dependence: review of the best and latest treatment options

Globally, an estimated 85% of lung cancer in men and 47% of lung cancer in women is attributable to tobacco smoking. Tobacco dependence treatment remains the most cost-effective way to prevent morbidity and mortality from lung cancer. Several effective pharmacotherapies are available to treat tobacco dependence. However, the long-term effectiveness of these treatments has been limited because the majority of smokers who attempt to stop smoking eventually relapse. Approaching the treatment of tobacco use and dependence as a chronic disease and the development of innovative drug therapies offer new hope for the treatment of tobacco-dependent patients. The diagnosis of lung cancer provides a teachable moment to motivate patients to attempt tobacco abstinence on which clinicians should capitalize. We review the currently available pharmacologic approaches to the treatment of tobacco dependence.

Tailoring nicotine replacement therapy: rationale and potential approaches

Nicotine replacement therapy (NRT) is an effective treatment for smoking cessation, but as with all such pharmacotherapies, the majority of smokers who use NRT products do not stop smoking or remain abstinent long term. Treatment outcome is affected by a range of individual-specific factors, as well as the pharmacokinetic profile of each NRT formulation. This has led to speculation that abstinence rates could be improved if NRT treatments were individually tailored to best match each individual's needs and preferences. There are also populations for whom special product and dosage considerations are warranted to maximise treatment safety.This paper reviews the rationale for NRT treatment, standard dose recommendations and recommendations for how to best match NRT treatment to the specific needs of individual smokers. We also review emerging evidence that genetic profiling may one day be a useful consideration for tailoring NRT treatment.

Effects of co-administration of bupropion and nicotinic agonists on the elevated plus-maze test in mice

There is evidence that the cholinergic nicotinic system is involved in the modulation of anxiety. Anxiolytic and anxiogenic effects of nicotine agonists have been reported in mice. Bupropion is an antidepressant drug which may alleviate some symptoms of nicotine withdrawal, although its effects on anxiety are not clear. It has been suggested that the interaction between bupropion and nicotinic mechanisms could be complex. The aim of the present study was to investigate acute effects of co-administration of bupropion and nicotinic agonists on the elevated plus-maze test in NMRI mice. Effects of nicotine, lobeline, and cytisine (0.35 and 0.175 mg/kg), administered alone or combined with bupropion (20 mg/kg) were tested in the plus-maze. Results indicated that nicotine (0.35 mg/kg) decreased number and percentage of entries and time spent in open arms, and increased percentage of protected stretched attend posture. Bupropion (20 mg/kg) plus lobeline (0.175 mg/kg) increased percentage of time spent in open arms, without altering total or closed arm entries. Our findings suggest that the highest dose of nicotine induces anxiogenic effects, which are counteracted when co-administered with bupropion. The combination of bupropion with a low dose of lobeline seems to have an anxiolytic profile in the conventional parameters of the plus-maze, although ethological measures do not support it clearly.

Bupropion: risks and benefits

Cigarette smoking represents one of the most preventable causes of death worldwide. However, success rates for stopping smoking are disappointingly low and are associated with high relapse rates. There is a need for a successful form of smoking cessation therapy. Bupropion is an effective therapy for smoking cessation and is recommended as first-line treatment in both US and UK guidelines. Its mechanism of action in smoking cessation is unclear, although it is thought that dopaminergic pathways are involved in the 'reward' circuit of drug dependence. Seizures are an important adverse effect of bupropion and care is needed when used in other conditions or with other medication that can lower the seizure threshold. Bupropion has been shown to be a cost-effective therapy for smoking cessation.

The safety of non-stimulant agents for the treatment of attention-deficit hyperactivity disorder

Due to their well-established efficacy and safety, stimulants are the drugs of first choice if medication for attention-deficit hyperactivity disorder (ADHD) is required. Nevertheless, for some individuals other, non-stimulant treatments are needed for several reasons. If so, atomoxetine is recommended as a second-line treatment. In addition, several tricyclic antidepressants, such as desipramine or imipramine, as well as alpha-2 agonists, especially clonidine or bupropion, might be efficient in treating ADHD, in particular in specific co-morbid conditions. Despite the fact that non-stimulant treatments in ADHD are usually well-tolerated with side effects being mostly moderate and transient, special safety aspects and precautions, specific for each drug, have to be considered whenever a non-stimulant treatment is chosen. This review focuses on the tolerability, occurrence of adverse events, precautions required to prevent severe adverse events, and essential pharmacological interaction in the treatment of ADHD symptoms by non-stimulants.

Weight of evidence: a review of concept and methods

"Weight of evidence" (WOE) is a common term in the published scientific and policy-making literature, most often seen in the context of risk assessment (RA). Its definition, however, is unclear. A systematic review of the scientific literature was undertaken to characterize the concept. For the years 1994 through 2004, PubMed was searched for publications in which "weight of evidence" appeared in the abstract and/or title. Of the 276 papers that met these criteria, 92 were selected for review: 71 papers published in 2003 and 2004 (WOE appeared in abstract/title) and 21 from 1994 through 2002 (WOE appeared in title). WOE has three characteristic uses in this literature: (1) metaphorical, where WOE refers to a collection of studies or to an unspecified methodological approach; (2) methodological, where WOE points to established interpretative methodologies (e.g., systematic narrative review, meta-analysis, causal criteria, and/or quality criteria for toxicological studies) or where WOE means that "all" rather than some subset of the evidence is examined, or rarely, where WOE points to methods using quantitative weights for evidence; and (3) theoretical, where WOE serves as a label for a conceptual framework. Several problems are identified: the frequent lack of definition of the term "weight of evidence," multiple uses of the term and a lack of consensus about its meaning, and the many different kinds of weights, both qualitative and quantitative, which can be used in RA. A practical recommendation emerges: the WOE concept and its associated methods should be fully described when used. A research agenda should examine the advantages of quantitative versus qualitative weighting schemes, how best to improve existing methods, and how best to combine those methods (e.g., epidemiology's causal criteria with toxicology's quality criteria).

Adverse effects of pharmacological therapy for nicotine addiction in smokers following a smoking cessation program

This multicenter, community-based, prospective, longitudinal study evaluated the safety of nicotine replacement therapy (NRT), bupropion, and combined therapy of NRT and bupropion for smokers seeking to quit, when these therapies were used under real-world conditions following a smoking cessation program. Participants were smokers aged 18 years or older who attended five smoking cessation clinics. Evaluations were made at 15, 30, 60, and 90 days. We investigated the possible existence of adverse effects as well as the severity of each adverse effect and its influence on the treatment course. The study included 904 smokers: 370 received NRT, 413 received bupropion, and 121 received combined therapy. At 15, 30, 60, and 90 days, adverse effects were reported by 43.8%, 33.1%, 22.3%, and 5.7% of subjects, respectively. Adverse effects were significantly more frequent in subjects receiving combined therapy or bupropion alone than in NRT-treated subjects at the 15-, 30-, and 60-day follow-ups. A total of 83 smokers (9.3%) withdrew from treatment and 116 (12.8%) stopped temporarily because of adverse effects. No differences were found in the percentages of discontinuation among the different treatment options. Adverse effects rarely were severe (n=10). Nevertheless, 41 subjects (4.5%) discontinued drug therapy indefinitely and 55 (6.1%) discontinued it temporarily because of mild adverse effects. Pharmacological therapies for smoking cessation are safe as long as they are appropriately prescribed and supervised by clinicians according to clinical practice guidelines. Adverse effects are primarily mild. Nonetheless, mild adverse effects may be perceived by patients as a serious enough problem to cause them to discontinue treatment.

Bupropion effects on aggressiveness and anxiety in OF1 male mice

RATIONALE

Bupropion is an antidepressant drug that is being used to help in giving up smoking. Its behavioral effects have been evaluated in different animal models, although limited information is available regarding its effects on aggressiveness, anxiety and exploratory behavior.

OBJECTIVES

Evaluate acute effects of bupropion on locomotor activity, isolation-induced aggression, hole-board and elevated plus-maze tests in OF1 male mice.

METHODS

In the first experiment, effects of bupropion (2.5, 5, 10, 20 and 40 mg/kg) on locomotion were evaluated. In the second experiment, isolation-induced aggression was assessed in isolated male mice previously classified as short attack latency (SL) and long attack latency (LL). Mice were treated with bupropion or vehicle and confronted with standard opponents for 10 min. In experiments 3 and 4, mice were treated with bupropion or vehicle and 30 min later examined in the plus-maze or in the hole-board apparatus.

RESULTS

In the actimeter, bupropion induced a dose-dependent increase in locomotion. During agonistic encounters, bupropion (10 mg/kg and 40 mg/kg) increased time devoted to attack in LL mice. In the plus-maze, no significant differences were found between bupropion-treated and vehicle-treated mice in the percentage of entries or time spent in open arms. In the hole-board, the highest dose of bupropion (40 mg/kg) significantly decreased number of head-dips and increased latency to the first head-dip.

CONCLUSIONS

During agonistic encounters the two sub-groups of mice (SL and LL) may display differential sensitivity in drug-induced changes on aggressiveness, since bupropion increased attack only in mice with "long attack latency" in the pre-screening test. In the plus-maze, this drug does not seem to have specific actions on anxiety and in the hole-board a high dose had similar effects to those induced by anxiogenic drugs.

Effects of acute bupropion administration on locomotor activity in adolescent and adult mice

Responses to some psychoactive substances seem to differ between adolescents and adults. Bupropion, an antidepressant which is also used for smoking cessation, induces a dose-dependent increase in locomotor activity in adult mice, although its behavioral actions in adolescents have not been evaluated. In the present study the effects of acute bupropion administration (5, 10, 15 and 20 mg/kg) on locomotor activity were examined in early adolescent (postnatal day (pnd): 29-31 days), late adolescent (pnd: 47-49 days) and adult (pnd > 70 days) male NMRI mice, using an infrared photocell system. Locomotion was recorded for a total period of 90 min. Results indicated that there were significant differences in motor activity counts between the three ages evaluated, with late adolescents being more active than early adolescents. Bupropion (at doses 20, 15 and 10 mg/kg) induced a significant increase in locomotion, but there was no significant interaction between age and treatment. This suggests that the locomotor-stimulating effects of bupropion can be observed at different ages (early adolescence, late adolescence and adulthood), although the detailed analysis of the temporal course of locomotion changes induced by different bupropion doses reflected some differences between ages. The lowest dose (5 mg/kg) failed to induce hyperactivity in either adolescent or adult mice.

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.

Effects of acute administration of bupropion on behavior in the elevated plus-maze test by NMRI mice

Bupropion attenuates some symptoms of nicotine abstinence, although its effects on anxiety are unclear. The present study investigates acute effects of bupropion (5, 10, 20 and 40 mg/kg) on anxiety as expressed in the elevated plus-maze test in male NMRI mice. Given the influence of locomotion in this test, effects of bupropion were also evaluated in an actimeter. Spontaneous motor activity remained significantly increased in mice treated with 10, 20 and 40 mg/kg of bupropion during the 60 min recorded. Results from the elevated plus-maze showed that 20 mg/kg increased total arm entries and 40 mg/kg increased total and open arm entries. Although the increase in the number of visits to the open arms suggests an anxiolytic-like effect, if the actions of this drug on locomotion are taking into account, one may conclude that the increase in open arm entries observed with the highest doses is a motor effect rather than anxiolysis per se. In addition, ethological measures failed to detect a clear anxiolytic profile since neither a significant decrease in total stretched attend postures nor a reduction in the percentage of protected forms of head dipping or stretched attend postures were observed at any dose tested. These results suggest that the elevated plus-maze is sensitive to the motor actions of bupropion and that this should be taken into account in the evaluation of the "emotional" effects of this drug.

Metabolism and biochemical effects of nicotine for primary care providers

Nicotine is a colorless and volatile liquid alkaloid naturally occurring in the leaves and stems of Nicotiana tabacum and Nicotiana rustica. Nicotine, the primary component of tobacco, is responsible for both tobacco product addiction (with chronic exposure) and the odor associated with tobacco. In addition to cigarettes, nicotine is found in chewing gum, transdermal patches, nasal spray, and sublingual tablets. Following its inhalation and absorption, nicotine and its metabolic products exert diverse physiologic and pharmacologic effects. This article covers the absorption and metabolism of nicotine, nicotine toxicity, pharmacologic effects of nicotine, nicotine-drug interactions, and the use of nicotine for the treatment of disease.

Residential treatment for smokeless tobacco use: a case series

We developed and implemented a novel 8-day residential treatment program for smokeless tobacco (ST) use. A multidisciplinary team delivered behavioral treatment, nicotine patches were adjusted to achieve 100% replacement of baseline peak serum nicotine concentrations, and bupropion sustained-release was prescribed. Mean participant age (+/- SD) was 47.4 +/- 18.2 years. Mean nicotine patch dose at program end was 43.2 mg/day +/- 13.9 (range 14 to 66 mg/d). Median percent replacement by serum nicotine concentrations was 86.6% (IQR: 75-113.8%). At 1 year, the biochemically-confirmed (urine anabasine <2.0 ng/mL) self-reported 7-day point prevalence tobacco abstinence rate was 58% (14/24). A residential treatment program for ST users may be effective. More research is needed to replicate our findings and determine if comparable abstinence rates can be achieved with outpatient ST treatment programs using similar behavioral and pharmacotherapies.

Bupropion sustained release for treatment of tobacco dependence

Tobacco use is a global pandemic. The most common pharmacological treatments of tobacco use and dependence include nicotine replacement therapy and nonnicotine medications. Bupropion sustained release (SR) is the only first-line nonnicotine medication recommended by the US Public Health Service Clinical Practice Guideline. Randomized controlled clinical trials have shown that bupropion SR doubles abstinence rates compared with placebo. Long-term treatment with bupropion SR may reduce or delay smoking relapse. Bupropion SR has an excellent adverse effect profile, although a risk exists for serious adverse effects such as seizures. The risk of serious adverse effects associated with bupropion SR can be reduced by careful selection of patients. This article reviews the evidence of efficacy and common adverse effects of bupropion SR and delineates the clinical characteristics of patients at higher risk for adverse effects when bupropion SR is prescribed for treatment of tobacco use and dependence.

Decreasing smoking behaviour and risk through CYP2A6 inhibition

The consequences of tobacco dependence are both health related and economic. Novel treatment approaches are needed to offer alternatives to patients and to improve treatment outcomes. We review concepts and selected recent discoveries in the area of treatment, with a specific orientation towards drug development. Current treatments are outlined and we highlight new strategies that are based on the manipulation of cytochrome P450 2A6 (CYP2A6) activity, which is responsible for the metabolism of nicotine. The clinical implications of CYP2A6 polymorphisms have been linked to a decreased risk of tobacco dependence, a decrease in number of cigarettes smoked and reduced risk of tobacco-related cancers. Further, we discuss a range of models for proof-of-concept studies for new treatments to alleviate tobacco dependence