Anisotropic local modification of crystal field levels in Pr-based pyrochlores: a muon-induced effect modeled using density functional theory

Although muon spin relaxation is commonly used to probe local magnetic order, spin freezing, and spin dynamics, we identify an experimental situation in which the measured response is dominated by an effect resulting from the muon-induced local distortion rather than the intrinsic behavior of the host compound. We demonstrate this effect in some quantum spin ice candidate materials Pr(2)B(2)O(7) (B=Sn, Zr, Hf), where we detect a static distribution of magnetic moments that appears to grow on cooling. Using density functional theory we show how this effect can be explained via a hyperfine enhancement arising from a splitting of the non-Kramers doublet ground states on Pr ions close to the muon, which itself causes a highly anisotropic distortion field. We provide a quantitative relationship between this effect and the measured temperature dependence of the muon relaxation and discuss the relevance of these observations to muon experiments in other magnetic materials.

Low-field superconducting phase of (TMTSF)2ClO4

The low-field phase of the organic superconductor (TMTSF)(2)ClO(4) is studied by muon-spin rotation. The zero temperature limit of the magnetic penetration depth within the TMTSF layers is obtained to be λ(ab)(0) = 0.86(2) μm. Temperature dependence of the muon-spin relaxation shows no indication of gap nodes on the Fermi surface nor of any spontaneous fields due to time-reversal-symmetry breaking. The weight of evidence suggests that the symmetry of this low-field phase is odd-frequency p-wave singlet, a novel example of odd-frequency pairing in a bulk superconductor.

Spin waves and revised crystal structure of honeycomb iridate Na2IrO3

We report inelastic neutron scattering measurements on Na2IrO3, a candidate for the Kitaev spin model on the honeycomb lattice. We observe spin-wave excitations below 5 meV with a dispersion that can be accounted for by including substantial further-neighbor exchanges that stabilize zigzag magnetic order. The onset of long-range magnetic order below T(N)=15.3  K is confirmed via the observation of oscillations in zero-field muon-spin rotation experiments. Combining single-crystal diffraction and density functional calculations we propose a revised crystal structure model with significant departures from the ideal 90° Ir-O-Ir bonds required for dominant Kitaev exchange.

Design and commissioning of a high magnetic field muon spin relaxation spectrometer at the ISIS pulsed neutron and muon source

The high magnetic field (HiFi) muon instrument at the ISIS pulsed neutron and muon source is a state-of-the-art spectrometer designed to provide applied magnetic fields up to 5 T for muon studies of condensed matter and molecular systems. The spectrometer is optimised for time-differential muon spin relaxation studies at a pulsed muon source. We describe the challenges involved in its design and construction, detailing, in particular, the magnet and detector performance. Commissioning experiments have been conducted and the results are presented to demonstrate the scientific capabilities of the new instrument.

Observation of a level crossing in a molecular nanomagnet using implanted muons

We have observed an electronic energy level crossing in a molecular nanomagnet (MNM) using muon spin relaxation. This effect, not observed previously despite several muon studies of MNM systems, provides further evidence that the spin relaxation of the implanted muon is sensitive to the dynamics of the electronic spin. Our measurements on a broken ring MNM [H(2)N(t)Bu(is)Pr][Cr(8)CdF(9)(O(2)CC(CH(3))(3))(18)], which contains eight Cr ions, show clear evidence for the S = 0 --> S = 1 transition that takes place at B(c) = 2.3 T. The crossing is observed as a resonance-like dip in the average positron asymmetry and also in the muon spin relaxation rate, which shows a sharp increase in magnitude at the transition and a peak centred within the S = 1 regime.

Functional Magnetic Resonance Imaging (FMRI)-based neurofeedback as a new treatment tool for depression

We investigated whether depressed patients who received fMRI-based neurofeedback are able to upregulate the activity in brain areas devoted to positive emotion processing and thereby establish improvements in mood state. Eight medicated patients with major depression participated in four separate fMRI sessions, each of which consisted of an emotion localiser and three neurofeedback runs. Target areas were selected individually with a functional localiser that identified the region most responsive to positive affective images. The target areas were in uni- or bilateral prefrontal cortex, insula or amygdala. During neurofeedback runs, patients received real-time feedback about activation levels in the target area. Each patient learnt to increase target area activity over successive sessions. Depression scores on the 17-item Hamilton Depression Rating Scale improved significantly. No such improvement was seen in a non-neurofeedback control group (N = 8) that was matched for symptom severity, demographics and medication and used the same cognitive/affective strategies that were employed successfully by the neurofeedback group, but outside the scanner. This group difference in treatment effects was supported by a significant interaction between the factors time (pre/post-intervention) and group (neurofeedback/controls) on the repeated measures ANOVA (F(1,14) = 10.15, p = .007). The neurofeedback group showed increasing activity in the ventral striatum and regions involved in cognitive control as training progressed. Upregulation of brain areas responsive to positive affective cues through fMRI-neurofeedback is thus a promising tool in the treatment of depression. The novelty of the present approach consists in the combination of biological and cognitive factors in the same intervention.

Total absence of ribs in a newborn with cerebrocostomandibular syndrome

Total absence of ribs is a rare finding that has occasionally been documented in patients with cerebrocostomandibular syndrome. Only 2 other reports document complete absence of ribs in 3 individuals, and we tabulate the findings of all the 4 cases of complete absence of ribs in this case report. Our case and the other 3 reported cases represent the extreme form of cerebrocostomandibular syndrome with regard to the costal defects.

Muon-fluorine entanglement in fluoropolymers

We present the results of muon spin relaxation measurements on the fluoropolymers polytetrafluoroethylene (PTFE), poly(vinylidene fluoride) (PVDF) and poly(vinyl fluoride) (PVF). Entanglement between the muon spin and the spins of the fluorine nuclei in the polymers allows us to identify the different muon stopping states that occur in each of these materials and provides a method of probing the local environment of the muon and the dynamics of the polymer chains.

Coexistence of static magnetism and superconductivity in SmFeAsO(1-x)F(x) as revealed by muon spin rotation

The recent observation of superconductivity with critical temperatures (Tc) up to 55 K in the pnictide RFeAsO(1-x)F(x), where R is a lanthanide, marks the first discovery of a non-copper-oxide-based layered high-Tc superconductor. It has raised the suspicion that these new materials share a similar pairing mechanism to the cuprate superconductors, as both families exhibit superconductivity following charge doping of a magnetic parent material. In this context, it is important to follow the evolution of the microscopic magnetic properties of the pnictides with doping and hence to determine whether magnetic correlations coexist with superconductivity. Here, we present a muon spin rotation study on SmFeAsO(1-x)F(x), with x=0-0.30 that shows that, as in the cuprates, static magnetism persists well into the superconducting regime. This analogy is quite surprising as the parent compounds of the two families have rather different magnetic ground states: itinerant spin density wave for the pnictides contrasted with the Mott-Hubbard insulator in the cuprates. Our findings therefore suggest that the proximity to magnetic order and associated soft magnetic fluctuations, rather than strong electronic correlations in the vicinity of a Mott-Hubbard transition, may be the key ingredients of high-Tc superconductors.

Tuning the interlayer spacing of high-T_{c} Bi-based superconductors by intercalation: measuring the penetration depth and the two-dimensional superfluid density

Substantial control of the interlayer spacing in Bi-based high temperature superconductors has been achieved through the intercalation of guest molecules between the superconducting layers. Measurements using implanted muons reveal that the penetration depth increases with increasing layer separation while T_{c} does not vary appreciably, demonstrating that the bulk superfluid density is not the determining factor controlling T_{c}. Our results strongly suggest that for Bi-based high temperature superconductors the superfluid density appearing in the Uemura scaling relation rho_{s} proportional, variantT_{c} should be interpreted as the two-dimensional density within the superconducting layers, which we find to be constant for each class of system investigated.

Muon spin relaxation study of LaTiO(3) and YTiO(3)

We report muon spin relaxation (μSR) measurements on two Ti(3+) containing perovskites, LaTiO(3) and YTiO(3), which display long-range magnetic order at low temperature. For both materials, oscillations in the time dependence of the muon polarization are observed which are consistent with three-dimensional magnetic order. From our data we identify two magnetically inequivalent muon stopping sites. The μSR results are compared with the magnetic structures of these compounds previously derived from neutron diffraction and μSR studies on structurally similar compounds.

Coexistence of magnetic fluctuations and superconductivity in the pnictide high temperature superconductor SmFeAsO1-xFx measured by muon spin rotation

Muon spin rotation experiments were performed on the pnictide high temperature superconductor SmFeAsO1-xFx with x=0.18 and 0.3. We observed an unusual enhancement of slow spin fluctuations in the vicinity of the superconducting transition which suggests that the spin fluctuations contribute to the formation of an unconventional superconducting state. An estimate of the in-plane penetration depth lambda ab(0)=190(5) nm was obtained, which confirms that the pnictide superconductors obey an Uemura-style relationship between Tc and lambda ab(0);(-2).

Physician advice for smoking cessation

BACKGROUND

Healthcare professionals frequently advise patients to improve their health by stopping smoking. Such advice may be brief, or part of more intensive interventions.

OBJECTIVES

The aims of this review were to assess the effectiveness of advice from physicians in promoting smoking cessation; to compare minimal interventions by physicians with more intensive interventions; to assess the effectiveness of various aids to advice in promoting smoking cessation, and to determine the effect of anti-smoking advice on disease-specific and all-cause mortality.

SEARCH STRATEGY

We searched the Cochrane Tobacco Addiction Group trials register. Date of the most recent search: September 2007.

SELECTION CRITERIA

Randomized trials of smoking cessation advice from a medical practitioner in which abstinence was assessed at least six months after advice was first provided.

DATA COLLECTION AND ANALYSIS

We extracted data in duplicate on the setting in which advice was given, type of advice given (minimal or intensive), and whether aids to advice were used, 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. We also considered the effect of advice on mortality where long-term follow-up data were available. We used the most rigorous definition of abstinence in each trial, and biochemically validated rates where available. Subjects lost to follow up were counted as smokers. Effects were expressed as relative risks. Where possible, meta-analysis was performed using a Mantel-Haenszel fixed effect model.

MAIN RESULTS

We identified 41 trials, conducted between 1972 and 2007, including over 31,000 smokers. In some trials, subjects were at risk of specified diseases (chest disease, diabetes, ischaemic heart disease), but most were from unselected populations. The most common setting for delivery of advice was primary care. Other settings included hospital wards and outpatient clinics, and industrial clinics. Pooled data from 17 trials of brief advice versus no advice (or usual care) detected a significant increase in the rate of quitting (relative risk (RR) 1.66, 95% confidence interval (CI) 1.42 to 1.94). Amongst 11 trials where the intervention was judged to be more intensive the estimated effect was higher (RR 1.84, 95% CI 1.60 to 2.13) but there was no statistical difference between the intensive and minimal subgroups. Direct comparison of intensive versus minimal advice showed a small advantage of intensive advice (RR 1.37, 95% CI 1.20 to 1.56). Direct comparison also suggested a small benefit of follow-up visits. Only one study determined the effect of smoking advice on mortality. This study found no statistically significant differences in death rates at 20 years follow up.

AUTHORS' CONCLUSIONS

Simple advice has a small effect on cessation rates. Assuming an unassisted quit rate of 2 to 3%, a brief advice intervention can increase quitting by a further 1 to 3%. Additional components appear to have only a small effect, though there is a small additional benefit of more intensive interventions compared to very brief interventions.

Nicotine replacement therapy for smoking cessation

BACKGROUND

The aim of nicotine replacement therapy (NRT) is temporarily to replace much of the nicotine from cigarettes to reduce motivation to smoke and nicotine withdrawal symptoms, thus easing the transition from cigarette smoking to complete abstinence.

OBJECTIVES

The aims of this review were:To determine the effect of NRT compared to placebo in aiding smoking cessation, and to consider whether there is a difference in effect for the different forms of NRT (chewing gum, transdermal patches, nasal spray, inhalers and tablets/lozenges) in achieving abstinence from cigarettes. To determine whether the effect is influenced by the dosage, form and timing of use of NRT; the intensity of additional advice and support offered to the smoker; or the clinical setting in which the smoker is recruited and treated. To determine whether combinations of NRT are more likely to lead to successful quitting than one type alone. To determine whether NRT is more or less likely to lead to successful quitting compared to other pharmacotherapies.

SEARCH STRATEGY

We searched the Cochrane Tobacco Addiction Group trials register for papers with 'nicotine' or 'NRT' in the title, abstract or keywords. Date of most recent search July 2007.

SELECTION CRITERIA

Randomized trials in which NRT was compared to placebo or to no treatment, or where different doses of NRT were compared. We excluded trials which did not report cessation rates, and those with follow up of less than six months.

DATA COLLECTION AND ANALYSIS

We extracted data in duplicate on the type of participants, the dose, duration and form of nicotine therapy, the outcome measures, method of randomization, and completeness of follow up. The main outcome measure was abstinence from smoking after at least six months of follow up. We used the most rigorous definition of abstinence for each trial, and biochemically validated rates if available. We calculated the risk ratio (RR) for each study. Where appropriate, we performed meta-analysis using a Mantel-Haenszel fixed-effect model.

MAIN RESULTS

We identified 132 trials; 111 with over 40,000 participants contributed to the primary comparison between any type of NRT and a placebo or non-NRT control group. The RR of abstinence for any form of NRT relative to control was 1.58 (95% confidence interval [CI]: 1.50 to 1.66). The pooled RR for each type were 1.43 (95% CI: 1.33 to 1.53, 53 trials) for nicotine gum; 1.66 (95% CI: 1.53 to 1.81, 41 trials) for nicotine patch; 1.90 (95% CI: 1.36 to 2.67, 4 trials) for nicotine inhaler; 2.00 (95% CI: 1.63 to 2.45, 6 trials) for oral tablets/lozenges; and 2.02 (95% CI: 1.49 to 3.73, 4 trials) for nicotine nasal spray. The effects were largely independent of the duration of therapy, the intensity of additional support provided or the setting in which the NRT was offered. The effect was similar in a small group of studies that aimed to assess use of NRT obtained without a prescription. In highly dependent smokers there was a significant benefit of 4 mg gum compared with 2 mg gum, but weaker evidence of a benefit from higher doses of patch. There was evidence that combining a nicotine patch with a rapid delivery form of NRT was more effective than a single type of NRT. Only one study directly compared NRT to another pharmacotherapy. In this study quit rates with nicotine patch were lower than with the antidepressant bupropion.

AUTHORS' CONCLUSIONS

All of the commercially available forms of NRT (gum, transdermal patch, nasal spray, inhaler and sublingual tablets/lozenges) can help people who make a quit attempt to increase their chances of successfully stopping smoking. NRTs increase the rate of quitting by 50-70%, regardless of setting. The effectiveness of NRT appears to be largely independent of the intensity of additional support provided to the individual. Provision of more intense levels of support, although beneficial in facilitating the likelihood of quitting, is not essential to the success of NRT.

Anomalous temperature evolution of the internal magnetic field distribution in the charge-ordered triangular antiferromagnet AgNiO2

Zero-field muon-spin relaxation measurements of the frustrated triangular quantum magnet AgNiO2 are consistent with a model of charge disproportionation that has been advanced to explain the structural and magnetic properties of this compound. Below an ordering temperature of TN=19.9(2) K we observe six distinct muon precession frequencies, due to the magnetic order, which can be accounted for with a model describing the probable muon sites. The precession frequencies show an unusual temperature evolution which is suggestive of the separate evolution of two opposing magnetic sublattices.

Muon-fluorine entangled states in molecular magnets

The information accessible from a muon-spin relaxation experiment can be limited due to a lack of knowledge of the precise muon stopping site. We demonstrate here the possibility of localizing a spin polarized muon in a known stopping state in a molecular material containing fluorine. The muon-spin precession that results from the entangled nature of the muon spin and surrounding nuclear spins is sensitive to the nature of the stopping site. We use this property to identify three classes of sites that occur in molecular magnets and describe the extent to which the muon distorts its surroundings.

Interventions to reduce harm from continued tobacco use

BACKGROUND

It may be reasonable to try to reduce the harm from continued smoking amongst smokers unable or unwilling to quit. Possible approaches to reduce the exposure to toxins from smoking include reducing the amount of tobacco used, and using less toxic products. The interventions evaluated in controlled trials have predominantly attempted to reduce the number of cigarettes smoked.

OBJECTIVES

To assess the effect of interventions intended to reduce the harm from smoking on the following: biomarkers of damage caused by tobacco, biomarkers of tobacco exposure, number of cigarettes smoked, quitting, and long-term health status.

SEARCH STRATEGY

We searched the Cochrane Tobacco Addiction Group Specialised Register using free text and MeSH terms for harm reduction, smoking reduction and cigarette reduction. The initial search was in March 2006, updated in March 2007.

SELECTION CRITERIA

Randomized or quasi-randomized controlled trials of interventions in tobacco users to reduce amount smoked, or to reduce harm from smoking by means other than cessation. Outcomes were change in cigarette consumption, markers of cigarette exposure and any markers of damage or benefit to health, measured at least six months from the start of the intervention.

DATA COLLECTION AND ANALYSIS

We pooled trials with similar interventions and outcomes using a fixed-effect model. Other studies were summarised narratively.

MAIN RESULTS

The 13 included trials all evaluated interventions to help smokers cut down the amount smoked. Self-reported reduction in cigarettes per day (CPD) was validated by reduction in carbon monoxide (CO) levels. Most trials tested nicotine replacement therapy (NRT) to assist reduction. No eligible studies evaluated the use of potentially reduced-exposure products. In a pooled analysis of eight trials, NRT significantly increased the odds of reducing CPD by 50% or more for people using nicotine gum or inhaler or a choice of product compared to placebo (n=3273, odds ratio [OR] 2.02, 95% confidence interval [CI] 1.55 to 2.62). Where average changes from baseline were compared for different measures, CO and cotinine consistently showed smaller reductions than CPD. Whilst the effect for NRT was significant, small numbers of people in either treatment or control group successfully sustained a reduction of 50% or more. Use of NRT also significantly increased the odds of quitting (OR 1.90, 95% CI 1.46 to 2.47). One trial of bupropion failed to detect an effect on reduction or cessation. Four trials of different types of advice and instructions on reducing CPD did not provide clear evidence.

AUTHORS' CONCLUSIONS

There is insufficient evidence about long-term benefit to give firm support the use of interventions intended to help smokers reduce but not quit tobacco use. Some people who do not wish to quit can be helped to cut down the number of cigarettes smoked and reduce their carbon monoxide levels by using nicotine gum or nicotine inhaler. Because the long-term health benefit of a reduction in smoking rate is unclear this application of NRT is more appropriately used as a precursor to quitting.

Chiral-like critical behavior in the antiferromagnet cobalt glycerolate

Critical exponents closely matching those of the N=2 chiral universality class have been obtained for the layered magnetic system cobalt glycerolate using muon spin relaxation. This class was originally introduced to represent geometrically frustrated triangular stacked-layer XY magnets with chiral noncollinear spin structures. Since the present magnetic system is a canted XY system without geometrical frustration or chiral degeneracy, the results indicate that the order parameter for canting in this system plays a similar role to the chiral order parameter in the geometrically frustrated systems, strongly suggesting that both types of noncollinear system share the same universality class.

Magnetism in geometrically frustrated YMnO3 under hydrostatic pressure studied with muon spin relaxation

The ferroelectromagnet YMnO3 consists of weakly coupled triangular layers of S=2 spins. Below T(N) approximately equal to 70 K muon-spin relaxation data show two oscillatory relaxing signals due to magnetic order, with no purely relaxing signals resolvable (which would require different coexisting spin distributions). The transition temperature T(N) increases with applied hydrostatic pressure, even though the ordered moment decreases. These results suggest that pressure increases both the exchange coupling between the layers and the frustration within the layers.

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.

Nicotine receptor partial agonists for smoking cessation

BACKGROUND

Nicotine receptor partial agonists may help smokers to quit by a combination of maintaining moderate levels of dopamine to counteract withdrawal symptoms (acting as an agonist) and reducing smoking satisfaction (acting as an antagonist). Varenicline was developed as a nicotine receptor partial agonist from cytisine, a drug widely used in central and eastern Europe for smoking cessation. The first trial reports of varenicline were released in 2006, and further trials are underway.

OBJECTIVES

The primary objective of this review is to assess the efficacy and tolerability of nicotine receptor partial agonists, including varenicline and cytisine, for smoking cessation.

SEARCH STRATEGY

We searched the Cochrane Tobacco Addiction Group's specialised register for trials, using the terms ('varenicline' or 'cytisine' or 'Tabex' or 'nicotine receptor partial agonist') and 'smoking' in the title or abstract, or as keywords. We also searched MEDLINE, EMBASE, PsycINFO and CINAHL using MeSH terms and free text, and we contacted authors of trial reports for additional information where necessary. The last search was in October 2006.

SELECTION CRITERIA

We included randomized controlled trials which compared the treatment drug with placebo. We also included comparisons with bupropion where available. We excluded trials which did not report a minimum follow-up period of six months from start of treatment.

DATA COLLECTION AND ANALYSIS

We extracted data in duplicate on the type of participants, the dose and duration of treatment, the outcome measures, the randomization procedure, concealment of allocation, and completeness of follow up. The main outcome measured was abstinence from smoking after at least six months from the beginning of treatment. We used the most rigorous definition of abstinence, and preferred biochemically validated rates where they were reported. Where appropriate we performed meta-analysis using the Mantel-Haenszel fixed-effect model.

MAIN RESULTS

We found five trials of varenicline compared with placebo for smoking cessation; three of these also included a bupropion experimental arm. We also found one relapse prevention trial, comparing varenicline with placebo. The six trials covered 4924 participants, 2451 of whom used varenicline. We identified one trial of cytisine (Tabex) for inclusion. The pooled odds ratio (OR) for continuous abstinence at 12 months for varenicline versus placebo was 3.22 (95% confidence interval [CI] 2.43 to 4.27). The pooled OR for varenicline versus bupropion was 1.66 (95% CI 1.28 to 2.16). The main adverse effect of varenicline was nausea, which was mostly at mild to moderate levels and usually subsided over time. The two trials which tested the use of varenicline beyond the 12-week standard regimen found the drug to be well-tolerated and effective during long-term use. The one cytisine trial included in this review found that more participants taking cytisine stopped smoking compared with placebo at two-year follow up, with an OR of 1.77 (95% CI 1.30 to 2.40).

AUTHORS' CONCLUSIONS

Varenicline increased the odds of successful long-term smoking cessation approximately threefold compared with pharmacologically unassisted quit attempts. In trials reported so far, more participants quit successfully with varenicline than with bupropion. The effectiveness of varenicline as an aid to relapse prevention has not been clearly established. The main adverse effect of varenciline is nausea, but this is mostly at mild to moderate levels and tends to reduce with habituation. There is a need for independent trials of varenicline versus placebo, to test the early findings. There is also a need for direct comparisons with nicotine replacement therapy, and for further trials with bupropion, to establish the relative efficacy of the treatments.Cytisine may also increase the chances of quitting, but the evidence at present is inconclusive.

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.