Bupropion improves sexual functioning in depressed minority women: an open-label switch study

Minority women often have a unique set of beliefs and expectations about medical treatment. At this time, there is a dearth of research looking at how depressed minority women respond to pharmacological interventions for the sexual concomitants of depression. This was the first study to examine the impact of a medication switch, from a selective serotonin reuptake inhibitor to bupropion SR, on the sexual functioning of depressed minority women. Eighteen minority women (5 Hispanic, 10 African American, 2 Asian American, and 1 Native American), who were experiencing poor tolerability and/or lack of efficacy on an adequate trial of a selective serotonin reuptake inhibitor for depression, along with low sexual desire, were enrolled in this prospective open-label study. The selective serotonin reuptake inhibitor and bupropion SR were cross-tapered with a target dose of 150 to 300 mg of bupropion SR. The patients were followed for 10 weeks, and measures of sexual functioning and depression (Hamilton Rating Scale for Depression) were administered in an academic medical setting. Data were collected from July 2003 to December 2004. In the group as a whole, there were significant improvements in desire (F1,17 = 34.86, P < 0.001), arousal (F1,17 = 25.99, P < 0.001), and orgasm (F1,17 = 20.16, P < 0.001), on the Changes in Sexual Functioning Questionnaire. African-American women demonstrated the greatest improvement in depression (F1,16 = 9.55, P = 0.006), desire (F1,16 = 8.62, P = 0.01), and arousal (F1,16 = 8.83, P = 0.009) after the medication switch. Overall, this intervention appeared to be an effective treatment of low sexual desire in a diverse group of depressed minority women. The majority of women successfully completed the trial and planned to continue using bupropion SR after their participation in the study.

Six-Month Trial of Bupropion With Contingency Management for Cocaine Dependence in a Methadone-Maintained Population

CONTEXT

No effective pharmacotherapies exist for cocaine dependence, although contingency management (CM) has demonstrated efficacy.

OBJECTIVE

To compare the efficacy of bupropion hydrochloride and CM for reducing cocaine use in methadone hydrochloride-maintained individuals.

DESIGN

This 25-week, placebo-controlled, double-blind trial randomly assigned participants to 1 of 4 treatment conditions: CM and placebo (CMP), CM and 300 mg/d of bupropion hydrochloride (CMB), voucher control and placebo (VCP), or voucher control and bupropion (VCB).

SETTING

Outpatient clinic at the Veterans Affairs Connecticut Healthcare System.

PARTICIPANTS

A total of 106 opiate-dependent, cocaine-abusing individuals.

INTERVENTIONS

All study participants received methadone hydrochloride (range, 60-120 mg). Participants receiving bupropion hydrochloride were given 300 mg/d beginning at week 3. In the CM conditions, each urine sample negative for both opioids and cocaine resulted in a monetary-based voucher that increased for consecutively drug-free urine samples during weeks 1 to 13. Completion of abstinence-related activities also resulted in a voucher. During weeks 14 to 25, only completion of activities was reinforced in the CM group, regardless of sample results. The voucher control groups received vouchers for submitting urine samples, regardless of results, throughout the study.

MAIN OUTCOME MEASURE

Thrice-weekly urine toxicologic test results for cocaine and heroin.

RESULTS

Groups did not differ in baseline characteristics or retention rates. Opiate use decreased significantly, with all treatment groups attaining equivalent amounts of opiate use at the end of the study. In the CMB group, the proportion of cocaine-positive samples significantly decreased during weeks 3 to 13 (P<.001) relative to week 3 and remained low during weeks 14 to 25. In the CMP group, cocaine use significantly increased during weeks 3 to 13 (P<.001) relative to week 3, but then cocaine use significantly decreased relative to the initial slope during weeks 14 to 25 (P<.001). In contrast, by treatment end, the VCB and VCP groups showed no significant improvement in cocaine use.

CONCLUSION

These findings suggest that combining CM with bupropion for the treatment of cocaine addiction may significantly improve outcomes relative to bupropion alone.

Dual Pharmacotherapy and Motivational Interviewing for Tobacco Dependence Among Drug Treatment Patients

This pilot study is the first to examine the feasibility and outcomes of dual pharmacotherapy for smoking cessation among drug treatment patients. The intervention consisted of 7 weeks of bupropion (300 mg), 12 weeks of nicotine gum, and 6 sessions of motivational interviewing. The trial was conducted among 28 patients recruited from 5 methadone clinics and employed a pretest-posttest design. At 6 months post quit date, 14% of participants met criteria for biochemically-verified abstinence. Among those still smoking, number of cigarettes smoked decreased significantly and most (88%) had made at least 1 serious quit attempt. Participation rates were excellent and no adverse effects on alcohol or illicit drug use were found. Although not a definitive test of the intervention, findings suggest that a multi-component approach to tobacco dependence is feasible and potentially effective in helping drug treatment patients achieve smoking cessation well beyond the end of treatment and that a large-scale randomized trial is warranted.

A randomized, open-label pilot comparison of gabapentin and bupropion SR for smoking cessation

This 6-week, randomized, open-label pilot study estimated the treatment effect size of gabapentin (n = 17) compared with bupropion SR (n = 19) for smoking cessation, thereby allowing sample size calculations for a definitive comparison study. The primary outcome measure was smoking cessation. Secondary outcome measures included smoking reduction and withdrawal severity. Gabapentin was less efficacious than bupropion for smoking cessation but was associated with fewer dropouts from adverse effects. Withdrawal severity was less with bupropion. Bupropion remains the first-line non-nicotine pharmacotherapy for smoking cessation. Further study is required to determine if gabapentin has any useful role in smoking cessation. Based on our primary outcome measure, 79 subjects would be required in each treatment group of a two-armed study to achieve 90% power for detecting a difference in efficacy between gabapentin and bupropion.

Mirtazapine treatment for pathological laughing and crying after stroke

Selective serotonin reuptake inhibitors (SSRIs) have been recognized as the treatment of choice for pathological laughing and crying (PLC), which is a common, distressing condition that follows stroke. There have been few reports about other treatment options for PLC. Here, the authors report rapid responses to mirtazapine in two patients with poststroke PLC who failed to respond to SSRIs or bupropion. In the first case, a 63-year-old woman with severe long-standing crying spells that had persisted for 3 months responded well to low-dose mirtazapine within a few days; she could not tolerate citalopram or sertraline. In the second case, both the laughing and crying spells of a 64-year-old woman were improved within a few days of mirtazapine administration, after they had not responded to bupropion. This is one of the first reports to suggest that mirtazapine may be an alternative to SSRIs for treating poststroke PLC.

ADHD and the dopamine transporter: are there reasons to pay attention?

The catecholamine dopamine (DA) plays an important role as a neurotransmitter in the brain in circuits linked to motor function, reward, and cognition. The presynaptic DA transporter (DAT) inactivates DA following release and provides a route for non-exocytotic DA release (efflux) triggered by amphetamines. The synaptic role of DATs first established through antagonist studies and more recently validated through mouse gene-knockout experiments, raises questions as to whether altered DAT structure or regulation support clinical disorders linked to compromised DA signaling, including drug abuse, schizophrenia, and attention deficit hyperactivity disorder (ADHD). As ADHD appears to have highly heritable components and the most commonly prescribed therapeutics for ADHD target DAT, studies ranging from brain imaging to genomic and genetic analyses have begun to probe the DAT gene and its protein for possible contributions to the disorder and/or its treatment. In this review, after a brief overview of ADHD prevalence and diagnostic criteria, we examine the rationale and experimental findings surrounding a role for human DAT in ADHD. Based on the available evidence from our lab and labs of workers in the field, we suggest that although a common variant within the human DAT (hDAT) gene (SLC6A3) is unlikely to play a major role in the ADHD, contributions of hDAT to risk maybe most evident in phenotypic subgroups. The in vitro and in vivo validation of functional variants, pursued for contributions to endophenotypes in a within family approach, may help elucidate DAT and DA contributions to ADHD and its treatment.

Sustained-release bupropion versus naltrexone in the treatment of pathological gambling: a preliminary blind-rater study

BACKGROUND

Pathological gambling (PG) is a relatively common and highly disabling impulse control disorder. A range of psychotherapeutic agents, including selective serotonin reuptake inhibitors, mood stabilizers, and opioid antagonists, has been shown to be effective in the treatment of PG. The use of selective serotonin reuptake inhibitors and opioid antagonists for PG is consistent with the observation that PG shares features of both the obsessive-compulsive spectrum disorders and addictive disorders. The aim of the study is to compare the effectiveness of sustained-release bupropion versus naltrexone in the treatment of PG.

METHODS

Thirty-six male pathological gamblers were enrolled in our study. A comprehensive psychiatric diagnostic evaluation was performed at baseline on all patients, and patients were screened for symptoms of gambling, depression, and anxiety using the South Oaks Gambling Screen, the Hamilton Depression Rating Scale, the Hamilton Anxiety Rating Scale, and the Clinical Global Impression-Severity Scale. In addition, the patients completed self-report questionnaires about their demographic status. Patients were randomized in 2 groups and received either naltrexone (n = 19) or sustained-release bupropion (n = 17) for 12 weeks in a parallel fashion. Treatment response was monitored using the Clinical Global Impression-Improvement Scale which was performed at weeks 2, 4, 8, and 12. Patients were also assessed for the presence of gambling behavior via an unstructured interview, which was also performed at weeks 2, 4, 6, 8, and 12. Raters were blind to the study treatment.

RESULTS

The majority of patients responded well to the drug treatment. Twelve of 17 patients in the sustained-release bupropion group completed the 12-week study, and 13 of 19 naltrexone patients completed the study. Nine (75%) of the 12 completers were rated as full responders in the sustained-release bupropion group versus 10 (76%) of 12 in the naltrexone group. Three (25%) of 12 completers in the bupropion group were rated as partial responders. In the naltrexone group, 3 (23%) of 13 completers were rated as partial responders. Full response was defined as the absence of gambling for a 2-week duration together with improvement on the Clinical Global Impression-Improvement Scale. Partial response was defined as a decrease in the frequency of gambling behavior and a decrease in the amount of money spent on gambling.

CONCLUSION

This preliminary study shows that sustained-release bupropion may be effective as naltrexone in the treatment of PG. Further studies are needed to confirm our findings.

[Assisting smoking cessation]

Smoking is the most important cause of preventable death in the world and the benefits of smoking cessation are clearly established regardless of the age of the smoker or the presence or absence of pathologies, whether caused by smoking or not. Even though this may appear obvious it is useful to recall that every medical consultation for any condition should include an assessment of smoking status, of the motivation to quit (which should be identified and reinforced) and of the readiness to quit. Assistance given can thus be adapted appropriately to the individual situation and should take into account validated recommendations for best practice. Advising and assisting smoking cessation requires a tailored approach which involves a number of elements centred on the addictive nature of smoking. The nature of dependence may differ and be of varying intensity in different individuals. The capacity to give up may also be very different. Obstructions to smoking cessation are often numerous and complex. Co morbidities and co-addictions can slow down the dynamics of change and their existence must be incorporated into an individualised approach. The transition of a smoker towards abstinence passes through numerous steps so that the addicted smoker is effectively a patient with a chronic disease. This explains many relapses and justifies the need to offer often specialised assistance over a prolonged period. Advising and assisting smokers to quit is a priority. It is thus necessary to organise the management of this process according to the specific skills of each health professional. This approach will address the global problem of tobacco while focusing on the specific problems of each smoker.

Bupropion (amfebutamone): caution during pregnancy

(1) Bupropion, which is also called amfebutamone, is an amphetamine marketed to assist with smoking withdrawal. (2) A registry of pregnancies exposed to bupropion has shown a higher-than-expected frequency of neonatal cardiac malformations: 7 of the 10 newborns with malformations had cardiac anomalies (70% of malformations), compared to about 25% in the general population. (3) An increased risk of birth defects, particularly cardiac malformations, is also suspected after exposure to amphetamine derivatives during pregnancy. (4) In practice, these disturbing data are one more reason not to use bupropion, a drug with a negative risk-benefit balance, even outside of pregnancy.

The influence of depressive symptoms on smoking cessation among African Americans in a randomized trial of bupropion

The influence of depressive symptoms on smoking cessation was examined among 600 African American smokers who participated in a randomized, placebo-controlled trial of sustained-release bupropion hydrochloride. Depressive symptoms were assessed at baseline, at week 6 (end of treatment), and at 6-month follow-up. The study examined three separate questions: (a) Whether depressive symptom levels were related to smoking cessation, (b) whether bupropion was more effective for smokers who had higher depressive symptoms at baseline (i.e., a moderator model), and (c) whether changes in depressive symptoms would account for the efficacy of bupropion for smoking cessation (i.e., a mediator model). Depressive symptoms at baseline were not predictive of cessation; however, increases in depressive symptoms from baseline predicted reduced cessation at the end of treatment, and higher depressive symptoms at week 6 and month 6 were associated with a reduced likelihood of smoking cessation at those time points. The moderator model was not supported, but the mediation analyses indicated that alleviation of depressive symptoms partly accounted for bupropion-assisted smoking cessation at end of treatment. Results extend prior findings to African American smokers and suggest that clinicians consider increases in depressive symptoms after quitting rather than baseline depressive symptoms in predicting risk of treatment failure. Results also suggest that even though bupropion may facilitate cessation in part by reducing depressive symptoms, it appears to be no more effective for more depressed smokers, and that mechanisms other than depressive symptom alleviation account for most of its efficacy.

Dopamine transporter availability in medication free and in bupropion treated depression: a 99mTc-TRODAT-1 SPECT study

BACKGROUND

Bupropion is thought to exert its antidepressive effect by blocking the dopamine transporter (DAT). The purpose of this study was to evaluate the DAT activity in depressed patients by means of 99mTc-TRODAT-1 SPECT in relation to the efficacy of bupropion treatment.

METHODS

In 12 healthy controls and 16 depressed patients the baseline DAT activity was examined. Nine of the 16 patients went through an additional second SPECT investigation, after 4 weeks of bupropion treatment.

RESULTS

In the depressed patients, the baseline DAT striatum-occipital ratio (SOR) (1.04+/-.36, mean+/-SD) was not significantly different from that in the control group (1.12+/-.33) (p>.05). Correlation was found between baseline SOR and HAM-D score change (r=-.745, p=.02) of the bupropion treated patients. The average DAT occupancy due to the bupropion treatment was 20.84+/-27.7%. No significant correlation between the therapeutical effectiveness and the occupancy was observed.

LIMITATIONS

One of the limiting factors of our study has been the lack of drug monitoring.

CONCLUSIONS

In good agreement with other PET studies, we found 20.84% DAT occupancy during bupropion treatment. The lack of correlation between the efficacy of therapy and occupancy of DAT may raise the question as to whether other mechanisms are involved in the effect of bupropion.

Influence of striatal dopamine transporter availability on the response to methylphenidate in adult patients with ADHD

In this study, we investigated whether availability of striatal dopamine transporter (DAT) may have an influence on the response of adult patients with attention deficit hyperactivity disorder (ADHD) on methylphenidate (MPH). In 18 non-smoking and non-medicated adult patients with ADHD, availability of DAT was measured with [(99m)Tc] TRODAT-1 SPECT. Then, the patients received methylphenidate (MPH), individually titrated up to 60 mg per day. Ten weeks later, clinical improvement was rated by Clinical Global Impressions scale. In all, 6 patients were classified as non-responders, and 12 responded to MPH. From the non-responders, 5 presented with a DAT availability below that of normal controls of the same age, whereas in the group of responders all patients had elevated DAT availability. There was a significant negative correlation between values for global clinical improvement and striatal DAT availability. In conclusion, ADHD patients with low DAT availability seem not to respond to therapy with MPH.

Self-efficacy and motivation to quit during participation in a smoking cessation program

The associations between failure to quit and posttreatment self-efficacy and motivation were examined among 600 African American smokers enrolled in a randomized trial testing the efficacy of bupropion for smoking cessation. Participants also received brief motivational counseling and were followed for 6 months. Baseline levels of self-efficacy and motivation for all participants were high (8.2 and 8.5 on a 10-point scale, respectively). Longitudinal analyses indicated that smokers who failed to quit were less likely than quitters to report high self-efficacy and motivation from posttreatment to follow-up. However, examination of mean self-efficacy and motivation scores at posttreatment and follow-up revealed that smokers continued to sustain high self-efficacy and motivation. Mean self-efficacy and motivation scores differed by less than 1 point from baseline levels, even though the majority of participants failed to quit smoking. Results suggest that unsuccessful participation in a smoking cessation program does not meaningfully reduce smokers' self-efficacy and motivation to quit.

Médicaments d’aide au sevrage tabagique

Physicians can aid their patients' smoking cessation by providing psychological support, advice, behavioral strategies, and drugs. Success depends on appropriate management, including selection of the right moment to begin treatment and an understanding of the development of the withdrawal syndrome, smoking urges, and the possibility of failure. The standard pharmacological treatment for nicotine dependence uses different forms of nicotine substitutes and bupropion, while we await data about other drugs currently under study. The score on the "simplified" Fagerström questionnaire usually determines the initial nicotine dose. Six forms of nicotine substitutes are available. They provide either prolonged nicotine release (transcutaneous patches) that prevents withdrawal symptoms, or rapid release through the buccal and nasal mucosa (chewing gum, suckers, inhalers and nasal sprays) to anticipate the positive effects represented by cigarettes and the urges occurring during withdrawal. The efficacy of these substitutes, widely studied, is approximately twice that of placebo. Their use is no longer contraindicated in patients with heart disease, when necessary. Bupropion should be used in treating nicotine dependence either as a first-line treatment, or if nicotine substitutes (150 mg/d the first week, 300 mg/d thereafter) fail. The combination of bupropion and nicotine substitutes can be considered, either from the outset for heavy or very heavy smokers, or afterwards, if withdrawal symptoms or urges to smoke persist in subjects treated by only one of these two drug classes. One of the new drugs under evaluation is rimonabant, the first representatives of a new class of drugs, selective CB1 endocannabinoid receptor antagonists. Promising results about its use in smoking cessation were released in 2004.

Non-nicotine pharmacotherapies for smoking cessation

International chronic obstructive pulmonary disease guidelines recommend that smokers be strongly advised to quit, and should be offered help in doing so. The most effective smoking-cessation interventions combine behavioural support with pharmacotherapies. For smokers who do not wish to use nicotine replacement treatments, bupropion is a safe and effective non-nicotine alternative first-line treatment. Nortriptyline and clonidine have demonstrated efficacy in aiding smoking cessation, but are regarded as second-line therapies. A number of other non-nicotine treatments show promise, but more data are required before these can be recommended in assisting smokers to stop.

Independent effects of tobacco abstinence and bupropion on cognitive function in schizophrenia

OBJECTIVE

The objective of this study was to examine the effects of tobacco abstinence and bupropion treatment on cognitive functioning in adult smokers with schizophrenia in the setting of a randomized, double-blind, placebo-controlled clinical trial of bupropion for smoking cessation.

METHOD

Fifty-three adults with schizophrenia (DSM-IV) took part in a trial of bupropion for smoking cessation. Subjects were enrolled in the study from August 1999 to March 2003. Forty-five subjects remained in the trial at week 4; 41 subjects, 19 taking bupropion and 22 taking placebo, completed the baseline and week 4 cognitive assessments and were included in the analysis of adjusted effects of abstinence and bupropion treatment on cognitive function.

RESULTS

Controlling for bupropion treatment and baseline performance, 7 days of tobacco abstinence was associated with slowed motor speed (finger tapping) but was not associated with worsening of performance on tests of attention (AX Continuous Performance Test [AX-CPT]), verbal learning and memory (California Verbal Learning Test [CVLT]), working memory (digit span), or executive function/inhibition (Stroop) and was not associated with worsening of any clinical measures. Controlling for abstinence status, bupropion was associated with reduction (improvement) in reaction time variability on the AX-CPT and with reduction in perseverative errors on the CVLT.

CONCLUSION

We conclude that 1 week of tobacco abstinence is associated with slowed motor speed but is not associated with detectable worsening in performance on a range of neuropsychological tests or clinical symptoms in the subset of patients who were able to quit smoking. We also conclude that bupropion treatment may be associated with improvement in variability of attention.

How does bupropion work as a smoking cessation aid?

Bupropion exhibits reasonable efficacy as a smoking cessation aid, yet its precise mechanisms of action remain unclear. This review evaluates the mechanism of action of bupropion by considering the clinical evidence in combination with results from pre-clinical experiments in vivo and in vitro. Bupropion is a weak inhibitor of dopamine and noradrenaline reuptake, and has also been shown to antagonise nicotinic acetylcholine receptor function. It is extensively metabolized in humans, its major metabolites reaching levels higher than those of bupropion itself. These metabolites share many of the pharmacological properties of bupropion, so they may play an important role in its clinical activity, yet they have been neglected in investigations into bupropion action. This review led to several conclusions: (1) the principal mode of bupropion action is upon the withdrawal symptoms following smoking cessation; (2) during withdrawal, bupropion may attenuate symptoms by mimicking nicotinic effects on dopamine and noradrenaline; (3) its ability to antagonize nicotinic receptors may prevent relapse by attenuating the reinforcing properties of nicotine, but probably cannot acutely reduce smoking; and (4) further exploration of bupropion metabolites and its role in withdrawal and relapse, within more appropriate animal models, could be crucial in the determination of the precise mechanisms by which bupropion exerts its activity in smoking cessation. Greater elucidation of the exact mechanisms of action of bupropion could lead to the development of new drugs even more beneficial in promoting smoking abstinence.

The feasibility of smoking reduction: an update

AIM

To update conclusions of a previous review of smoking reduction on the extent to which (1) smokers spontaneously reduce their smoking, (2) smokers who try to quit and fail return to smoking less, (3) smokers can substantially reduce and maintain reductions via pharmacological and behavioral treatments and (4) smokers compensate when they reduce.

METHOD

Qualitative systematic review.

DATA SOURCES

Systematic computer searches and other methods.

STUDY SELECTION

Published and unpublished studies of smokers not trying to stop smoking. We located 13-26 studies for each of the four aims.

DATA EXTRACTION

The first author entered data with confirmation by second author.

DATA SYNTHESIS

Due to the heterogeneity of methods and necessity of extensive recalculation, a meta-analysis was not feasible.

RESULTS

Few daily smokers spontaneously reduce. Among those who try to stop smoking and relapse, some return to reduced smoking but whether they maintain this reduction is unclear. Nicotine replacement (and perhaps behavior therapies) can induce smokers not interested in quitting to make significant reductions in their smoking and maintain these over time. Some compensatory smoking occurs with reduction but significant declines in smoke exposure still occur.

CONCLUSIONS

These results indicate that reduction is feasible when aided by treatment. Whether reduction should be promoted will depend on the effect of reduction on health outcomes and future cessation.

Behavioural and pharmacological magnetic resonance imaging assessment of the effects of methylphenidate in a potential new rat model of attention deficit hyperactivity disorder

RATIONALE

The psychomotor stimulant methylphenidate is used in the treatment of attention deficit hyperactivity disorder (ADHD). Whereas the mechanism is not fully understood it is suggested to involve restoration of impaired dopamine function found in ADHD.

OBJECTIVES

The aim of this study was to determine the effects of methylphenidate on brain region activation in vivo using pharmacological magnetic resonance imaging (phMRI) in a potential rat model of ADHD.

METHODS

Rats were treated bi-daily [from postnatal day (PND) 24] for 4 days with the dopamine re-uptake inhibitor GBR 12909 (30 mg/kg i.p) or vehicle (control). On PND 57 rats were administered methylphenidate (4 mg/kg i.p) and locomotor activity measured. In a separate group of animals, blood oxygen level dependent (BOLD) response was measured using phMRI to determine changes in brain region activation produced by methylphenidate (4 mg/kg i.p.) in GBR 12909-pretreated or control rats.

RESULTS

Methylphenidate produced a greater locomotor-stimulant response in controls compared with GBR 12909 rats. Pretreatment with GBR 12909 reduced the BOLD response produced by methylphenidate compared with that in control animals. The main effects of methylphenidate on the BOLD response were seen in the caudate, frontal cortex, hippocampus and hypothalamus.

CONCLUSIONS

Short-term treatment with GBR 12909 in young rats causes long-term changes in dopaminergic systems, altering the methylphenidate-induced behavioural response and brain region activation compared with that in vehicle-pretreated rats. The results further support the view that altered dopaminergic function may be an important factor in ADHD and the value of animal models with this functional neurochemical deficit.

An innovative tobacco use cessation program for military dental clinics

Tobacco use is the chief avoidable cause of death and illness in our society. Military leaders are concerned with rising medical costs and the related negative effects on combat readiness associated with tobacco use. Tobacco use cessation (TUC) programs available in the military services have not reached their full potential. Dental officers have an opportunity to assume a more active role as first-line providers in TUC programs. This paper presents a model TUC program for use in military dental clinics. It emphasizes the dentist's role in directly prescribing pharmacologic agents in nicotine replacement therapy (NRT) combined with appropriate patient counseling. Other key elements of this TUC program include the non-threatening manner in which patients are offered access to TUC, its convenience when compared with other programs, and the minimal cost to implement this program.

The impact of smoking cessation on objective and subjective markers of sleep: review, synthesis, and recommendations

Sleep disturbance is commonly reported as a prominent subjective symptom by quitting smokers. However, little research on this issue has used objective measures of sleep quality. Previous research has relied mainly on retrospective report of sleep disturbance, with few studies investigating sleep during the initial period after quitting tobacco use. Studies that have used objective measurements suggest that sleep fragmentation is a common occurrence during the withdrawal period. In sleep medicine, sleep disturbance is viewed as a consequence of frequent arousals and is now considered to have particularly deleterious daytime consequences, including sleepiness and dysphoric mood. Recent work also indicates that such awakenings affect the cardiovascular system by providing repetitive bursts of sympathetic nervous system activation, possibly contributing to elevated levels of cardiovascular and cerebrovascular morbidity. Pharmacological treatments designed to facilitate smoking cessation are ineffective for sustained abstinence in many smokers, which may be related to sleep disturbance. Indeed, preliminary evidence suggests that the administration of nicotine replacement therapy (NRT) or bupropion can result in disrupted sleep, particularly in women. However, to better understand the role that nicotine withdrawal and bupropion or NRT treatment, independently and in combination, might play in sleep disturbance, it is necessary to develop a better understanding of the nature of the sleep disturbance than can be provided by self-report. This is particularly important for the development of treatment approaches targeted to ameliorate sleep disruption as part of an overall smoking cessation strategy. The present review seeks to report the current state of knowledge based on extant findings and argues for the need to conduct more detailed polysomnographic investigations of the potentially vicious cycle of smoking cessation leading to sleep disturbances that may prove iatrogenic to sustained cessation.