Non-nicotine pharmacotherapy for smoking cessation

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.

Current and Emerging Pharmacotherapies for Cessation of Tobacco Smoking

Tobacco use disorder is a chronic illness. With its high comorbidity rate, it is a major cause of years of life lost or years lived with disability; however, it is also considered the most preventable cause of death in developed countries. Since the development of nicotine replacement therapy (NRT) in 1978, treatment options have continued to evolve and expand. Despite this, currently available treatments remain insufficient, with less than 25% of smokers remaining abstinent 1 year after treatment. In this article, we review existing and emerging smoking cessation pharmacotherapies, with a special emphasis on the most promising agents that are currently being investigated. A search of the Cochrane Database of Systematic Reviews and the PubMed, Ovid, and ClinicalTrials.gov databases (August 2 to September 1, 2017) was undertaken for articles on smoking cessation pharmacotherapies, applying no language restrictions. More than 40 pharmacotherapies were reviewed including conventional pharmacotherapies-NRT, bupropion, and varenicline (all approved by the U.S. Food and Drug Administration as first-line treatment of smoking cessation)-and novel therapies: cytisine, N-acetylcysteine, cycloserine, memantine, baclofen, topiramate, galantamine, and bromocriptine. Studies of combination NRT and varenicline showed the greatest smoking cessation rates. Clonidine and nortriptyline are second-line treatments used when first-line treatments fail or are contraindicated, or by patient preference. Some novel therapies, especially acetylcholinesterase inhibitors, cytisine, and N-acetylcysteine, display promising results. Because the results of randomized clinical trials were reported using varied end points and outcome measures, direct comparisons between different pharmacotherapies cannot easily be evaluated. Additional high-quality randomized double-blind placebo-controlled trials with long-term follow-up, using validated sustained abstinence measures, are needed to find more effective smoking cessation aids.

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

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

Reducing Pulmonary Disease: The Pharmacist’s Role in Smoking Cessation

As an important interface with the healthcare system for many patients, pharmacists are in a unique position to assist patients with quitting smoking, thereby improving patients’ pulmonary health. Because nicotine replacement therapy products and bupropion are available to patients largely via pharmacies, the pharmacist has become a logical candidate for providing smoking cessation assistance. Furthermore, research has shown that when pharmacists counsel patients on medications for quitting smoking, their intervention positively impacts smoking cessation rates. This article provides a review of methods for cessation and provides pharmacists with feasible and effective smoking cessation counseling strategies for implementation into everyday practice. The intervention approach draws heavily upon the U.S. Public Health Service Clinical Practice Guideline for Treating Tobacco Use and Dependence.

Pharmacotherapy for smoking cessation: pharmacological principles and clinical practice

Strategies for assisting smoking cessation include behavioural counselling to enhance motivation and to support attempts to quit and pharmacological intervention to reduce nicotine reinforcement and withdrawal from nicotine. Three drugs are currently used as first line pharmacotherapy for smoking cessation, nicotine replacement therapy, bupropion and varenicline. Compared with placebo, the drug effect varies from 2.27 (95% CI 2.02, 2.55) for varenicline, 1.69 (95% CI 1.53, 1.85) for bupropion and 1.60 (95% CI 1.53, 1.68) for any form of nicotine replacement therapy. Despite some controversy regarding the safety of bupropion and varenicline, regulatory agencies consider these drugs as having a favourable benefit/risk profile. However, given the high rate of psychiatric comorbidity in dependent smokers, practitioners should closely monitor patients for neuropsychiatric symptoms. Second-line pharmacotherapies include nortriptyline and clonidine. This review also offers an overview of pipeline developments and issues related to smoking cessation in special populations such as persons with psychiatric comorbidity and pregnant and adolescent smokers.

An efficient early phase 2 procedure to screen medications for efficacy in smoking cessation

RATIONALE

Initial screening of new medications for potential efficacy (i.e., Food and Drug Administration (FDA) early phase 2), such as in aiding smoking cessation, should be efficient in identifying which drugs do, or do not, warrant more extensive (and expensive) clinical testing.

OBJECTIVES

This focused review outlines our research on development, evaluation, and validation of an efficient crossover procedure for sensitivity in detecting medication efficacy for smoking cessation. First-line FDA-approved medications of nicotine patch, varenicline, and bupropion were tested as model drugs, in three separate placebo-controlled studies. We also tested specificity of our procedure in identifying a drug that lacks efficacy, using modafinil.

RESULTS

This crossover procedure showed sensitivity (increased days of abstinence) during week-long "practice" quit attempts with each of the active cessation medications (positive controls) versus placebo, but not with modafinil (negative control) versus placebo, as hypothesized. Sensitivity to medication efficacy signal was observed only in smokers high in intrinsic quit motivation (i.e., already preparing to quit soon) and not smokers low in intrinsic quit motivation, even if monetarily reinforced for abstinence (i.e., given extrinsic motivation).

CONCLUSIONS

A crossover procedure requiring less time and fewer subjects than formal trials may provide an efficient strategy for a go/no-go decision whether to advance to subsequent phase 2 randomized clinical trials with a novel drug. Future research is needed to replicate our results and evaluate this procedure with novel compounds, identify factors that may limit its utility, and evaluate its applicability to testing efficacy of compounds for treating other forms of addiction.

Influence of Neuronal Nicotinic Receptors over Nicotine Addiction and Withdrawal

Cigarette smoking represents an enormous, global public health threat. Nearly five million premature deaths during a single year are attributable to smoking. Despite the resounding message of risks associated with smoking and numerous public health initiatives, cigarette smoking remains the most common preventable cause of disease in the United States. Fortunately, even in an adult smoker, smoking cessation can reverse many of the potential harmful effects. The symptoms associated with nicotine withdrawal represent the major obstacle to smoking cessation. This minireview examines the roles of various nicotinic receptors in the mechanisms of nicotine dependence, discusses the potential role of the habenula-interpeduncular nucleus axis in nicotine withdrawal, and highlights nicotinic receptors containing the β4 subunit as a potential pharmacological target for smoking cessation strategies.

Examining the clinical efficacy of bupropion and nortriptyline as smoking cessation agents in a rodent model of nicotine withdrawal

RATIONALE

At present, there is a lack of an established animal model to demonstrate the clinical efficacy of smoking cessation agents in the laboratory. The aim of this study was to compare the effects of the antidepressants bupropion and nortriptyline, clinically proven smoking cessation aids, within a rodent model of a nicotine withdrawal based on somatic measures.

MATERIALS AND METHODS

Male hooded Lister rats were chronically exposed to nicotine (3.16 mg kg1 day1) for 7 days via SC implanted ALZET osmotic minipumps. Animals were acutely pre-treated with bupropion (10, 30 or 60 mg/kg, IP) or nortriptyline (1.5, 4.7 and 15 mg/kg, IP), and nicotine withdrawal was precipitated by mecamylamine (1 mg/kg).

RESULTS

Precipitation of nicotine withdrawal led to an increase in somatic signs including body shakes, chews, eye blinks, foot licks, head shakes and ptosis. Bupropion dose-dependently decreased the total abstinence scores and reduced the occurrence of some individual somatic signs. Pre-treatment with 60 mg/kg bupropion did not result in a significant increase in total abstinence scores or individual somatic signs scores after mecamylamine challenge, compared to the mecamylamine control group, suggesting nicotine withdrawal is fully attenuated at this dose. Similarly, the highest dose of nortriptyline reduced total abstinence scores and some individual somatic signs to the level of the mecamylamine control group. However, nortriptyline was only effective at alleviating somatic measures of withdrawal at doses which also suppressed locomotor activity.

CONCLUSION

In concurrence with clinical findings proposing alleviation of withdrawal states as a possible mechanism of bupropion and nortriptyline's smoking cessation action, both drugs were found to ameliorate somatic signs of nicotine withdrawal in rodents.

Developments in pharmacotherapy for tobacco dependence: past, present and future

In the mid-1970s there were no effective pharmacological treatments for tobacco dependence. The invention of nicotine gum was a major treatment advance and also greatly helped our understanding of the nature of tobacco dependence. There are now eight effective pharmacotherapies (nicotine gum, patch, nasal spray, inhaler, lozenge/tablet, bupropion, nortriptyline and clonidine) available to aid smoking cessation. Other non-nicotine agents that show promise are under investigation, including glucose, rimonabant, selegiline and varenicline. Greater knowledge of the mechanisms of action of the effective non-nicotine agents should lead to better understanding of the nature of tobacco dependence. Future research into optimal treatments should examine long-term combination pharmacotherapy combined with improved psychosocial support that is partly designed to enhance medication compliance. In addition, there is a need for studies designed to evaluate the efficacy of pharmacotherapies in populations such as youth, pregnant smokers and smokers with co-occurring mental health problems.

Nicotine and non-nicotine smoking cessation pharmacotherapies

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

Effect of sustained-release (SR) bupropion on craving and withdrawal in smokers deprived of cigarettes for 72 h

RATIONALE

Sustained-release (SR) bupropion enhances quit rates of smokers, generally decreases tobacco withdrawal, and in some studies, reduces craving.

OBJECTIVE

Investigate the effects of SR bupropion on craving and withdrawal during cigarette abstinence.

METHODS

Twenty three smokers participated in three 17-day periods composed of 14 out-patient days followed by 3 (72 h) in-patient days. During the out-patient days, subjects received SR bupropion, placebo, or no drug. During the in-patient days, subjects were abstinent from cigarettes on two occasions while receiving either SR bupropion or placebo and smoked freely during the other occasion. SR bupropion was titrated over the first three out-patient days followed by a fixed dose (300 mg/day) for 14 days (including the three in-patient abstinence days). Cigarette craving, withdrawal, and selected physiological measures were assessed repeatedly over the 72-h periods.

RESULTS

During the 72-h periods, craving intensity was significantly lower with free smoke and SR bupropion than with placebo, and significantly lower during free smoke than during SR bupropion. Overall withdrawal symptoms were significantly lower with free smoke than with either placebo or SR bupropion. Among individual withdrawal symptoms (excluding craving), appetite increase was significantly reduced during SR bupropion compared to placebo. During placebo and SR bupropion, craving intensity displayed a circadian pattern that was different from that observed during free smoke.

CONCLUSIONS

SR bupropion reduced craving and appetite increase during smoking abstinence. These findings support the hypothesis that craving and withdrawal symptoms may be controlled by distinct central nervous system pathways.

Smoking cessation in patients with coronary artery disease

BACKGROUND

Smoking cessation is an important factor in the primary and secondary prevention of cardiac events. Although multiple clinical trials have examined the efficacy of various smoking cessation aids, a systematic review of the efficacy and safety of smoking cessation aids has not been done.

METHODS

This paper reviews the effects of smoking on coronary artery disease. In addition, we identify randomized controlled trials examining the efficacy and safety of smoking cessation aids from the years 1970 to 2004. We then pooled the trial results for 6- and 12-month rates of continuous smoking abstinence.

RESULTS

The 4 principal mechanisms of cardiovascular damage caused by cigarette smoking are induction of a hypercoagulable state, reduction of oxygen delivery because of carbon monoxide, coronary vasoconstriction, and nicotine-induced hemodynamic effects. Our review of clinical trials suggests that each smoking cessation aid improved continuous smoking abstinence rates at both 6 and 12 months compared with placebo. The 12-month abstinence rates for the active versus placebo treatments were the following: nicotine patch 11.1% versus 5.5%, nicotine gum 27.3% versus 16.5%, nicotine inhaler 16.9% versus 9.1%, bupropion 18.5% versus 6.6%, and behavioral therapy 20.0% versus 13.9%.

CONCLUSIONS

Several smoking-related mechanisms are responsible for the development of atherosclerosis and the induction of cardiac events. Smoking cessation aids effect a modest increase in smoking abstinence at 12 months compared with placebo. In spite the apparent success of cessation aids, smoking relapse rates are quite high.

Assisting with tobacco cessation

Tobacco use is the primary preventable cause of morbidity and mortality in the United States today. The consequences of smoking are well documented, and it is the responsibility of every health care provider to routinely screen and offer treatment to their patients who smoke. Nurses are no exception; we are uniquely qualified to provide practical skills training to our patients. Irrefutable data exist that even 3 minutes of counseling can have a positive influence that moves the patient who smokes further along the continuum toward quitting. The treatment recommendations and strategies that will be discussed are found in the Agency for Health Care Policy and Research guideline entitled "Treating Tobacco Use and Dependence." The algorithm will be broken down into practical interview questions and activities that every nurse can implement with his or her patients, regardless of practice setting.

Benefits and risks of pharmacological smoking cessation therapies in chronic obstructive pulmonary disease

Smoking cessation is the most effective way to reduce the risk of developing chronic obstructive pulmonary disease (COPD) or to reduce its progression. However, little is known about the efficacy and safety of different pharmacological smoking cessation therapies used for the treatment of patients with COPD who smoke. The aim of this review was to evaluate the benefits and risks of pharmacological smoking cessation therapies in COPD. We conducted an extensive computer-aided literature search which resulted in the identification of four papers that met the inclusion criteria and contributed to this review. In two studies the efficacy of nicotine polacrilex (nicotine gum) was assessed. In one study, which did not have a control group, the efficacy of nicotine nasal spray was evaluated. The fourth study, a placebo-controlled trial, evaluated the efficacy of bupropion sustained release. The results of these studies indicated that nicotine gum, nicotine nasal spray and bupropion have a good safety profile and seem to increase abstinence rates in smokers with COPD. The incidence and nature of specific adverse effects occurring in patients with COPD seem to be comparable with the adverse effects reported by healthy smokers. However, the efficacy seems to depend on the follow-up period used to define success (i.e. abstinence rates decline with longer follow-up), as well as the intensity and duration of the concomitant psychosocial intervention. This review indicates that for a continuation of the effect of pharmacological smoking cessation therapies, the combination of pharmacotherapy (to reduce craving and withdrawal) and a relapse-prevention programme, in which attention is focused on the behavioural aspects of smoking and smoking cessation, seems to increase abstinence, especially when the psychosocial intervention is prolonged for a longer period. Also, the characteristics of the smokers who are motivated to quit must be taken into account in order to increase the number of successful attempts to quit smoking and prevent relapses. We therefore recommend using a holistic approach in which the possible coexistence of multiple problems (which are known to affect the success of smoking cessation strategies) is integrated.

Hypericum perforatum attenuates nicotine withdrawal signs in mice

RATIONALE

Hypericum perforatum is used as a natural antidepressant, and other antidepressants have been marketed to aid in smoking cessation.

OBJECTIVE

We investigated the effects of an extract of Hypericum perforatum (Ph-50) on withdrawal signs produced by nicotine abstinence in mice.

METHODS

Nicotine (2 mg/kg, four injections daily) was administered for 14 days to mice. Different doses of Ph-50 (125-500 mg/kg) were administered orally immediately after the last nicotine injection. In another experiment, Ph-50 (500 mg/kg) was orally administered in combination with nicotine, i) starting from day 8 until the end of the nicotine treatment period, or ii) during nicotine treatment and after nicotine withdrawal, or iii) immediately after the last nicotine injection. On withdrawal from nicotine, all animals were evaluated for locomotor activity and abstinence signs.

RESULTS

The locomotor activity reduction induced by nicotine withdrawal was abolished by Ph-50, which also significantly and dose-dependently reduced the total nicotine abstinence score when injected after nicotine withdrawal.

CONCLUSIONS

These data show that treatment with Hypericum perforatum attenuates nicotine withdrawal signs in mice. Further studies are necessary to test the possibility that it may be used for smoking cessation treatment in humans.

Adolescent smoking: epidemiology and approaches for achieving cessation

The initiation of smoking typically occurs during adolescence. To date, most adolescent smoking control efforts have focused on prevention; attempting to identify and influence factors that contribute to experimentation and initiation. However, given the large number of adolescent smokers, it is important that effort also be directed toward facilitating cessation. Many adolescents are addicted to cigarettes and report withdrawal symptoms that are similar to those experienced by adults. Relapse rates are high; few adolescents who try to quit on their own are successful. Clinician-delivered smoking cessation interventions have a positive impact in adults and should be applied to adolescents to promote and sustain abstinence. Although pharmaceutical aids for cessation have been shown to be well tolerated and effective in adults, less is known about their use in adolescents. As such, clinicians are encouraged to explore whether pharmaceutical aids have been approved for use in adolescents in their country and to use discretion when considering their use in patients <18 years of age. Because pediatricians are in a unique position to facilitate tobacco cessation counseling, they should routinely ask their patients whether they use tobacco, advise users to quit, assess readiness to quit, assist with quitting, and arrange follow-up counseling. Tobacco cessation efforts can be enhanced by teaming with other health professionals (e.g. nurses, dentists, pharmacists, social workers) or worksite and community-based organizations that provide health promotion services.

Stopping smoking: a prospective, randomized, double-blind study comparing nortriptyline to placebo

OBJECTIVE

The administration of antidepressant drugs was shown to positively affect the rate of smoking cessation. This study evaluates the efficacy of nortriptyline in an antismoking program.

METHODS

A possible randomized double-blind study that included 144 patients who were randomized to receive nortriptyline, 75 mg/d (68 patients), or placebo (76 patients), during 6 consecutive weeks. All patients attended behavioral group orientation for 5 weeks. The rate of success, complications, adherence to the regime, and factors of pretreatment prognosis were evaluated (multivariate analysis).

RESULTS

The groups were balanced in relation to the characteristics of the patients on entering the study. Patients receiving nortriptyline showed significantly higher cessation rate (55.9%) compared to the group receiving placebo (23.3%; p < 0.001). In a univariate analysis on prognosis factors influencing the rate of cessation in our study, the Fagerström test results (p = 0.005) and nortriptyline (p < 0.001) were identified. Logistic regression showed that a Fagerström test score of < 7 (odds ratio [OR], 3.1; 95% confidence interval [CI], 1.47 to 6.7; p = 0.003) and nortriptyline use (OR, 4.1; 95% CI, 2 to 8.3; p < 0.001) were independent factors impacting the rate of success for smoking cessation. No significant complications were observed in the nortriptyline group.

CONCLUSION

This study showed that nortriptyline significantly increases the smoking cessation rate in chronic smokers, as compared to the placebo group, without any significant side effects.

Vaccines against nicotine: how effective are they likely to be in preventing smoking?

Cigarette smoking is the most preventable cause of death in industrialised countries. 30% of all deaths in smokers in the 35 to 69 years age range are attributed to chronic cigarette smoking; smokers dying in this age cohort lose an average of 23 years of life. Public health campaigns have attempted to reduce initiation of smoking in adolescents and to foster quitting in dependent smokers. The prevalence of smoking has declined in the US to 25% of the population, but this figure has held constant for the last decade. Vaccines against nicotine are a novel concept in the field of smoking cessation research and have not yet reached the stage of clinical testing. Vaccines could reduce smoking behaviour in 3 groups of smokers: (i) current smokers attempting to quit; (ii) former smokers wanting to avoid the possibility of relapse; and (iii) adolescent smokers before they become confirmed smokers. The rationale behind the approach is that nicotine is the pharmacological agent controlling the rate of cigarette smoking, and reducing its rate and extent of uptake into the brain may have therapeutic benefits.

Tobacco smoking, nicotine, and nicotine and non-nicotine replacement therapies

Tobacco smoking is associated with an increased risk for the development of coronary and pulmonary vascular diseases and smoking cessation will greatly reduce this risk. Nicotine replacement and nonnicotine modalities have been used alone and in combination to help in smoking cessation. These treatment modalities appear to be safe in patients with known stable coronary artery disease.

Clearing the smoke: the scientific rationale for tobacco abstention with plastic surgery

The use of tobacco is a significant contributor to preventable morbidity and mortality in the United States. A significant proportion of cardiovascular diseases, various oral and pulmonary neoplasms, nonmalignant respiratory diseases, and peripheral vascular disorders can be attributed to the use of cigarettes. Surgical outcomes can also be adversely affected as a result of cigarette smoking with intraoperative and postoperative pulmonary, cardiovascular, and cerebrovascular complications as well as increased wound healing complications. These are found across the entire spectrum of surgical specialties. Tissue ischemia and wound-healing impairment secondary to the influence of tobacco is particularly problematic for the plastic surgeon, especially during elective facial aesthetic procedures, cosmetic and reconstructive breast operations, abdominoplasty, free-tissue transfer, and replantation procedures. By educating and providing guidelines to those patients who smoke and by refusing to operate on individuals who fail to abstain, tobacco-associated surgical morbidity in the plastic and reconstructive surgery patient can be eliminated.

Smoking status and psychosocial variables in type 1 diabetes mellitus

While depression, anxiety, and negative affect are associated with smoking and smoking cessation outcomes in healthy individuals, these associations have not been established in smokers with chronic diseases such as diabetes mellitus, a condition which greatly increases cardiovascular disease risk. Other psychosocial variables such as stress and locus of control may also be associated with smoking but are seldom reported. We examined stress, affect, and locus of control by smoking status in patients with type 1 diabetes mellitus. Results indicated that current smokers reported significantly higher levels of perceived stress, a more negative affect, and higher powerful others locus of control compared with nonsmokers. These findings indicate that those patients who have diabetes and who smoke are at greater risk for depressive symptoms. This knowledge may aid clinicians in their attempts to help these patients quit smoking.

Zyban: an effective treatment for nicotine addiction

Recent research has identified nicotine as a powerfully addictive substance. This article outlines how the new non-nicotine smoking cessation drug, Zyban, can help people to break the cycle of addiction and stop smoking.