Nortriptyline for smoking cessation: a review

Cardiovascular Effects of Smoking and Smoking Cessation: A 2024 Update

Smoking is a significant risk factor for both acute and chronic cardiovascular diseases. These diseases contribute to approximately twenty percent of all-cause mortality. Research indicates that quitting smoking can substantially reduce or even reverse the harmful effects associated with smoking on cardiovascular health. Notably, these benefits can be observed in a relatively short period compared to the duration of smoking history. This article aims to provide data to understand the effects of smoking on the cardiovascular system locally as well as its effects as a pandemic globally and hence provide comprehensive strategies in the management of cardiovascular patients for smoking cessation.

Current Pharmacotherapies for Smoking Cessation and Promising Emerging Drugs

OBJECTIVE

Pharmacotherapy is commonly used during quit attempts and has shown an increase in the likelihood of achieving abstinence. However, with established pharmacotherapies, abstinence rates following a quit attempt remain low, and relapse is common. This review aims to investigate the efficacy and harm profiles of current and emerging pharmacotherapies.

METHODS

Literature review of current and emerging pharmacotherapies for smoking cessation and tobacco use disorder.

RESULTS

Emerging pharmacotherapies include new formulations of existing therapies, drug repurposing and some new treatments. New treatments are welcome and may incorporate different mechanisms of action or different safety and tolerability profiles compared to existing treatments. However, emerging pharmacotherapies have yet to demonstrate greater efficacy compared to existing treatments. The emergence of Electronic Nicotine Delivery Systems (ENDS) or 'vaping' is a feature of the current debate around tobacco use disorder. ENDS appear to facilitate switching but not quitting and are controversial as a harm minimisation strategy.

LIMITATIONS

Studies included a broad range of therapies and trial designs that should be compared with their differences taken into consideration.

CONCLUSION

Strategies to successfully quit smoking vary between individuals and may extend beyond pharmacotherapy and involve complex psychosocial factors and pathways.

Psychopharmacology of smoking cessation medications: focus on patients with mental health disorders

The adverse effects of smoking cessation in individuals with mental health disorders have been a point of concern, and progress in the development of treatment has been slow. The primary first-line treatments for smoking cessation are Nicotine Replacement Therapy, Bupropion, Varenicline, and behavioural support. Nortriptyline and Clonidine are second-line treatments used when the first-line treatments are not effective or are contraindicated. Smoking cessation medications have been shown to be effective in reducing nicotine cravings and withdrawal symptoms and promoting smoking cessation among patients living with mental disorders. However, these medications may have implications for patients' mental health and need to be monitored closely. The efficacy and side effects of these medications may vary depending on the patient's psychiatric condition, medication regimen, substance use, or medical comorbidities. The purpose of this review is to synthesise the pharmacokinetics, pharmacodynamics, therapeutic effects, adverse effects, and pharmacological interactions of first- and second-line smoking cessation drugs, with an emphasis on patients suffering from mental illnesses. Careful consideration of the risks and benefits of using smoking cessation medications is necessary, and treatment plans must be tailored to individual patients' needs. Monitoring symptoms and medication regimens is essential to ensure optimal treatment outcomes.

Antidepressants for smoking cessation

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

How to persuade more primary care professionals to adopt a valued smoking cessation referral aid: a cross-sectional study of facilitators and barriers

BACKGROUND

To study the factors associated with the intention of primary care professionals (PCPs) to use or not use a referral aid (RA) for selecting an evidence-based smoking cessation intervention (EBSCI).

METHODS

Participants (n = 85) were recruited from June to September 2020 to complete an online questionnaire based on the I-Change Model to assess the factors associated with the adoption of RA. The differences between PCPs with (n = 37) and without (n = 48) the intention to adopt in terms of demographics, motivational factors, and post-motivational factors were subsequently assessed. Correlation and logistic regression analyses were conducted to investigate the factors associated with the intention to adopt.

RESULTS

Both groups indicated that they highly appreciated the RA. However, PCPs without the intention to adopt expressed a more negative attitude towards the RA, experienced less social support, showed low self-efficacy, and encountered barriers such as lack of time and skills. The factors most strongly associated with the intention to adopt were advantages, disadvantages, self-efficacy, less barriers, working in a solo practice and age.

CONCLUSIONS

The adoption of RA can be facilitated in two ways. The first one is by increasing the added value of the tool through a second round of co-creation focusing on the adoptability of the RA in practice. The second approach is by communicating the added value of referring to EBSCIS and thereby using the RA by implementing it in smoking cessation training for PCPs, which could also help to improve the attitude, social support, self-efficacy, and perceived skills in terms of RA usage among PCPs.

IMPACT

This study is the first work in the Netherlands to investigate the willingness of PCPs to actively refer patients to other EBSCIs in addition to providing face-to-face counseling themselves.

TRIAL REGISTRATION

The study was registered at the Netherlands Trial Register (NL7020, https://www.trialregister.nl/trial/7020 ).

Nicotine Use Disorder in Older Adults

Nicotine is one of the most abused substances worldwide. Just as in adolescence and adulthood, tobacco use is also problematic in the elderly. Older people are more vulnerable to smoking consequences because of the additive effects of smoke. Cardiovascular diseases are the most common health problems associated with smoking; however, other systems are also affected, including the respiratory, nervous, integumentary, and many other systems. Smoking cessation is a difficult task especially in the elderly; therefore, physicians should encourage older patients to quit with every patient-physician encounter by offering counseling and replacement therapy.

Smoking Addiction and Strategies for Cessation

Cigarette smoking is the leading cause of chronic obstructive pulmonary disease (COPD) worldwide. Smoking cessation is thus integral to the treatment of COPD. Nicotine addiction is a disease dependent on the complex interactions of neurotransmitter pathways, conditioned behaviors, environmental cues, genetic predisposition, and personal life circumstances, which render some more susceptible to tobacco abuse than others. The most successful smoking cessation programs are individualized, comprehensive, and utilize combinations of clinician counseling, behavioral reinforcement, community resources, advanced technology support (eg, smartphone apps, and Internet Web sites), and pharmacotherapy (both nicotine-based and nonnicotine medications). E-cigarettes were introduced to the US market in 2006 and touted as a safer alternative to tobacco cigarette smoking. Unfortunately, over the last 5 to 10 years, recreational e-cigarette use, or "vaping," has increased in popularity, especially among adolescents. This has introduced nicotine addiction to an entire generation of nonsmokers and resulted in numerous cases of acute lung disease, now known as e-cigarette or vape product use-associated lung injury (EVALI). In light of these adverse events, e-cigarettes and vape products are not currently recommended as a smoking cessation aid.

A referral aid for smoking cessation interventions in primary care: study protocol for a randomized controlled trial

BACKGROUND

To expedite the use of evidence-based smoking cessation interventions (EBSCIs) in primary care and to thereby increase the number of successful quit attempts, a referral aid was developed. This aid aims to optimize the referral to and use of EBSCIs in primary care and to increase adherence to Dutch guidelines for smoking cessation.

METHODS

Practice nurses (PNs) will be randomly allocated to an experimental condition or control condition, and will then recruit smoking patients who show a willingness to quit smoking within six months. PNs allocated to the experimental condition will provide smoking cessation guidance in accordance with the referral aid. Patients from both conditions will receive questionnaires at baseline and after six months. Cessation effectiveness will be tested via multilevel logistic regression analyses. Multiple imputations as well as intention to treat analysis will be performed. Intervention appreciation and level of informed decision-making will be compared using analysis of (co)variance. Predictors for appreciation and informed decision-making will be assessed using multiple linear regression analysis and/or structural equation modeling. Finally, a cost-effectiveness study will be conducted.

DISCUSSION

This paper describes the study design for the development and evaluation of an information and decision tool to support PNs in their guidance of smoking patients and their referral to EBSCIs. The study aims to provide insight into the (cost) effectiveness of an intervention aimed at expediting the use of EBSCIs in primary care.

Candidate pharmacological treatments for substance use disorder and suicide identified by gene co-expression network-based drug repositioning

Patients with substance use disorders (SUD) are at high risk to die by suicide. So far, the neurobiology of the suicide-SUD association has not been elucidated. This study aimed to identify potential pharmacological targets among hub genes from brain gene co-expression networks of individuals with SUD in a suicidal and non-suicidal context. Post-mortem samples from the prefrontal cortex of 79 individuals were analyzed. Individuals were classified into the following groups: suicides with SUD (n = 28), suicides without SUD (n = 23), nonsuicides with SUD (n = 9), nonsuicides without SUD (n = 19). Gene expression profiles were evaluated with the Illumina HumanHT-12 v4 array. Co-expression networks were constructed in WGCNA using the differentially expressed genes found in the comparisons: (a) suicides with and without SUD and (b) nonsuicides with and without SUD. Hub genes were selected for drug-gene interaction testing in the DGIdb database. Among drugs interacting with hub genes in suicides we found MAOA inhibitors and dextromethorphan. In the nonsuicide individuals, we found interactions with eglumegad and antipsychotics (olanzapine, clozapine, loxapine). Modafinil was found to interact with genes in both suicides and nonsuicides. These drugs represent possible candidate treatments for patients with SUD with and without suicidal behavior and their study in each context is encouraged.

Antidepressants for smoking cessation

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Topiramate for smoking cessation: Systematic review and meta-analysis

INTRODUCTION

Topiramate is an antiepileptic drug that has been used for many labeled and off-labeled indications. It may be useful in reducing withdrawal symptoms of various addictive agents such as alcohol, cocaine, cannabis and smoking. To date, some studies have examined the effectiveness of topiramate for smoking cessation. The present review aims to synthesize the results from those studies and determine topiramate effectiveness in smoking cessation.

METHODS

A comprehensive search was conducted in the databases: PubMed/Medline, Cochrane, Egyptian Knowledge Bank, and Google Scholar. All clinical trials that examined the effect of topiramate, compared with the placebo, on smoking cessation rate were included. Statistical analysis using fixed effect models, heterogeneity and sensitivity analysis were conducted using RevMan 5.3.

RESULTS

Five trials met the inclusion criteria and were included in the meta-analysis. Topiramate non-significantly increased prolonged smoking abstinence rate (OR=1.19, 95% CI: 0.57–2.5) compared with the placebo. On the other hand, topiramate significantly increased the abstinence rate at weeks 4, 6, 8 and 12 (OR=3.07, 95% CI: 1.19–7.93; OR=4.03, 95% CI: 1.98–8.2; OR=2.29, 95% CI: 1.23–4.28; and OR=2.45, 95% CI: 1.37–4.39; respectively) compared with the placebo.

CONCLUSIONS

Based on the five trials, where publication bias cannot be excluded, the current evidence is not sufficient to show a significant difference to favor topiramate in prolonged smoking cessation over the placebo, although the 12th week point prevalence favored topiramate.

Current advances in research in treatment and recovery: Nicotine addiction

The health harms of combusted tobacco use are undeniable. With market and regulatory pressures to reduce the harms of nicotine delivery by combustion, the tobacco product landscape has diversified to include smokeless, heated, and electronic nicotine vaping products. Products of tobacco combustion are the main cause of smoking-induced disease, and nicotine addiction sustains tobacco use. An understanding of the biology and clinical features of nicotine addiction and the conditioning of behavior that occurs via stimuli paired with frequent nicotine dosing, as with a smoked cigarette, is important for informing pharmacologic and behavioral treatment targets. We review current advances in research on nicotine addiction treatment and recovery, with a focus on conventional combustible cigarette use. Our review covers evidence-based methods to treat smoking in adults and policy approaches to prevent nicotine product initiation in youth. In closing, we discuss emerging areas of evidence and consider new directions for advancing the field.

Can the use of varenicline improve the efficacy of pharmacotherapy for nicotine addiction?

Introduction: Smoking is a huge medical and social problem in Poland, with as many as about 24% of Poles being addicted to nicotine. Approximately 6 million people worldwide die every year from conditions that are closely related to tobacco addiction, such as cancer and cardiovascular, metabolic or lung diseases. The difficulty in combatting nicotine dependence is largely due to the complex mechanism of this addiction. The motivation of a patient to quit smoking is of great importance in the difficult withdrawal process. Strengthening this motivation is one of the most important tasks of physicians and addiction therapists.

Overview of literature: Nicotine replacement therapy (NRT) has been the most widely known way to break away from smoking addiction for many years now. It involves delivering nicotine to the body in ways that are less harmful than through tobacco smoke. As a consequence, the cravings for nicotine are reduced, making it easier for the patient to break with the addiction. Clinical trials have shown that the use of NRT is associated with a 50-70% increased chance of maintaining abstinence from smoking compared to placebo. There are many NRT products, including nicotine chewing gum, nicotine patches, lozenges, dissolvable nicotine sticks, or inhalers. Bupropion is a selective dopamine–noradrenaline reuptake inhibitor. This drug is one of the most commonly used in the pharmacotherapy of depression in the United States. At the same time, it has been found to have a positive effect on people trying to break up with the habit of smoking cigarettes. The mechanism of action remains unknown in this case, but studies clearly indicate the efficacy of bupropion, which is comparable to the efficacy of NRT. Varenicline is a partial agonist selective for α4β2 nicotinic acetylcholine receptors. It has a higher affinity for these receptors than nicotine. By stimulating them, it causes an increase in dopamine secretion (but to a lesser extent than cigarette smoking), helping in this way ease withdrawal symptoms.

Conclusions: Varenicline has higher efficacy than bupropion and NRTs. Simultaneous use of two NRT forms increases the effectiveness of this method to a level comparable to varenicline. Contrary to previous reports, it seems that varenicline does not increase self-aggressive behaviour and the risk of suicide. The effectiveness of antinicotinic drugs depends on the sex of the patient. For both sexes, the most effective drug is varenicline. It is slightly more effective in women than in men. By contrast, NRT and bupropion show greater therapeutic potential in men.

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.

Clinical Effects of Cigarette Smoking: Epidemiologic Impact and Review of Pharmacotherapy Options

Cigarette smoking-a crucial modifiable risk factor for organ system diseases and cancer-remains prevalent in the United States and globally. In this literature review, we aim to summarize the epidemiology of cigarette smoking and tobacco use in the United States, pharmacology of nicotine-the active constituent of tobacco, and health consequence of cigarette smoking. This article also reviews behavioral and pharmacologic interventions for cigarette smokers and provides cost estimates for approved pharmacologic interventions in the United States. A literature search was conducted on Google Scholar, EBSCOhost, ClinicalKey, and PubMed databases using the following headings in combination or separately: cigarette smoking, tobacco smoking, epidemiology in the United States, health consequences of cigarette smoking, pharmacologic therapy for cigarette smoking, and non-pharmacologic therapy for cigarette smoking. This review found that efficacious non-pharmacologic interventions and pharmacologic therapy are available for cessation of cigarette smoking. Given the availability of efficacious interventions for cigarette smoking cessation, concerted efforts should be made by healthcare providers and public health professionals to promote smoking cessation as a valuable approach for reducing non-smokers' exposure to environmental tobacco smoke.

Need for medication to complement catecholamines in smoking cessation of hardcore smokers

Many smokers find it difficult to stop smoking without assistance. The antidepressants bupropion and nortriptyline can aid smoking cessation. The main aim of this study was to understand the pathophysiology of smoking cessation better based on biological backgrounds. We investigated the following biological markers for any alterations during smoking cessation in the absence of pharmacotherapy: the dopamine metabolite homovanillic acid (HVA), the noradrenaline metabolite 3-methoxy-4-hydroxyphenylglycol (MHPG) and brain-derived neurotrophic factor (BDNF). Assessment and blood sampling were performed at a baseline (the start) time point and at a critical time point during smoking cessation. Seven of 30 smokers quit during a 16-week follow-up period; these smokers were defined as remission group from tobacco dependence. The remaining 23 smokers were categorized as hardcore smokers. The smoking group was compared with 23 non-smokers matched for age and gender. We compared blood levels of biological markers in each of the three groups. The hardcore smoker group showed significant decreases in HVA and MHPG levels between baseline and the critical time point (p=0.018 and p=0.033, respectively). However, the remission from tobacco dependence group exhibited no significant changes in any of the biomarkers examined. They had lower scores on the Minnesota nicotine withdrawal scale than the hardcore smoker group (p=0.002). The hardcore smoker group had higher MHPG and BDNF levels than the non-smoker group (p=0.002 and p<0.001, respectively). Hardcore smokers experience severe nicotine withdrawal symptoms. Nicotine withdrawal is associated with catecholamine deficiency. The resulting withdrawal symptoms make quitting difficult for hardcore smokers. These hardcore smokers may require medication to compensate for the catecholamine deficit. Non-nicotinic medications such as bupropion, nortriptyline, or varenicline may be required to bolster the catecholamine deficit in hardcore smokers.

[Psychotherapy and pharmacotherapy for harmful tobacco use and tobacco dependency]

Tobacco consumption is one of the major preventable health risk factors. In Germany approximately 110,000 people prematurely die from tobacco-related diseases and approximately 50% of regular smokers are considered to be tobacco dependent. Nevertheless, motivation to quit smoking is low and the long-term abstinence rates after attempts to stop smoking without professional support are far below 10%. As part of the S3 treatment guidelines 78 recommendations for motivation and early interventions for smokers unwilling to quit as well as psychotherapeutic and pharmacological support for smokers willing to quit were formulated after an systematic search of the current literature. More than 50 professional associations adopted the recommendations and background information in a complex certification process. In this article the scientific evidence base regarding the psychotherapeutic and pharmacological treatment options as well as recommendations and further information about indications and treatment implementation are presented. By following these guidelines for treatment of heavy smokers who are willing to quit combined with individual and group therapies on the basis of behavioral treatment strategies and pharmacological support, long-term success rates of almost 30% can be achieved.

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.

Amitifadine, a triple monoamine re-uptake inhibitor, reduces nicotine self-administration in female rats

A wider diversity of drug treatments to aid smoking cessation is needed to help tailor the most efficacious treatment for different types of smokers. This study was conducted to determine whether amitifadine, which inhibits re-uptake of dopamine, norepinephrine and serotonin, would decrease nicotine self-administration at doses that do not cause adverse side effects. Adult female Sprague-Dawley rats were trained to self-administer nicotine intravenous (IV) and were given acute doses of amitifadine in a repeated measures counterbalanced design. Effects of amitifadine on locomotor activity and food motivated responding were also evaluated. Chronic amitifadine effects were also examined. The 30 mg/kg amitifadine dose significantly reduced nicotine self-administration. The 5 and 10 mg/kg doses reduced nicotine self-administration during the first 15 min of the session when the greatest amount of nicotine was self-administered. The 30 mg/kg amitifadine dose, but not the lower doses caused a significant reduction in locomotor activity averaged over the one-hour session and reduced food motivated responding. The 10 mg/kg dose caused hypoactivity at the beginning of the session, but 5 mg/kg did not cause any hypoactivity. The effects of chronic amitifadine treatment (10 mg/kg) over the course of 15 sessions was also determined. Amitifadine caused a significant reduction in nicotine self-administration, which was not seen to diminish over two consecutive weeks of treatment and a week after enforced abstinence. Amitifadine significantly reduced nicotine self-administration. This prompts further research to determine if amitifadine might be an effective treatment for smoking cessation.

Tobacco use and cessation for cancer survivors: an overview for clinicians

Approximately 30% of all cancer deaths in the United States are caused by tobacco use and smoking. Cancers of eighteen sites have been causally linked to smoking, the most common of which are the lung, head and neck, bladder, and esophagus. While quit rates and quit attempt rates are relatively high shortly after a cancer diagnosis, the recidivism rates are also high. Therefore, screening, treating, and preventing relapse to tobacco use is imperative among patients with and survivors of cancer. To date, research has consistently shown that a combination of pharmacologic and behavioral interventions is needed to achieve the highest smoking cessation rates, with a recent emphasis on individualized treatment as a most promising approach. Challenges in health care systems, including the lack of appropriate resources and provider training, have slowed the progress in addition to important clinical considerations relevant to the treatment of tobacco dependence (eg, a high degree of comorbidity with psychiatric disorders and other substance use disorders). However, continued tobacco use has been shown to limit the effectiveness of major cancer treatments and to increase the risk of complications and of developing secondary cancers. The authors recommend that oncology providers screen all patients for tobacco use and refer users to specialized treatment when available. Alternatively, oncology clinicians can provide basic advice on tobacco use cessation and pharmacotherapy and/or referral to outside resources (eg, quitlines). Herein, the authors summarize the current knowledge on tobacco use and its treatment, with a focus on the related available evidence for patients with and survivors of cancer.

Emerging drugs for the treatment of tobacco dependence: 2014 update

INTRODUCTION

Tobacco dependence remains a global epidemic and the largest preventable cause of morbidity and mortality around the world. Smoking cessation has benefits at all ages but remains challenging for several reasons, among which are the complexities of nicotine addiction and limitations of available pharmacotherapies.

AREAS COVERED

This review summarizes current and emerging pharmacotherapies for the treatment of tobacco dependence, including first- and second-line recommended agents. Medications with alternative primary indications that have been investigated as potential treatments for tobacco dependence are also discussed. Articles reviewed were obtained through searches of PubMed, Ovid MEDLINE, ClinicalTrials.gov and the Pharmaprojects database.

EXPERT OPINION

Current evidence suggests that the two most effective pharmacotherapies to treat tobacco dependence are varenicline and combination nicotine replacement therapy. Alternative agents investigated demonstrate mixed rates of success in achieving long-term abstinence from smoking. No single pharmacotherapy will serve as a universally successful treatment given the complex underpinnings of tobacco dependence and individuality of smokers. The ultimate goal of tobacco research with respect to pharmacotherapeutic development continues to be providing clinicians with an armamentarium of drugs to choose from allowing for tailoring of treatment for smokers.

Antidepressants for smoking cessation

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Pharmacological intervention of nicotine dependence

Nicotine dependence is a major cause of mortality and morbidity all over the world. Various medications have been tried to treat nicotine dependence including nicotine replacement therapy, bupropion, and varenicline. A newer venture to nicotine dependence treatment is a nicotine vaccine which is yet to get footsteps in common practice. The present review assimilates various pharmacotherapeutic measures to address nicotine dependence. However, it is to be noted that psychological interventions, when combined with pharmacotherapy, offer the greatest benefits to the patients.

Medications for substance use disorders

In this article, the authors briefly review the pharmacotherapeutic agents that are currently available for the treatment of substance use disorders. Nicotine replacement therapies are most effective for tobacco cessation. Naltrexone, acamprosate, and disulfiram are effective for reducing alcohol use. The most effective pharmacotherapies for opiate use disorders are agonist therapies, including methadone and buprenorphine. The authors also examine recent advances in medication development for other substance use disorders such as stimulant addiction. The role of medication adherence and behavioral treatments and the integration of behavioral and pharmacotherapeutic interventions are also discussed.

[Risk factor "smoking" : smoking cessation in patients with cardiovascular diseases]

Smoking is the most frequent cause of avoidable premature death. Annually, almost 6 million people die due to nicotine consumption. Comparing modifiable cardiovascular risk factors, smoking has the strongest impact on cardiovascular mortality. More than 50% of all premature myocardial infarctions are related to nicotine consumption. Even in patients with known coronary disease receiving optimal medical therapy, there is a remarkable additional preventive effect of smoking cessation detectable. Therefore, smoking cessation is an essential component of primary and secondary prevention strategies. Smoking cessation programs applying a combination of behavior therapy and supporting medical treatment have been demonstrated to be the most effective.

[Pharmacotherapeutic treatment strategies for smoking cessation]

Regular tobacco smoking occurs in about 35% of the male and 25% of the female German population. Individual attempts to independently quit smoking and to remain abstinent for 1 year have been shown to be successful in less than 5% of cases. This rate can be doubled by means of individual consulting and cognitive-behavioral interventions and additional pharmacological treatment might increase abstinence rates up to 25%. Apart from nicotine substitution (e.g. transdermal, oral and inhalative applications) and bupropion, recent studies have shown beneficial effects of varenicline for smoking cessation and abstinence. Varenicline, a selective partial nicotinergic agonist, has been specifically developed for the purpose of smoking cessation. Currently available data suggest that varenicline is more effective compared to nicotine substitution therapy and bupropion, increasing the abstinence likelihood by a factor of 2.3 compared to a placebo. Recent data regarding anti-nicotine vaccines suggest that this approach might yield a comparable treatment outcome and probably even better relapse-preventing effects than conventional psychopharmacological strategies. The first anti-nicotine vaccines are expected to be approved by national authorities within the forthcoming 1-2 years.

Safety of nortriptyline at equivalent therapeutic doses for smoking cessation: a systematic review and meta-analysis

BACKGROUND

The limited use of nortriptyline for smoking cessation is likely due to concerns about its serious adverse effects.

OBJECTIVE

To examine the safety of nortriptyline at doses equivalent to those used in aiding smoking cessation.

DATA SOURCES

A systematic search of relevant articles in MEDLINE, EMBASE, the Cochrane Database of Systematic Reviews, CINAHL, PsychINFO, WHO publications and the Clinical Trials database (through November 2008).

STUDY SELECTION

All studies of nortriptyline at doses between 75 and 100 mg in any indication were reviewed.

DATA EXTRACTION

The quality of included studies was assessed based on the Jadad score. Data were extracted using a data extraction form.

DATA SYNTHESIS

From 442 potentially relevant articles identified, 17 studies met our selection criteria and were included for data analysis. Indications for nortriptyline in these studies were smoking cessation (eight studies), depression (five studies), neuropathic pain (three studies) and schizophrenia (one study). 2885 individuals participated in these studies, with exposure time ranging between 4 and 12 weeks. The major comparator used in these trials was placebo. Overall, no life-threatening events occurred in these studies. Orthostatic hypotension was significantly higher in nortriptyline users than in comparator groups (relative risk 2.8; 95% CI 1.4, 5.3). Other adverse events significantly associated with nortriptyline were anticholinergic-related effects including drowsiness, dizziness, gastrointestinal disturbance and dysgeusia.

CONCLUSIONS

Current evidence suggests that nortriptyline, at doses between 75 and 100 mg, is not significantly associated with serious adverse events when administered in patients without underlying cardiovascular disease.

Targeting nicotine addiction: the possibility of a therapeutic vaccine

Cigarette smoking is the primary cause of lung cancer, cardiovascular diseases, reproductive disorders, and delayed wound healing all over the world. The goals of smoking cessation are both to reduce health risks and to improve quality of life. The development of novel and more effective medications for smoking cessation is crucial in the treatment of nicotine dependence. Currently, first-line smoking cessation therapies include nicotine replacement products and bupropion. The partial nicotinic receptor agonist, varenicline, has recently been approved by the US Food and Drug Administration (FDA) for smoking cessation. Clonidine and nortriptyline have demonstrated some efficacy, but side effects may limit their use to second-line treatment products. Other therapeutic drugs that are under development include rimonabant, mecamylamine, monoamine oxidase inhibitors, and dopamine D3 receptor antagonists. Nicotine vaccines are among newer products seeking approval from the FDA. Antidrug vaccines are irreversible, provide protection over years and need booster injections far beyond the critical phase of acute withdrawal symptoms. Interacting with the drug in the blood rather than with a receptor in the brain, the vaccines are free of side effects due to central interaction. For drugs like nicotine, which interacts with different types of receptors in many organs, this is a further advantage. Three anti-nicotine vaccines are today in an advanced stage of clinical evaluation. Results show that the efficiency of the vaccines is directly related to the antibody levels, a fact which will help to optimize the vaccine effect. The vaccines are expected to appear on the market between 2011 and 2012.

Treatment of nicotine addiction: present therapeutic options and pipeline developments

Tobacco use is a global pandemic that poses a substantial and costly health burden. There are some treatment options are available, but currently marketed smoking-cessation drugs lack high levels of efficacy, particularly in real-life settings. Consequently, there is a compelling need for more effective pharmacotherapies to aid smokers in maintaining long-term abstinence. Advances in the understanding of the mechanisms involved in nicotine dependence have recently been translated into new medications and vaccines that interfere with nicotine signaling, many of which are currently at an advanced stage of development. In the present article we review current and emerging pharmacotherapies for tobacco dependence, focusing on the mechanistic rationale for their potential anti-addiction efficacy, major findings in preclinical and clinical studies, and future research directions.

Current treatment options in smoking cessation

Cigarette smoking is the most important modifiable risk factor for premature mortality. Many common and serious diseases, including coronary artery disease, chronic obstructive lung disease, stroke, and cancer, are strongly linked to cigarette smoking. Smoking cessation is difficult due to nicotine addiction and withdrawal symptoms. Comprehensive programs for tobacco control can substantially reduce the frequency of tobacco use. Physicians can improve screening and increase cessation rates by asking patients about tobacco use at every office visit. The spectrum of available smoking cessation interventions ranges from simple advice to intensive behavioral support and pharmacological treatment. Medications currently approved by the US Food and Drug Administration for smoking cessation include nicotine replacement therapy (patch, gum, lozenge, inhaler, and nasal spray), bupropion, and varenicline. Nortriptyline and clonidine have been used in patients who do not tolerate first-line agents. New drug therapies, such as nicotine vaccines, are being developed. The US Public Health Service Guideline, published in 2008, recommends a combination of behavioral support and pharmacologic therapy. In summary, smoking cessation should be based on a patient's coexisting medical conditions, level of smoking, compliance, previous experience with cessation agents, and the cost of therapy.

Pharmacotherapy of addictive disorders

Substance use disorders are highly prevalent in the United States and cause considerable damage to our society. They are underrecognized and undertreated despite a vast body of literature demonstrating the efficacy of treatment using both psychosocial and psychopharmacological modalities. For the last decade, research and progress into the biological basis of the addictive process has led to a rapidly growing number of pharmacological agents used to interrupt the addictive process at its various stages such as the initiation of substance abuse, the transition from abuse to dependence, and the prevention of drug reinstatement or relapse. Food and Drug Administration-approved medications exist for nicotine, alcohol, and opioid use disorders, and progress is being made to develop agents for stimulant use disorders. Regarding nicotine use disorders, nicotine replacement therapies,bupropion and varenicline, have Food and Drug Administration approval, and future options exist with endocannabinoid antagonists and immune therapy. Aversive agents, opiate antagonists, and glutamate based interventions are currently approved to treat alcohol use disorders with future promise with GABAergic, serotonergic, and endocannabinoid system agents. Opiate addiction is treated by approved agonist and antagonist mu-opioid medications with the future potential for agents that can modulate the stress systems and the iboga alkaloids. Although no pharmacotherapies are currently approved for cocaine addiction, promising lines of research include agents that affect dopaminergic, GABAergic, serotonergic,and glutamatergic systems as well as the promise for immune therapies.

Exploring scenarios to dramatically reduce smoking prevalence: a simulation model of the three-part cessation process

OBJECTIVES

We used a simulation model to analyze whether the Healthy People 2010 goal of reducing smoking prevalence from the current 19.8% rate to 12% by 2010 could be accomplished by increasing quit attempts, increasing the use of treatments, or increasing the effectiveness of treatment.

METHODS

We expanded on previous versions of the tobacco control simulation model SimSmoke to assess the effects of an increase in quit attempts, treatment use, and treatment effectiveness to reduce smoking prevalence. In the model, we considered increases in each of these parameters individually and in combination.

RESULTS

Individually, 100% increases in quit attempts, treatment use, and treatment effectiveness reduced the projected 2020 prevalence to 13.9%, 16.7%, and 15.9%, respectively. With a combined 100% increase in all components, the goal of a 12% adult smoking prevalence could be reached by 2012.

CONCLUSIONS

If we are to come close to reaching Healthy People 2010 goals in the foreseeable future, we must not only induce quit attempts but also increase treatment use and effectiveness. Simulation models provide a useful tool for evaluating the potential to reach public health targets.

Therapeutic advances in the treatment of nicotine addiction: present and future

While the proportion of the adult population that smokes has declined steadily in several westernized societies, the rate of successful quit attempts is still low. This is because smokers develop nicotine dependence, a powerful addiction that may require multiple attempts and long-term treatment to achieve enduring abstinence. Currently available first-line agents for smoking cessation therapy include nicotine replacement therapy (available in several formulations, including transdermal patch, gum, nasal spray, inhaler, and lozenge), bupropion (an atypical antidepressant), and varenicline (a partial agonist of the α4β2 nicotinic acetylcholine receptor that was recently developed and approved specifically for smoking cessation therapy). Second-line agents are nortriptyline (a tricyclic antidepressant agent) and the antihypertensive agent clonidine. With the exception of varenicline, which has been shown to offer significant improvement in abstinence rates over bupropion, all of the available treatments appear similarly effective. The adverse event profiles of nortriptyline and clonidine make them more appropriate for second-line therapy, when first-line treatments have failed or are not tolerated. However, the currently marketed smoking cessation drugs reportedly lack high levels of efficacy, particularly in real-life settings. New medications and vaccines with significant clinical advantage are now in the advanced stage of development and offer promise. These include nicotine vaccines and monoamine type B inhibitors. In this review article we discuss current and emerging pharmacotherapies for tobacco dependence focusing on their mechanisms of action, efficacy and adverse event profiles.

Reaching Healthy People 2010 by 2013: A SimSmoke simulation

BACKGROUND

Healthy People (HP2010) set as a goal to reduce adult smoking prevalence to 12% by 2010.

PURPOSE

This paper uses simulation modeling to examine the effects of three tobacco control policies and cessation treatment policies-alone and in conjunction-on population smoking prevalence.

METHODS

Building on previous versions of the SimSmoke model, the effects of a defined set of policies on quit attempts, treatment use, and treatment effectiveness are estimated as potential levers to reduce smoking prevalence. The analysis considers the effects of (1) price increases through cigarette tax increases, (2) smokefree indoor air laws, (3) mass media/educational policies, and (4) evidence-based and promising cessation treatment policies.

RESULTS

Evidence-based cessation treatment policies have the strongest effect, boosting the population quit rate by 78.8% in relative terms. Treatment policies are followed by cigarette tax increases (65.9%); smokefree air laws (31.8%); and mass media/educational policies (18.2%). Relative to the status quo in 2020, the model projects that smoking prevalence is reduced by 14.3% through a nationwide tax increase of $2.00, by 7.2% through smokefree laws, by 4.7% through mass media/educational policies, and by 16.5% through cessation treatment policies alone. Implementing all of the above policies at the same time would increase the quit rate by 296%, such that the HP2010 smoking prevalence goal of 12% is reached by 2013.

CONCLUSIONS

The impact of a combination of policies led to some surprisingly positive possible futures in lowering smoking prevalence to 12% within just several years. Simulation models can be a useful tool for evaluating complex scenarios in which policies are implemented simultaneously, and for which there are limited data.

Modeling the impact of smoking-cessation treatment policies on quit rates

BACKGROUND

Smoking-cessation treatment policies could yield substantial increases in adult quit rates in the U.S.

PURPOSE

The goals of this paper are to model the effects of individual cessation treatment policies on population quit rates, and to illustrate the potential benefits of combining policies to leverage their synergistic effects.

METHODS

A mathematical model is updated to examine the impact of five cessation treatment policies on quit attempts, treatment use, and treatment effectiveness. Policies include: (1) expand cessation treatment coverage and provider reimbursement; (2) mandate adequate funding for the use and promotion of evidence-based, state-sponsored telephone quitlines; (3) support healthcare system changes to prompt, guide, and incentivize tobacco treatment; (4) support and promote evidence-based treatment via the Internet; and (5) improve individually tailored, stepped-care approaches and the long-term effectiveness of evidence-based treatments.

RESULTS

The annual baseline population quit rate is 4.3% of all current smokers. Implementing any policy in isolation is projected to increase the quit rate to between 4.5% and 6%. By implementing all five policies in combination, the quit rate is projected to increase to 10.9%, or 2.5 times the baseline rate.

CONCLUSIONS

If fully implemented in a coordinated fashion, cessation treatment policies could reduce smoking prevalence from its current rate of 20.5% to 17.2% within 1 year. By modeling the policy impacts on the components of the population quit rate (quit attempts, treatment use, treatment effectiveness), key indicators are identified that need to be analyzed in attempts to improve the effect of cessation treatment policies.

Pharmacogenetics of smoking cessation therapy

Nicotine dependence is a major health problem, with a large amount of smoking-related premature deaths and disabilities. The dependence mechanism of nicotine is especially complex and is under strong genetic influence. Smoking cessation is associated with substantial health benefits. Evidence from animal and human studies suggests that genetic polymorphisms influencing pharmacokinetics and pharmacodynamics of nicotine may have great potential for aiding smoking treatment. There are more than 30 association studies and one genome-wide association study (GWAS) between genetic polymorphisms and smoking cessation following nicotine replacement therapy (NRT) and/or bupropion therapy. However, only a few candidate genes or regions were analyzed more than twice and even these genes require additional investigations in different therapeutic schemes. There are a growing number of new pharmacologic options that have not been pharmacogenetically assessed according to published literature. In addition, molecular genetics studies are needed to assess the functional mechanisms of some putative association results. Taken together, the preliminary findings are promising but raise the need for new studies with adequate sample sizes and adjustment for several potential confounding factors frequently neglected, such as comorbidity and sociodemographic factors. The current state of the art in the field encourages an optimist view that personalized treatment approaches may become possible. However, the current scientific evidence still does not support the use of pharmacogenetic tests in routine smoking cessation therapy.

Smoking cessation toolbox for allergists

OBJECTIVES

To review nicotine addiction, to examine how tobacco use has a direct negative impact on common disorders seen in allergy practice, and to provide a summary of the national guidelines for treating tobacco use and dependence.

DATA SOURCES

OVID searches were performed cross-referencing the keywords tobacco cessation, tobacco use, environmental tobacco exposure, and smoking with multiple disorders commonly seen in allergy practice. References of the chosen articles were also examined.

STUDY SELECTION

Articles were selected based on their relevance to the subject matter and currency.

RESULTS

The current US smoking rate far exceeds the desired national goal established by Healthy People 2010. Efforts have been made by the US Public Health Department to streamline the treatment of smoking use and dependence for all physicians. Published research strongly supports the negative impact smoking has on asthma, chronic rhinitis, allergic sensitization, and immunodeficiency disorders.

CONCLUSIONS

Allergists know the significant impact that smoking has and will make on the lives and health of patients. It is important for these specialists to make an impact on the chronic disease of tobacco addiction because it directly affects the care rendered. By using the standardized tobacco use treatment concept of the 5 A's (ask, advise, assess, assist, and arrange), allergists can make a positive impact on reducing US smoking rates and improve patient health. Screening, providing brief counseling, and prescribing first-line smoking cessation medications will help the United States get closer to achieving the national goal laid out in Healthy People 2010 of smoking rates of 12% or less.

The novel nicotinic receptor antagonist, N,N'-dodecane-1,12-diyl-bis-3-picolinium dibromide (bPiDDB), inhibits nicotine-evoked [(3)H]norepinephrine overflow from rat hippocampal slices

Smoking is a significant health concern and strongly correlated with clinical depression. Depression is associated with decreased extracellular NE concentrations in brain. Smokers may be self-medicating and alleviating their depression through nicotine stimulated norepinephrine (NE) release. Several antidepressants inhibit NE transporter (NET) function, thereby augmenting extracellular NE concentrations. Antidepressants, such as bupropion, also inhibit nicotinic receptor (nAChR) function. The current study determined if a recently discovered novel nAChR antagonist, N,N'-dodecane-1,12-diyl-bis-3-picolinium dibromide (bPiDDB), inhibits nicotine-evoked NE release from superfused rat hippocampal slices. Previous studies determined that bPiDDB potently (IC(50)=2 nM) inhibits nicotine-evoked striatal [(3)H]dopamine (DA) release in vitro, nicotine-evoked DA release in nucleus accumbens in vivo, and nicotine self-administration in rats. In the current study, nicotine stimulated [(3)H]NE release from rat hippocampal slices (EC(50)=50 microM). bPiDDB inhibited (IC(50)=430 nM; I(max)=90%) [(3)H]NE release evoked by 30 microM nicotine. For comparison, the nonselective nAChR antagonist, mecamylamine, and the alpha7 antagonist, methyllycaconitine, also inhibited nicotine-evoked [(3)H]NE release (IC(50)=31 and 275 nM, respectively; I(max)=91% and 72%, respectively). Inhibition by bPiDDB and mecamylamine was not overcome by increasing nicotine concentrations; Schild regression slope was different from unity, consistent with allosteric inhibition. Thus, bPiDDB was 200-fold more potent inhibiting nAChRs mediating nicotine-evoked [(3)H]DA release from striatum than those mediating nicotine-evoked [(3)H]NE release from hippocampus.

Treatment of tobacco dependence in mental health and addictive disorders

People with mental health and addictive (MHA) disorders smoke at high rates and require tobacco treatment as a part of their comprehensive psychiatric care. Psychiatric care providers often do not address tobacco use among people with mental illness, possibly owing to the belief that their patients will not be able to quit successfully or that even short-term abstinence will adversely influence psychiatric status. Progress in the development of treatments has been slow in part because smokers with current MHA disorders have been excluded from most smoking cessation trials. There are several smoking cessation treatment options, including psychological and pharmacological interventions, that should be offered to people with an MHA disorder who smoke. Building motivation and readiness to quit smoking is a major challenge, and therefore motivational interventions are essential. We review the treatment options for people with tobacco dependence and MHA disorders, offer recommendations on tobacco assessment and tailored treatment strategies, and provide suggestions for future research. Treatment efficacy could be enhanced through promoting smoking reduction as an initial treatment goal, extending duration of treatment, and delivering it within an integrated care model that also aims to reduce the availability of tobacco in MHA treatment settings and in the community.