Antidepressants for smoking cessation
- PMID: 32319681
- PMCID: PMC7175455
- DOI: 10.1002/14651858.CD000031.pub5
Antidepressants for smoking cessation
Update in
-
Antidepressants for smoking cessation.Cochrane Database Syst Rev. 2023 May 24;5(5):CD000031. doi: 10.1002/14651858.CD000031.pub6. Cochrane Database Syst Rev. 2023. PMID: 37230961 Free PMC article. Review.
Abstract
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.
Copyright © 2020 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Conflict of interest statement
SH: none reported
JHB: none reported
JLB: none reported
BH: none reported
NL: none reported
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Update of
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Antidepressants for smoking cessation.Cochrane Database Syst Rev. 2014 Jan 8;2014(1):CD000031. doi: 10.1002/14651858.CD000031.pub4. Cochrane Database Syst Rev. 2014. Update in: Cochrane Database Syst Rev. 2020 Apr 22;4:CD000031. doi: 10.1002/14651858.CD000031.pub5. PMID: 24402784 Free PMC article. Updated.
References
References to studies included in this review
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- Hall SM, Gorecki JA, Reus VI, Humfleet GL, Munoz RF. Belief about drug assignment and abstinence in treatment of cigarette smoking using nortriptyline. Nicotine & Tobacco Research 2007;9(4):467-71. - PubMed
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- Johns DA. The efficacy of combination therapy with varenicline and bupropion for smoking cessation. Annals of Oncology 2017;28 Suppl 2:6-8.
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Levine 2010 {published data only}
McCarthy 2008 {published data only}
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- McCarthy DE, Piasecki TM, Lawrence DL, Fiore MC, Baker TB. Efficacy of bupropion SR and individual counseling among adults attempting to quit smoking (POS1-041). In: Society for Research on Nicotine and Tobacco 10th Annual Meeting; 2004 February 18-21; Phoenix (AZ). 2004.
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Minami 2014 {published data only}
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Myles 2004 {published data only}
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NCT00308763 {published data only}
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NCT00495352 {published data only}
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- NCT00495352. The pharmacogenetic study, readiness to change, and pharmacological intervention for smoking cessation in schizophrenia. clinicaltrials.gov/ct2/show/NCT00495352 (first received 3 July 2007).
NCT00578669 {published data only}
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- NCT00578669. Sequential use of fluoxetine for smokers With elevated depressive symptoms. clinicaltrials.gov/ct2/show/NCT00578669 (first received 21 December 2007).
NCT00593099 {published data only}
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- NCT00593099. A preliminary study of sustained-release bupropion for smoking cessation in bipolar affective disorder. www.clinicaltrials.gov/ct2/show/NCT00593099 (first received 14 January 2008).
NCT01406223 {published data only}
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- NCT01406223. Mechanistic evaluations of pre-cessation therapies for smoking cessation. clinicaltrials.gov/ct2/show/NCT01406223 (first recieved 1 August 2011).
Niaura 2002 {published data only}
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Parsons 2009 {published data only}
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- EudraCT 2005-000662-39. A 2x2 phase II randomized controlled trial to investigate the efficacy of NRT plus St John's wort versus NRT plus placebo in smoking cessation and to examine the efficacy of chromium nicotinate versus placebo in preventing weight gain while stopping smoking. - SJW and chromium in smoking cessation. clinicaltrialsregister.eu/ctr-search/search?query=2005-000662-39 (first received 4 October 2005).
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- ISRCTN31302738. A 2 x 2 phase II randomised controlled trial to investigate the efficacy of St John's wort versus placebo in smoking cessation and the efficacy of chromium intake in preventing weight gain. isrctn.com/ISRCTN31302738 (first received 8 February 2006).
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- Parsons A, Ingram J, Inglis J, Aveyard P, Johnstone E, Brown K, et al. A proof of concept randomised placebo controlled factorial trial to examine the efficacy of St John's wort for smoking cessation and chromium to prevent weight gain on smoking cessation. Drug and Alcohol Dependence 2009;102(1-3):116-22. 9400123000005315 - PubMed
Perkins 2013 {published data only}
Piper 2007 {published data only}
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- Piper ME, Federman EB, McCarthy DE, Bolt DM, Smith SS, Fiore MC, et al. Mediators of bupropion treatment effects (SYM 2C). Society for Research on Nicotine and Tobacco 14th Annual Meeting; 2008 February 26 - March 1; Portland (OR) 2008:31. 9400123000005187 [9400123000005187]
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Piper 2009 {published and unpublished data}
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Prochazka 2004 {published data only}
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- NCT00018148. Combined nortriptyline and transdermal nicotine for smoking cessation. clinicaltrials.gov/ct2/show/NCT00018148 (first received 5 July 2001).
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- Rose JE, Behm FM. Combination varenicline/bupropion treatment benefits male NRT-nonresponders. In: Society for Research on Nicotine and Tobacco 19th Annual Meeting; 2013 March 13-16 Boston (MA). 2013:261.
Rose 2017 {published data only}
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- NCT01806779. Combination bupropion/varenicline for smoking cessation in male smokers. clinicaltrials.gov/ct2/show/NCT01806779 (first received 7 March 2013).
Rovina 2009 {published data only}
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Saules 2004 {published and unpublished data}
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- Schmitz JM, Stotts AL, Mooney ME, Delaune KA, Moeller GF. Bupropion and cognitive-behavioral therapy for smoking cessation in women.[erratum appears in Nicotine Tob Res. 2007 Jul;9(7):785]. Nicotine & Tobacco Research 2007;9(6):699-709. - PubMed
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Selby 2003 {published and unpublished data}
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- GlaxoSmithKline Clinical Trials Register. Study No: ZYB40001. A randomized, double-blind, placebo-controlled, 12-week smoking cessation trial of Zyban (150 mg bid) in adult smokers previously treated with Zyban. ctr.glaxowellcome.co.uk-Summary-bupropion-IV_ZYB40001.pdf (accessed 23 August 2006).
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Sheng 2013 {published data only}
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- Sheng LX, Tang YL, Jiang ZN, Yao CH, Gao JY, Xu GZ, et al. Sustained-release bupropion for smoking cessation in a Chinese sample: a double-blind, placebo-controlled, randomized trial. Nicotine & Tobacco Research 2013;15(2):320-5. 9400123000018059 - PubMed
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Sood 2010 {published data only}
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- NCT00405912. St. John's wort for tobacco cessation. clinicaltrials.gov/ct2/show/NCT00405912 (first received 30 November 2006).
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- Carrington A, Doran N, Spring B. Fluoxetine moderates the association between trait-anxiety and smoking status following behavioral treatment for smoking cessation (POS4-81). In: Society for Research on Nicotine and Tobacco 9th Annual Meeting; 2003 February 19-22; New Orleans (LA). 2003.
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Tonstad 2003 {published data only}
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Urdapilleta‐Herrera 2013 {published data only}
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- Urdapilleta-Herrera E, Pina-Rosales MF, Vargas-Rojas MI, Ramirez-Venegas A, Sansores-Martinez R. Bupropion together with cognitive-conductual therapy (CBT) is an alternative for a long-term abstinence of smoking. European Respiratory Journal 2013;42(57):3347.
Uyar 2007 {published data only}
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- Uyar M, Bayram N, Filiz A, Elbek O, Topçu A, Dikensoy O, et al. Comparison of nicotine patch and bupropion in treating tobacco dependence. European Respiratory Journal 2005;26(Suppl 49):388s.
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Wagena 2005 {published data only}
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Weinberger 2010 {published and unpublished data}
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- Weinberger AH, Reutenauer EL, Jatlow PI, O'Malley SS, Potenza MN, George TP. A double-blind, placebo-controlled, randomized clinical trial of oral selegiline hydrochloride for smoking cessation in nicotine-dependent cigarette smokers. Drug and Alcohol Dependence 2010;107(2-3):188-95. 9400123000005586 - PMC - PubMed
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- Weinberger AH, Reutenauer EL, Solorzano M, O'Malley SS, Potenza MN, George TP. A randomized placebo controlled clinical trial of selegiline for smoking cessation (abstract 653). CPDD 71st Annual Meeting; 2009 June 20-25; Reno (NV).
Weiner 2012 {published data only}
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- Mann-Wrobel MC, Bennett ME, Weiner EE, Buchanan RW, Ball MP. Smoking history and motivation to quit in smokers with schizophrenia in a smoking cessation program. Schizophrenia Research 2011;126(1-3):277-83. 9400123000006008 - PubMed
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White 2005 {published data only}
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Wittchen 2011 {published data only}
Zellweger 2005 {published data only}
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Cropsey 2015 {published data only}
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Edwards 1989 {published data only}
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Evins 2008 {published data only}
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Fatemi 2005 {published data only}
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Frederick 1997 {published data only}
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Gawin 1989 {published data only}
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Gifford 2011 {published data only}
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Glover 2002 {published data only}
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Gold 2002 {published data only}
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Hall 2009 {published data only}
Hall 2011 {published data only}
Hatsukami 2004 {published data only}
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Hawk 2008 {unpublished data only}
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Hawk 2015 {published data only}
Hays 2001 {published data only}
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Hays 2009 {published data only}
Hilberink 2005 {published data only}
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Hitsman 1999 {published data only}
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Houtsmuller 2002 {published data only}
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Jacobs 1971 {published data only}
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Kalman 2004 {unpublished data only}
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Khunrong 2016 {published data only}
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Killen 2006 {published data only}
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Kotz 2009 {published data only}
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Kras 2010 {published data only}
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Lawvere 2006 {published data only}
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Monuteaux 2007 {published data only}
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Mooney 2008 {published data only}
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Mooney 2016 {published data only}
Naranjo 1990 {published data only}
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NCT00032084 {published data only}
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- NCT00032084. S0002 - a program to quit smoking with or without bupropion in treating patients with stage I or II non-small cell lung cancer who have undergone surgery. clinicaltrials.gov/show/NCT00032084 (first received 27 January 2003).
NCT00119210 {published data only}
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- NCT00119210. Pilot study of bupropion for smoking cessation in postpartum non-breastfeeding women. clinicaltrials.gov/show/NCT00119210 (accessed 13 July 2005).
NCT00136747 {published data only}
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NCT00136786 {published data only}
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- NCT00136786. Effect of memantine versus bupropion on smoking relapse in nicotine-dependent individuals - 3. clinicaltrials.gov/show/NCT00136786 (first received 29 August 2005).
NCT00158171 {published data only}
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- NCT00158171. Effectiveness of various smoking cessation therapies in reducing smoking in adolescents - 1. clinicaltrials.gov/show/NCT00158171 (first received 29 August 2005).
NCT00248118 {published data only}
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- NCT00248118. Efficacy and safety of bupropion for treatment of adolescent smoking. clinicaltrials.gov/ct2/show/NCT00248118 (first received 3 November 2005).
NCT00320697 {published data only}
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- NCT00320697. Smoking relapse prevention in schizophrenia. clinicaltrials.gov/show/NCT00320697 (first received 3 May 2006).
NCT00390923 {published data only (unpublished sought but not used)}
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- NCT00390923. Testing a full substitution therapy approach as treatment of tobacco dependence. clinicaltrials.gov/ct2/show/NCT00390923 (first received 23 October 2006).
NCT00484692 {published data only}
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- NCT00484692. Randomized trial of ultrashort psychotherapy vs sustained-release bupropion for smoking cessation. clinicaltrials.gov/show/NCT00484692 (first received 3 May 2006).
NCT00580853 {published data only}
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- NCT00580853. The effect of varenicline (Chantix) and bupropion (Zyban) on smoking lapse behavior. clinicaltrials.gov/show/nct00580853 (first received 27 December 2007).
NCT00670904 {published data only}
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- NCT00670904. Randomized trial assessing the effectiveness of a pharmacist-delivered program for smoking cessation. clinicaltrials.gov/show/NCT00670904 (first received 2 May 2008). - PubMed
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- NCT00936299. Bupropion for ADHD in adolescents with substance use disorder. clinicaltrials.gov/ct2/show/NCT00936299 (first received 10 July 2009).
NCT01850589 {published data only}
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- NCT01850589. Comparison of conservative and aggressive smoking cessation treatment strategies in a vascular surgery office practice. clinicaltrials.gov/show/NCT01850589 (first received 10 July 2009).
NCT01965405 {published data only}
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- NCT01965405. Smoking cessation for people living with HIV/AIDS. clinicaltrials.gov/show/nct01965405 (first received 18 October 2013).
NCT02736474 {published data only}
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- NCT02736474. Naltrexone and bupropion combination on obese, smoking patients with schizophrenia. clinicaltrials.gov/show/NCT02736474 (first received 13 April 2016).
NCT03471767 {published data only}
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- NCT03471767. AXS-05 phase II trial on smoking behavior. clinicaltrials.gov/show/NCT03471767 (first received 21 March 2018).
NCT03920319 {published data only}
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- NCT03920319. Bupropion and cigarette-related cues in smokers. clinicaltrials.gov/show/nct03920319 (first received 18 April 2019).
Neumann 2000 {published and unpublished data}
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References to ongoing studies
NCT03326128 {published data only}
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