TOBACCO ADDICTION

Treatments for Tobacco addiction:

I. Nicotine replacement therapies

  1. Transdermal nicotine
  2. Nicotine gum: start with one 2mg piece per day for every 2 cigarettes previously smoked; for pts who smoke > 1 PPD or have Fagerstrom scores > 6, one 4mg piece for every 3-4 cigarettes previously smoked. Chew a couple of times then keep between cheek and gum. Chew a couple of times once a min for 15-30min per dose. Avoid while using beverages.
  3. Nicotine nasal spray: Use 1 spray in each nostril at a time. Can use 8-10 doses/day initially; taper after 6wks. Can cause some rhinorrhea, sneezing, and nasal irritation but that decreases after 1 wk; use along with the patch may increase long-term cessation rates (BMJ 318:285, 1999--JW)

II. Bupropion

  1. Bupropion as sole pharmacologic treatment for tobacco addiction
    1. 615 nondepressed adult smokers w/o history of sz randomized to buproprion 100, 150, or 300mg/d vs. placebox 7wks. At 7wks, success rates at quitting were 38.6% at 300/d vs. 19% with placebo (other doses intermediate); at 12mos, quit rates were 23.1% at 300/d vs. 12.4% in placebo group (sig.) (NEJM 337:1195, 1997--AFP)
    2. 893 pts > 18yo smoking > 14 cigarettes/day randomized to bupropion 150mg BID, nicotine patch, both, or double placebo, x 9wks. At 12mos, smoking prevalence was 84.4% in placebo group, 83.6% in nicotine group, 69.7% in bupropion-only group, and 64.5% in combined-therapy group (NEJM 340:685, 1999--AFP)
    3. However, in a randomized trial in 429 smokers abstinent x 7wks on Bupropion, adding an additional 45wks of bupropion (vs. placebo) was ass'd with sig. increased abstinence rates at the end of tx (55% vs. 42%); however, abstinence rates were identical 1y after tx ended (Ann. Int. Med. 135:423, 2001--JW)
  2. Bupropion as adjunctive therapy to nicotine replacement
    1. In a randomized study of 243 smokers randomized to bupropion 150mg BID vs. placebo; all also received nicotine replacement.  No sig. diff. in 1y quit rates between the two groups (Arch. Int. Med. 164:1797, 2004--AFP)
  3. Risk of sz at 300 QD is about 0.1%; higher if other risks for sz are plresent, e.g. EtOH withdrawal or use of cocaine.
  4. Side f/x include agitation, insomnia, tremor, HA, and dry mouth.
  5. Don't combine w/MAOIs or ritonavir and avoid concurrent SSRI's (reprts of panic and/or psychosis when used in combination w/fluoxetine).
  6. Recc'd dose is 150 QD x 3d then BID x 7-12wks. OK to combine w/nicotine replacement. Quit during 2nd wk of tx.

III. Tricyclic Antidepressants

  1. 144 non-depressed smokers 18-65yo randomized to nortriptyline 75mg/d vs. placebo; all also participated in group behavioral treatment.  At 6mos, cessation rate was sig. greater in nortriptyline group (20.6% vs. 5.3%) (Chest 122:403, 2002--AFP)

IV. Varenicline (an alpha-4-beta-2-nicotonic receptor partial agonist)

  1. Reduces reinforcing effect of nicotine
  2. In a study in 638 smokers 18-65yo randomized to varenicline, bupropion, or placebo x 7wks, varenicline goup had sig. greater quit rates at 4wks (48% vs. 33% for bupropion and 17% with placebo) and 1y (14% for varenicline and 5% for placebo; summary didn't give data for bupropion)  (Arch. Int. Med. 166:1553, 2006--JW)
  3. In a study in 1,025 generally healthy smokers 18-75yo randomized to varenicline 1mg BID, bupropion SR 150mg BID, or placebo x 12wks, at 52wks, abstinence rates were 21.9% in the varenicline group vs. 16.1% with bupropion and 8.4% with placebo.  The varenicline-placebo diff. was significant but the varenicline-bupropion diff. was not.  28% of varenicline recipients experienced nausea (JAMA 296:47, 2006--abst)
  4. In a study in 1,027 adults smokers randomized to varenicline 1mg BID, bupropion SR 150mg BID, vs. placebo x 12wks, at 52wks, abstinence rates were 23% in the varenicline group vs. 14.6% with bupropion and 10.3% with placebo.  Both the varenicline-placebo and varenicline-bupropion diffs. were sig.  29% of varenicline recipients experienced nausea (JAMA 296:56, 2006--abst)
  5. In a study in 1,,210 adults smokers who had been abstinent for at least 1wk at the end of a 12wk course of open-label varenicline 1mg BID, randomized to continued varenicline 1mg BID vs. placebo x 12 additional weeks, at 52wks, the varenicline group had sig. higher abstinence rates (43.6% vs. 36.9%) (JAMA 296:64, 2006--abst)

"Fagerstrom" test for nicotine dependence:

I. How soon after you wake up do you smoke your first cigarette?

  1. 5 min or less: 3
  2. 6-30min: 2
  3. 31-60min: 1
  4. >60min: 0

II. Do you find it difficult to refrain from smoking in places where it is forbidden (e.g. in church, at the library, in a theater)?

  1. Yes 1
  2. No 0

III. Which cigarette in the day would you hate most to give up?

  1. The first in the morning 1
  2. Any other 0

IV. How many cigarettes per day do you smoke?

  1. 10 or less 0
  2. 11-20 1
  3. 21-30 2
  4. >31 3

V. Do you smoke more frequently during the first hours after waking than during the rest of the day?

  1. Yes 1
  2. No 0

VI. Do you smoke if you are so ill that you are in bed most of the day?

  1. Yes 1
  2. No 0

Scores of > 6 are generally interpreted as indicating a high degree of dependence, with more severe withdrawal sx, greater difficulty in quitting and benefit from nicotine replacement (Br. J. Addict 86:1119, 1991)