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Smoking Cessation: Medications Work, but for How Long?

Treatment with either of 2 antidepressants improved quit rates at 12 weeks, but this benefit was not maintained over a year.

Despite clinicians' efforts to encourage smoking cessation, rates of quitting remain low. Two antidepressants, bupropion hydrochloride and nortriptyline hydrochloride, have demonstrated efficacy in aiding smoking cessation. Because concomitant psychotherapy appears to improve outcomes for depressed patients taking antidepressants, researchers sought to determine whether psychotherapy would enhance the smoking-cessation effects of these medications. The researchers randomized 220 smokers (at least 10 cigarettes per day; 97 women) to receive 12 weeks of nortriptyline (titrated to achieve a serum level of 50-150 ng/mL), bupropion (150 mg/day on the first 3 and last 3 days of treatment, 300 mg/day on all other days), or placebo. Within these groups, patients were further randomized to 12 weeks of psychotherapy or medical management. Participants were stratified by history of depression, sex, and daily cigarette consumption.

Subjects were followed for up to 52 weeks; cigarette abstinence was determined by expired carbon monoxide levels (10 ppm or lower), urinary cotinine levels (60 ng/mL or lower), and self-reports. At 12 weeks, in an analysis that considered subjects with missing data to be nonabstinent, abstinence was significantly more common in the medication groups than in the placebo group. In addition, psychotherapy enhanced outcomes in all groups. However, at 52 weeks, the differences among the groups were no longer significant. There were no significant differences in abstinence rates by sex or by the presence or absence of depression diagnoses.

Comment: This study provides good and bad news for busy practitioners. Medication alone increases rates of smoking cessation; psychotherapy need not be added. On the other hand, in this study abstinence was not maintained, and treatment was discontinued at 12 weeks. It would be extremely helpful to know whether sustained treatment would foster sustained nicotine abstinence. Nonpsychiatrists are best advised to prescribe bupropion for smoking cessation, because nortriptyline requires serum testing, has more significant side effects, and can be dangerous if an overdose occurs. In addition, bupropion is probably less likely to cause weight gain, so women may be more likely to stick with bupropion therapy.

— Nada L. Stotland, MD, MPH

Published in Journal Watch Women's Health November 19, 2002

Citation(s):

Hall SM et al. Psychological intervention and antidepressant treatment in smoking cessation. Arch Gen Psychiatry 2002 Oct; 59:930-6.

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