What antidepressants are also effective for tobacco cessation?

Antidepressants for Tobacco Cessation

Bupropion is the most effective antidepressant for tobacco cessation, with evidence showing it increases long-term smoking abstinence rates by 69% compared to placebo (OR 1.69,95% CI 1.53-1.85). 1

Primary Options

Bupropion

• Mechanism: Acts as a norepinephrine and dopamine reuptake inhibitor
• Efficacy: Increases cessation rates at 6+ months compared to placebo (19.7% vs 11.5%) 1
• Standard dosing:
  • Start at 150 mg once daily for 3 days
  • Increase to 150 mg twice daily (300 mg total)
  • Treatment duration: 7-12 weeks 2
• Benefits:
  • Minimal weight gain during cessation attempts 3
  • Can be used in patients with depression 4
  • May help with SSRI-associated sexual dysfunction 5

Nortriptyline

• Second-line option due to side effect profile 1
• Tricyclic antidepressant that aids smoking cessation

Comparative Effectiveness

• Varenicline vs Bupropion: Varenicline shows higher cessation rates than bupropion (RR 0.68, CI 0.56-0.83) 1
• NRT vs Bupropion: No significant difference in abstinence rates at 6+ months 1
• Combination therapy: Bupropion + NRT is more effective than bupropion alone (RR 1.24, CI 1.06-1.45) but not more effective than NRT alone 1

Special Considerations

Patient Selection for Bupropion

• Best candidates:
  • Smokers with comorbid depression 4
  • Patients concerned about weight gain during cessation 3
  • Patients on SSRIs (can be safely added) 5
• Contraindications:
  • History of seizures or conditions lowering seizure threshold
  • Current use of MAO inhibitors
  • Brain metastases 2

Side Effects and Monitoring

• Common side effects: Insomnia, dry mouth, anxiety/jitteriness 2
• Serious concerns:
  • Seizure risk (0.1% at therapeutic doses ≤450 mg/day) 2
  • Neuropsychiatric symptoms, especially in patients <24 years 2
  • Potential for increased blood pressure and heart rate 2

Drug Interactions

• CYP2D6 inhibition: Bupropion inhibits CYP2D6, potentially increasing levels of drugs metabolized by this pathway (e.g., certain antidepressants, antipsychotics, beta-blockers) 6
• Avoid combining with:
  • MAO inhibitors (risk of hypertensive reactions)
  • Drugs that lower seizure threshold
  • Alcohol (reduced tolerance) 6

Clinical Approach

1. Screen for contraindications (seizure history, eating disorders, MAO inhibitor use)
2. Start bupropion 1-2 weeks before target quit date
3. Monitor for side effects, particularly neuropsychiatric symptoms
4. Consider combination therapy with NRT for enhanced efficacy
5. Continue treatment for 7-12 weeks

Effectiveness in Special Populations

• Patients with depression: Bupropion can simultaneously treat depression and aid smoking cessation 4
• Patients with anxiety: Higher anxiety scores may predict better response to bupropion for smoking cessation at 6 months 7

Bupropion remains the most well-studied and effective antidepressant for smoking cessation, with the added benefit of addressing depressive symptoms that may emerge during the quitting process.