Applied Evidence
Unhealthy drug use: How to screen, when to intervene
Recognizing and helping patients at risk for a substance use disorder doesn’t have to be time-consuming. Here’s how to make screening and...
SSRIs. None of the 4 SSRIs investigated in the trials (fluoxetine, paroxetine, sertraline, citalopram) improved smoking cessation rates more than placebo.1 The 5 RCTs that studied the drugs followed participants for as long as a year. None of the participants were depressed at the time of the studies, although some had a history of depression.
The sertraline RCT used individual counseling sessions in conjunction with either sertraline or placebo. All participants had a history of major depression.
The paroxetine trial used NRT in all patients randomized to either paroxetine or placebo.
Venlafaxine. The serotonin-norepinephrine reuptake inhibitor venlafaxine didn’t improve smoking cessation rates over 12 months.1
MAOIs. Neither of the 2 MAOIs increased smoking cessation rates.1 The moclobemide RCT followed participants for 12 months; the 5 selegiline RCTs followed participants for as long as 6 months.
Other antidepressants. An RCT with 19 participants found that doxepin didn’t improve smoking cessation at 2 months.1 One RCT and one open, randomized trial of St. John’s wort found no benefit for smoking cessation.1,2
RECOMMENDATIONS
The United States Public Health Service (USPHS) and the University of Michigan Health System (UMHS) guidelines recommend the following FDA-approved pharmacotherapies as first-line agents for smoking cessation: sustained-release bupropion, NRT (gum, inhaler, lozenge, nasal spray, or patch), and varenicline.3,4 They say that clonidine and nortriptyline are also effective but recommend them as second-line agents because these drugs lack FDA approval for this purpose.
The USPHS also recommends combinations of NRT and bupropion for long-term use. Because of additional cost and limited benefit, UMHS recommends reserving NRT-bupropion combination therapy for highly addicted tobacco users who have several failed quit attempts.
The United States Preventive Services Task Force guideline emphasizes counseling and interventions to prevent tobacco use; it doesn’t provide recommendations for pharmacotherapy.5 It does cite the same agents recommended by USPHS and UMHS as effective.