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Evidence summaries

Interventions for Smoking Cessation in Patients with Psyhiatric Disorders

Varenicline, nicotine replacement therapy, and bupropion increase smoking abstinence rates in smokers with psychiatric disorders without jeopardising their mental state. Level of evidence: "A"

A Cochrane review [Abstract] 1 included 7 RCTs with a total of 340 patients with schizophrenia. The trials comparing bupropion with placebo showed that smoking cessation rates after bupropion were significantly higher at the end of treatment (RR 2.84; 95% CI 1.61 to 4.99; 7 trials, n=340) and after 6 months (RR 2.78; 95% CI 1.02 to 7.58; 5 trials, n=214). Expired carbon monoxide level and the number of cigarettes smoked daily were significantly lower with bupropion at the end of therapy (MD -10.77, 95% CI -16.52 to -5.01; 3 trials, n=184) but not after 6 months (MD 0.40, 95% CI -5.72 to 6.53; 2 trials, n=104). There were no significant differences in positive, negative and depressive symptoms between bupropion and placebo group. There was no report of major adverse event such as seizures with bupropion.

A secondary analyses of safety and efficacy outcomes by psychiatric diagnosis in EAGLES (Evaluating Adverse Events in a Global Smoking Cessation Study), a 12-week, randomized, double-blind, triple-dummy, placebo- and active (NRT)-controlled trial 2 of varenicline and bupropion with 12-week follow-up, in a subset population with a psychiatric disorder (n = 4092). Primary end-point parameters were incidence of prespecified moderate and severe neuropsychiatric adverse events (NPSAEs) and weeks 9 to 12 continuous abstinence rates. The observed NPSAE incidence across treatments was 5.1% to 6.3% in those with a psychotic disorder (n=390), 4.6% to 8.0% in those with an anxiety disorder (n = 792), and 4.6% to 6.8% in those with a mood disorder (n = 2910). Neither varenicline nor bupropion was associated with significantly increased NPSAEs relative to NRT or placebo in the psychiatric cohort or any psychiatric diagnostic subcohort. There was a significant effect of treatment on continuos abstinence (P < 0.0001) and no significant treatment-by-diagnostic subcohort interaction (P = 0.24). Abstinence rates with varenicline were superior to bupropion, NRT, and placebo, and abstinence with bupropion and NRT was superior to placebo. Within-diagnostic subcohort comparisons of treatment efficacy yielded estimated odds ratios for 9-12 abstinence rates versus placebo of greater than 3.00 for varenicline, greater than 1.90 for bupropion, and greater than 1.80 for NRT for all diagnostic groups.

Comment: The quality of the evidence is downgraded by study quality (inadequate allocation concealment).

    References

    • Tsoi DT, Porwal M, Webster AC. Interventions for smoking cessation and reduction in individuals with schizophrenia. Cochrane Database Syst Rev 2010 Jun 16;6:CD007253 [Review content assessed as up-to-date: 10 January 2013]. [PubMed]
    • Evins AE, Benowitz NL, West R et al. Neuropsychiatric Safety and Efficacy of Varenicline, Bupropion, and Nicotine Patch in Smokers With Psychotic, Anxiety, and Mood Disorders in the EAGLES Trial. J Clin Psychopharmacol 2019;39(2):108-116. [PubMed]

Primary/Secondary Keywords