Smoking and mental health - NCSCT

Smoking cessation interventions for individuals with mental disorders 5
nicotine substitution as a harm reduction strategy for people who experience
difficulty with nicotine withdrawal (see section 5.3)
5.2.3 Bupropion
In general population studies, bupropion is similarly effective to singleformulation
NRT for smoking cessation, with a pooled RR relative to placebo of
1.69 (95% CI 1.53–1.85). 2 For people with SMI, in three trials comparing
bupropion with placebo, delivered with group therapy, 35–37 meta-analysis
confirmed strong and significant superiority of treatment with bupropion at trial
endpoints (RR = 4.18, 95% CI 1.30–13.42). 24 Effectiveness was also
demonstrated in two trials comparing a bupropion/NRT combination with NRT
only, delivered together with group therapy, 38,39 with an RR for cessation of 2.34
(95% CI 1.12–4.91). 24 A Cochrane review of bupropion effectiveness in people
with schizophrenia, 25 involving seven trials, estimated a pooled RR of cessation
of 2.78 (95% CI 1.02–7.58), with no reported serious adverse events. 26
The primary adverse effect of bupropion is an increased risk of seizures, so
bupropion should be used with particular caution together with other
medications used in SMI, including tricyclic antidepressants and some
antipsychotic agents, which also lower the seizure threshold. Bupropion is
contraindicated in bipolar affective disorder because it is an antidepressant and
hence theoretically poses a risk of precipitating mania. Other cautions on
bupropion use are summarised in section 5.2.5.
5.2.4 Varenicline
The nicotine receptor partial agonist varenicline is probably the most effective
cessation pharmacotherapy in the general population of smokers (summary OR
for 12-month continuous abstinence for varenicline relative to placebo = 3.22,
95% CI 2.43–4.27). 1 It is more effective in cessation trials than bupropion (OR
for varenicline vs bupropion = 1.66, 95% CI 1.28–2.16). 1 To date, however,
evidence on the effectiveness of varenicline in people with mental disorders is
particularly limited, in large part because of early concerns that varenicline may
lead to the exacerbation of symptoms, especially depression, and induce thoughts
of self-harm and suicide. Although a large UK primary care epidemiological
study in the general population of smokers has reported that these serious
adverse events are generally rare in people who use medication to quit smoking,
and are not statistically significantly more common with varenicline, modest
increases in risk of adverse events, which may be particularly relevant to those
with mental disorders, could not be ruled out. 40
In people with SMI, a recent randomised trial conducted in the USA, 41 and a
review of case and pilot studies on the efficacy and tolerability of varenicline in
© Royal College of Physicians 2013 87