Antidepressants for smoking cessation

• Published in: Cochrane database of systematic reviews 2023-05, Vol.5 (5), p.CD000031
• Main Authors: Hajizadeh, Anisa, Howes, Seth, Theodoulou, Annika, Klemperer, Elias, Hartmann-Boyce, Jamie, Livingstone-Banks, Jonathan, Lindson, Nicola
• Format: Article
• Language: English
• Subjects: Adolescent; Adult; Antidepressive Agents - adverse effects; Bupropion - adverse effects; Child; Complementary & alternative medicine; Humans; Interventions to help smokers and other tobacco users to quit; Lungs & airways; Nicotinic Agonists - adverse effects; Nortriptyline - adverse effects; Smoking Cessation - methods; Tobacco, drugs & alcohol; Varenicline - adverse effects; Young Adult
• ISSN: 1469-493X; 1469-493X
• DOI: 10.1002/14651858.CD000031.pub6

The pharmacological profiles and mechanisms of antidepressants are varied. However, there are common reasons why they might help people to stop smoking tobacco: nicotine withdrawal can produce short-term low mood that antidepressants may relieve; and some antidepressants may have a specific effect on neural pathways or receptors that underlie nicotine addiction. To assess the evidence for the efficacy, harms, and tolerability of medications with antidepressant properties in assisting long-term tobacco smoking cessation in people who smoke cigarettes. We searched the Cochrane Tobacco Addiction Group Specialised Register, most recently on 29 April 2022. We included randomised controlled trials (RCTs) in people who smoked, comparing antidepressant medications with placebo or no pharmacological treatment, an alternative pharmacotherapy, or the same medication used differently. We excluded trials with fewer than six months of follow-up from efficacy analyses. We included trials with any follow-up length for our analyses of harms. We extracted data and assessed risk of bias using standard Cochrane methods. Our primary outcome measure was smoking cessation after at least six months' follow-up. We used the most rigorous definition of abstinence available in each trial, and biochemically validated rates if available. Our secondary outcomes were harms and tolerance outcomes, including adverse events (AEs), serious adverse events (SAEs), psychiatric AEs, seizures, overdoses, suicide attempts, death by suicide, all-cause mortality, and trial dropouts due to treatment. We carried out meta-analyses where appropriate. We included a total of 124 studies (48,832 participants) in this review, with 10 new studies added to this update version. Most studies recruited adults from the community or from smoking cessation clinics; four studies focused on adolescents (with participants between 12 and 21 years old). We judged 34 studies to be at high risk of bias; however, restricting analyses only to studies at low or unclear risk of bias did not change clinical interpretation of the results.  There was high-certainty evidence that bupropion increased smoking cessation rates when compared to placebo or no pharmacological treatment (RR 1.60, 95% CI 1.49 to 1.72; I = 16%; 50 studies, 18,577 participants). There was moderate-certainty evidence that a combination of bupropion and varenicline may have resulted in superior quit rates to varenicline alone (RR 1.21, 95% CI 0.95 to 1.55; I