Alternative Therapies for Smoking Cessation

A majority of researchers have proved that an estimated number of six billion people die globally due to tobacco- related diseases (WHO, 2013). For each person who succumbs to death due to a smoking-related disease, at least one person out of thirty individuals suffered a serious medical condition caused by smoking. Many smokers have admitted to wanting to quit, but they find it difficult. An example of this fact can be seen in North America where around half of the smokers want to quit, but only 3 or 4 percent realize long-term abstinence (Selby et al., 2015). Over the years, different pharmacotherapies have been used to reduce the levels of smoking, and they have deemed successful, even though there has been rare direct evidence on the relative effectiveness. Furthermore, there have been several medications for smoking cessation, which have indicated improvements in long-term abstinence. Despite the proven efficacy for some of the medications, most smokers have reported not to use them in their cessation journey. The most common class of pharmacotherapy that have been are the antidepressants. However, the available information concerning the best-recommended medication for smoking cessation is little, thereby presenting a hard task for the health care providers. The paper will assess the use of Wellbutrin (bupropion), a Selective Serotonin Reuptake Inhibitor (SSRI) to help in the reduction of smoking.

In the late 1990s, the bupropion antidepressant was the first non-nicotine pharmacotherapy to be utilized in smoking cessation as approved by the United States Food and Drug Administration. Whereas the drug has been estimated to double the odds of quitting about the placebo, the cessation rates are still low. Deeper comprehension of the mechanism by which the drug works may assist the health workers to understand its efficacy. Over the years, the clinical studies that have existed have concentrated on bupropion ability to introduce negative symptoms. Even though the effects of these symptoms have been highly reported, the effectiveness of the medicine is still questionable because of the mixed reactions. The neurobiological actions of the drug state that smoking reinforcement to be assessed as a treatment approach. As health care providers, it is important to keep in mind that bupropion is a stimulator as well as an inhibitor to dopamine and nicotinic acetylcholine receptor contender. Hence, the effects may limit the positive results for the drugs. 

Background

Many medical practitioners have believed that antidepressants contribute to smoking cessation. Since nicotine is a common element in tobacco and is known to cause depression symptoms, the use of the antidepressants may relieve the symptoms. Secondly, nicotine is assumed to have antidepressant effects that are possible of maintaining smoking, and antidepressants can be used as remedies. Thirdly, some antidepressant shave been known to have specific influences on the central nervous system (CNS) underlying nicotine use and addiction. Although nicotine replacement is the most common therapy towards smoking cessation, some of the medical healthcare providers have preferred not to use it. On the other hand, others need alternative therapies after registering a failure in nicotine therapy. 

Objective

The goal of this review is to explore and evaluate the effects of Bupropion medication towards achieving long-term smoking cessation.

Methods

Search Strategy

The initial search of the articles relating to the topic was limited to the use of Google Scholar, PubMed, and Ovid. At first, it was difficult to type the appropriate words in the search button to get the appropriate articles. However, the use of the word such as “SSRI,” “smoking issues,” “Wellbutrin,” and “antidepressants” turned out to be very helpful. Furthermore, most of the results that popped up were highly relatable to the research topic. Google scholar was a helpful search engine because it brought additional information highly relatable to the topic as well as the works cited. Besides, the Ovid navigator made the search easy because it grouped the articles in chronological order. The review was based on articles published in the last five years. Therefore, the site was easy to use because sorted the resource materials as per the years of publication. Additionally, the PubMed was useful in the search as it brought up many articles relating to the topic just by a one-word search. Moreover, the review explored the Cochrane Central Register of Controlled Trials (CENTRAL). These trials included those indexed in MEDLINE, SciSearch and PsycINFO, EMBASE, and other reviews, reports, and abstracts in the last five years. 

After a fruitful search, the paper settled for 13 articles that explored the use of bupropion as an SSRI towards achieving smoking cessation. The publication dates of the articles ranged from 2011-2016. As my priority for my selection criteria, I resolved to utilize the randomized trials that involved the comparison of antidepressant therapies to placebo, or an alternative pharmacotherapy for smoking cessation. The trials also included nicotine replacement therapy (NRT), bupropion and NRT plus Wellbutrin for smoking cessation. Also, the review did not dismiss other methods of studies utilized in the source such as the mixed method designs, interviews, and the analysis of the case reports. Furthermore, there was an inclusion of trials comparing different doses to prevent relapse or assist smoker in reducing the intake of cigarettes. 

The type of participants included current smokers or those who had recently quit. Since some of the trials waited for six months follow-up, they were excluded from the review. Data collection and analysis The data extracted was in duplicate as per the study population, the nature of the medication used, the resulting measures, methods of randomization, and the completion of the follow-up. The primary outcome measure of was the quitting of smoking after at least one hundred and eighty days for the patients at the baseline depicted a risk ratio(RR). 

To enhance the analysis and gain a deeper understanding of the literature review, the emphasis was put on the classification of the participants. To cover for each participant in each study, the study utilized strict criteria for the definition of cessation, whereby only the individuals who biochemically met the definition of abstinence were considered to have stopped smoking. The subjects were grouped into categories of those who were in the process of quitting and those who had quit in the follow-up. Furthermore, the review did not dismiss the approach of intention-to-treat analysis. This was where the subjects were perceived as randomized but did not play a role in the data. Thereafter, there was a summary of the study under the Risk Ratio (RR) category. The number of the random individuals calculated this as the number of quitters in intervention groups divided. Conversely, the figure would be calculated as the number of quitters in the control group over the number randomized to control groups. The study had a control ratio of 1.0. In case the calculations turned up to be more than 1.0, it meant that the rate of ceasing to smoke was higher in the treatment groups than in the control groups. 

Results

This section will explore and evaluate the evidence identified from the literature review relating the use of Wellbutrin towards smoking cessation. Thirteen articles published between the year 2010 and 2016 were used in the analysis of the paper. The findings included the randomized trials that involved the comparison of antidepressant therapies to placebo, or an alternative pharmacotherapy for smoking cessation. These trials also included nicotine replacement therapy (NRT), bupropion and NRT plus Wellbutrin for smoking cessation (Hughes, 2007, Piper et al., 2009, Karam-Hage et al., 2014, Rose & Behm, 2013, Hawk, et al., 2015). Also, the deep review of the articles was considered. 

To begin, one common result as per the analysis of the thirteen-article indicted that no difference exists in smoking cessation efficacy among the antidepressants Wellbutrin, nicotine replacement therapy, and their combination with behavioral therapy in clinical practice. For the smokers who had experienced depression in the past, the use Wellbutrin has been found to be more effective. The estimated sample sizes in the reviews included 1071 smokers who received behavioral therapy on a weekly basis and 418 randomized to an NRT of their choice (Hughes, 2014). Meanwhile, those who only received the drug were 409, and those who received both the medication and NRT were 244. The participants were individuals who smoked daily and had no preference for the type of treatment. Since the trials took place in NHS clinics, participants undergoing the NRT trial were to select a single product, and their dosages took a period of twelve weeks. On the other hand, the participants assigned to exclusively bupropion took a total dosage of 150 mg for the first six days and 300 mg for the remaining eight weeks as per the summary of the product characteristics (Hughes, 2014). This allowance was established to give room for alteration in case a patient registered failures towards quitting smoking. For instance, the dose could be reduced or switched. The results indicated no strong evidence concerning the efficacy of NRT, bupropion, and their combination. 

Additionally, three of the articles that made a comparison between bupropion and NRT found out that the use of bupropion was more effective, and this was especially in the one that was placebo-controlled (Hughes, 2014). However, the three article also presented a list of side effects relating to the use bupropion. For instance, there were three cases of allergies reported. One reaction involved anaphylaxis and an admission to the hospital is considered necessary. Also, one of the participants reported being teary all the time and having suicidal thoughts. These cases plus one involving chronic chest pains had to be withdrawn from the treatment of bupropion and transferred to NRT to continue with their pharmacotherapy. This particular review also reported few adverse effects for the individuals who used NRT towards the cessation of smoking. Other symptoms that were reported by the participants included insomnia or disturbed sleeping patterns, which was experienced by almost thirty percent who were taking bupropion. Symptoms like headaches, dry mouths, nausea, dizziness, chest pains, altering moods, loss of appetite, and disorientation were reported to be higher in those taking bupropion. On the other hand, the smokers who were under NRT displayed symptoms such as nasal irritation for the nicotine nasal spray and skin irritation for the nicotine patch. These were the two major symptoms for the patient under NRT. However, a thorough evaluation of the research indicates that the ratings of the treatments were not significantly different even after the display of the symptoms. 

The trials did not base their findings on the original analysis about the pharmacotherapy; instead, it focused on the current tryouts. However, one common similarity in these findings and the original showed that bupropion had particular negative symptoms amongst its users.

Meanwhile, out of the thirteen studies, five of the studies did a follow-up on the participants for at least twelve months from the start of the therapy towards or the day they have set for quitting. Five studies making up 37% had six months follow-up (Hughes, 2007, Piper et al., 2009, Karam-Hage et al., 2014, Rose & Behm, 2013, Hawk, et al., 2015). The remaining eight studies reported a positive result of abstinence. However, in one of the articles that talked about smoking cessation on individuals who used alcohol, only the prevalence rates were outlined, and there was no clear definition concerning abstinence. As a secondary resource, thirty-six trials assessed bupropion as a pharmacotherapy working single-handedly towards preventing smoking. Furthermore, the reviews had a separate analysis of trials that tested the efficacy of bupropion and the use of NRT.

Out of all the studies, only one utilized the placebo control, which differentiated two doses of pharmacotherapy. All the trials were considered randomized, but quite some them did not succeed in reporting randomization more precisely. Specifically, one bupropion trial (Myles 2004) talked about the use of random number table with a blinded allocation list. Hence, the list was perceived to be highly inadequate. Since this was a manageable trial review, the inclusion, and the exclusion criteria did not alter the results. The restriction of the inclusion method, which included the pharmacotherapy versus the placebo, had no major effects on the results. The biochemical definition of abstinence was not mentioned thereby some of the studies had a challenge in determining the absolute quitter (Da Costa, 2002). Some of the studies failed to come up with a sustained outcome about who had quit smoking after undergoing treatment using bupropion. Most of the researchers depended on self-reports from the patients.

Summary

The literature review was to find out the alternative for smoking cessation especially the effectiveness of the use of Wellbutrin or as widely known bupropion. In a review of Google Scholar, PubMed, and Ovid, the essay was able to find materials that answered the stipulated question. Also, the review received a significant contribution from Cochrane Central Register of Controlled Trials (CENTRAL). These trials included those indexed in MEDLINE, SciSearch and PsycINFO, EMBASE, and other reviews, reports, and abstracts in the last five years. As a summary of the results, it is rational to state that the use of bupropion is effective towards smoking cessation. The findings supported the use of Wellbutrin SSRI to help smokers quit and maintain abstinence. 

Discussion

Even though the literature review used thirteen articles, they were able to provide a solid evidence base affirming the advantages of using SSRIs in enhancing smoking cessation. Most of the studies have revealed that the bupropion is an effective pharmacotherapy in helping individuals who are addicted to the tobacco. The treatment intervention does not necessarily need to combine with nicotine replacement treatments (NRT) to be effective. However, being an antidepressant, the drug is known to elicit certain negative symptoms depending on the level of addiction of the tobacco, or the other substance abuse. However, it should be noted that there is lack of statistical heterogeneity to indicating that the use of bupropion increases long-term quitting and its maintenance. The control scale ratio of the use of this pharmacotherapy is 1.5-1.9, which shows the efficacy and the sustainability of the drug. The treatment consequences seem common across a range of populations. This means that the post symptoms after the drug use are comparable to many smokers across the globe. 

A majority of the studies have talked about the combination of the medication with nicotine related therapies, but there is still insufficient evidence to support the efficacy. The meta-analysis for the current United States Public Health Service (USPHS) reported that a ratio of 1.3 to 1.8 for a combination as compared to the nicotine patch alone (Fiorce, 2008). The difference in the study ratio as seen in the study and the USPHS might be because of the exclusion of the populations that are difficult to treat because of the multiple issues they experience. For instance, a patient who is suffering from depression is an alcoholic as well as a chain smoker. 

Looking at the meta-analysis of one of the articles by Hall et al. (2013), which compared the bupropion trial by giving a dose of 300 mg/day and 150 mg/day, the latter failed to register significant long-term success. Even though the power of the comparison was not adequate to create an equivalent, particularly for the people with stressful side effects such as insomnia, a reduction in the dose to 150 mg or less would b an option to halt the pharmacotherapy. It is right to state that the medical field lacks sufficient data and evidence that proves the effectiveness of using bupropion and NRT. Across many studies all over the globe, the comparisons show that the efficacy of the two methods is similar. However, the choice between the two treatment approaches will be based on the preferences of an individual. In such situations, the individuals will look into the level of addiction and the urgency to quit smoking. 

Consequently, in the trials, the participant who was treated with bupropion were more likely to quit than those subjected to nicotinic agonist. The existing evidence has supported the wide use of bupropion in many clinical settings all over the globe. On the other hand, nicotine replacement therapy has managed to experience success in over ninety studies (Stapeleton et al., 2013). The efficacy levels of these antidepressant drugs towards preventing smoking are known to overlap. Although, there have been differing US guidelines (US DHHS, 2000) that argue that smokers with depression problems should resolve to the use of bupropion rather than the NRT (Fiore et al., 2000). However, the basis for their argument falls short because no research has been done by to prove which type of antidepressants is the best for depressed clients. 

Medical practitioners should consider various factors before deciding on the treatment plan for smokers. For instance, they should respect the patient preferences, availability of funds, medical history, mental history, and their consent and willingness to cooperate. Recent studies by (Gonzale2006, Jorenby, 2006, Nides, 2006) have indicated that bupropion is a good pharmacotherapy for the patients who have realized failure while undergoing the nicotine replacement therapy (Perkins et al., 2013). 

Additionally, it is important to keep in mind that all medications designed for smoking cessation are capable of producing clinically considerable adverse effects. During the initial steps of screening to check for potential side-effects, 10% of the individuals on antidepressants have to stop taking them because of the possible negative interactions of the drugs. There have been few reports indicating that bupropion has at one point caused the deaths, although there are no facts to support these claims. The main reasons why this class of drugs has been linked to deaths is because of their relationship with the mental health. Some of the psychiatric disorders that might arise because of the use of these drugs include suicidal ideations, attempts, and psychosis. It is important to keep in mind that the use of antidepressant drugs may induce depression in people especially if they are depression-free clients (Hughes, 2007).

A large part of the literature review supports the use of bupropion towards assisting smokers to quit and abstain from the use. Moreover, Wellbutrin cab is combined with NRT in cases where particular clients do not respond well to one single treatment. In case one line of treatment fails, the medical practitioners can switch the medicines depending on the physical and mental reaction of the patients. Patients should not be forced to take specific drugs, but they should consent. Even though there are other antidepressants used to reduce smoking, Wellbutrin is a major trademark, and it is widely known. The medical practitioner should be conversant with the effects and the interactions of these class of drugs when dealing with drug addicts. This is significant because research has revealed that a majority of drug addicts use more than one type of drug. Therefore, the administration of these drugs should be done carefully to avoid adverse side effects that might harm a patient. 

Recommendations for Practice

Before the medical practitioners embark on the use of pharmacotherapy, they should keep in mind that smoking is a behavior. As psychologist say, behaviors can be learned, unlearnt, or re-learnt. Therefore, instead of dwelling on the biological assistance through the use of antidepressants, they can perform behavioral therapy as well. Not only will this speed up the recovery levels but it will also ensure a comprehensive health care provision. The act of smoking is usually precipitated by many factors such as peer influence, anxiety, self-esteem issues, and stress among other causes. People who smoke should be treated just like the normal clients for therapy.

It is recommended that the therapist of the psychologist build a therapeutic relationship with them to get to the root source of their underlying issues. The uncovering of these issues will speed up the levels of recovery because the patients will gain deeper insights about themselves and their. The goal of the therapeutic treatment should be to empower the patients to realize their weaknesses and strengths. They are the solutions to their problems. Therefore, integrating pharmacotherapy and psychotherapy towards the cessation of smoking may speed up quitting, abstinence, and encourage the client to engage in adaptive behaviors.

Furthermore, a thorough history taking of the patients is important before administering any drugs to them. Based on the literature review, it is seen that the use of bupropion and NRT might have adverse side effects depending on the physical and the mental state of the patient. Therefore, conducting prior tests are important because it can prevent a health care institution or a practitioner from getting unnecessary lawsuits. 

Recommendations for Research

Further research should be conducted on the effect of bupropion on the patients especially those who are already suffering from depression. Also, the age diversity while conducting future research should be considered because the thirteen reviewed articles did not focus on the extreme of ages. It majorly focused on the youths.

References

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