Pharmacotherapy for smoking.

Evidence Cochrane reviews: • Nicotine replacement therapy (NRT): 132 RCTs.1 -Overall risk ratio (RR) and 95% confidence interval (CI) of abstinence: 1.58 (1.50 to 1.66); similar for gum, patch, inhaler, and lozenge. -Adverse events (AEs): local irritation related to product type; no evidence of increased myocardial infarction. • Antidepressants: 49 bupropion and 9 nortriptyline RCTs.2 -The RR (95% CI) for cessation over placebo at 6 to 12 months: bupropion 1.69 (1.53 to 1.85); nortriptyline 2.03 (1.48 to 2.78). -Bupropion AEs: primarily insomnia and dry mouth; 7% to 12% AE drop-out rate; rarely seizure (about 1/1000) and suicidal thoughts or behaviour (association unclear). -Nortriptyline AEs: primarily dry mouth, drowsiness, light-headedness, and constipation (less at lower doses); 4% to 12% drop-out rate from AEs. • Varenicline: 9 RCTs.3 -The RR (95% CI) for cessation at 6 to 12 months over placebo was 2.33 (1.95 to 2.80). -Varenicline AEs: primarily nausea, insomnia, and abnormal dreams; 10% AE drop-out rate4; neuropsychiatric AEs (eg, depression, agitation, suicidal thoughts or behaviour) are infrequent but require monitoring.5 -Reported benefit of varenicline might be influenced by industry funding and lack of a pragmatic design. Assuming 10% placebo cessation rates (mean across studies), approximate numbers needed to treat (at 6 to 12 months) are as follows: varenicline 8, nortriptyline 10, bupropion 10, and NRT 16.