Tobacco Dependence: Drug Therapy

Therapy goal

• Alleviation of withdrawal symptoms.

Therapy recommendations

Note any symptoms of tobacco withdrawal syndrome that may occur:

• First withdrawal symptoms after 1-2 h.
• Increase in symptoms in the first 6-12 h.
• Maximum of complaints after 1-3 days
• Persistence of complaints up to 3 weeks

Typical withdrawal symptoms include craving (violent desire for tobacco), dysphoric mood to depression, anhedonia (inability to feel pleasure and joy), anxiety, irritability, restlessness, appetite increase, difficulty concentrating, and insomnia (sleep disturbance).

Therapy recommendations:

• Nicotine-containing preparations:
  • Nicotine gum, sublingual, tablets and lozenges, for smokers with inconsistent tobacco use throughout the day.
  • Nicotine patches, start with the highest dosage, for regular tobacco use.
• Drug therapy with: Bupropion (drive-enhancing antidepressant), varenicline (partial nicotine agonist).
• See also under “Further therapy” as well as under the chapter “Smoking cessation“.

Further notes

• FDA warns of seizures and interactions with alcohol; according to a cohort study, taking varenicline for smoking cessation is not associated with an increased risk of cardiac or mental events
• The FDA has put the warnings about varenicline and bupropion into perspective, concluding that side effects related to smoking cessation success rate using nicotine patches (with varenicline or bupropion) were about twice as high as in the placebo group.
• Patients taking varenicline for 12 weeks have a 34% increased risk of cardiovascular events during that time; however, the absolute risk is low, at 3.95 events per 1,000 verenicline users.