The safety of treatments for tobacco use disorder

ABSTRACT

Introduction: Tobacco continues to be a leading cause of preventable morbidity and mortality in the world. First-line pharmacotherapies for the treatment of tobacco use disorder include nicotine replacement therapy, bupropion sustained-release (SR), and varenicline. We provide an overview of current evidence on the safety of first-line pharmacotherapies for the treatment of tobacco use disorder.

Areas covered: Randomized clinical trials published in English up to July 2015 were identified and reviewed through searches of PUBMED using the terms nicotine replacement therapy, bupropion SR, varenicline, smoking, and tobacco cessation.

Expert opinion: Nicotine replacement has few contraindications and side effects and can be recommended to almost all tobacco users. Bupropion SR should be used with caution in patients with bipolar disorder or liver or kidney disease, and alternative treatments should be considered for patients with a history of seizures or who are at risk for seizures. The only contraindication for varenicline is an allergy to the medication, and nausea is the most common side effect. Varenicline can be used safely in patients with cardiovascular disease. Varenicline can be used in patients with stable psychiatric disease and safety can be ensured through close clinical monitoring.

KEYWORDS:

• Bupropion SR
• cessation
• nicotine replacement therapy
• safety
• smoking
• tobacco
• varenicline

Article highlights

• First-line pharmacotherapies for the treatment of tobacco use disorder include NRT, bupropion SR, and varenicline.

• All three of the first-line pharmacotherapies for the treatment of tobacco use disorder have established efficacy.

• Nicotine replacement therapies have minor side effects and nicotine patches, gum, and lozenge can be obtained OTC.

• Bupropion SR should be prescribed with caution in patients with bipolar disorder, renal impairment, liver disease, or a seizure history or at risk for seizures.

• Evidence exists that bupropion SR may be protective against major cardiovascular events.

• Varenicline is one of the most effective medications for the treatment of tobacco use disorder, has a favorable safety profile, and nausea is its most common side effect.

• Compared to bupropion SR, varenicline does not have any drug interactions and few contraindications.

• Varenicline use is safe for the treatment of tobacco use disorder in patients with cardiovascular disease.

• Varenicline use is safe for the treatment of tobacco use disorder in patients with stable psychiatric disease. Safety in this population can be enhanced through close clinical monitoring.

• Improvement in the treatment of tobacco use disorder will be advanced through the evaluation of combination therapies.

This box summarizes key points contained in the article.

Declaration of interest

JO Ebbert reports grants from Pfizer during the conduct of the study. He also reports grants from Takeda, JHP Pharmaceuticals, US Department of Defense, Pfizer, national Institutes of Health and GlaxoSmithKline outside of the submitted work. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.