Bupropion (brands: Wellbutrin, Zyban, Aplenzin, Buproban, Budeprion, Forfivo) is an antidepressant medications that can be helpful for treating tobacco use disorder by reducing cravings and helping with nicotine withdrawal symptoms. It has multiple sustained- and extended-release formulations, which have varying dose ranges. However, while all may be helpful for tobacco use disorder, technically the brand Zyban is FDA-approved for this indication and is doses at 150mg daily for several days and then increased to 150mg PO twice daily. It is contraindicated in seizure disorders and bulimia nervosa, and should be used with caution in patients with psychiatric disorders, especially bipolar spectrum disorders. It can be combined with other tobacco use disorder medications (i.e., nicotine replacement therapy or varenicline), with some evidence of enhanced efficacy.
Nicotine Replacement Therapy
Nicotine replacement therapy reduces nicotine withdrawal and cravings, and can therefore help people stop using nicotine-containing products. However, it can also be useful to help people cut down on their use of nicotine-products or not use these products in places where they are not allowed to (eg., addiction treatment settings, restaurants jobs), even if they are not ready or willing to stop using entirely. It comes in five different formulations, all of which have widely varying dose ranges:
- Patch (available over-the-counter)
- Gum (available over-the-counter)
- Lozenge (available over-the-counter)
- Inhaler (prescription-only)
- Nasal spray (prescription-only)
There are essentially no absolute contraindications to using nicotine replacement therapy. It is very safe and the health risks from using nicotine-containing products come from other chemical in them (eg., tobacco smoke, vaping liquid) rather than from the nicotine itself. There is evidence that one of the most effective treatments for tobacco use disorder/nicotine dependence is to combine a long-acting form of nicotine replacement therapy (i.e., patch) with one of the short-acting forms (eg., gum, lozenge, inhaler, nasal spray) for breakthrough withdrawal symptoms. Nicotine replacement therapy can also be combined with bupropion but there is limited evidence for combining it with varenicline.
Varenicline (brand: Chantix) is a partial agonist at nicotinic acetylcholine receptors, and works by reducing nicotine withdrawal and cravings, as well as providing negative reinforcement for using nicotine-containing products (i.e., mild nicotine toxicity symptoms). There is evidence that varenicline may be the most effective single treatment for tobacco use disorder/nicotine dependence. Maintenance dosing for varenicline is 1mg PO twice daily. There are essentially no absolute contraindications to using varenicline, though it has been associated with insomnia and disturbing/vivid dreams. It is important to note that varenicline has been proven to be safe from a neuropsychiatric standpoint in both individuals with and without psychiatric disorders, and a related black box warning has been removed by the FDA. There is preliminary evidence that varenicline may also help individuals with tobacco and alcohol use disorders reduce their alcohol consumption.