Antidepressants and Smoking Cessation

Clinical Question

Which antidepressants help patients stop smoking?

Evidence-Based Answer

Bupropion and nortriptyline increase the likelihood of smoking cessation, but selective serotonin reuptake inhibitors (SSRIs) do not.

Practice Pointers

The U.S. Preventive Services Task Force1 and U.S. Department of Health and Human Services2 recommend that physicians screen all adults for tobacco use and recommend intervention for those who report using tobacco products. There is good evidence that brief behavioral counseling and pharmacotherapy increase rates of abstinence. More intensive counseling has a dose-response relationship, with more minutes of contact producing better results. Nicotine replacement and bupropion have been approved by the U.S. Food and Drug Administration for use in smoking cessation.

Hughes and colleagues reviewed the literature to see if other antidepressants also improve rates of smoking cessation. All trials had at least six months of follow-up. Although nortriptyline and bupropion had the most studies meeting the inclusion criteria, there were also trials on sertraline, venlafaxine, and fluoxetine. Patients taking bupropion (19.3 versus 10.2 percent; pooled odds ratio [OR], 2.0; 95 percent confidence interval [CI], 1.7 to 2.3) or nortriptyline (18.5 versus 7.6 percent; pooled OR, 2.8; 95 percent CI, 1.8 to 4.3) had long-term abstinence rates higher than in those taking placebo. One small trial comparing bupropion with nortriptyline did not show a statistically significant difference. In five studies of SSRIs (largely fluoxetine) with 1,521 patients, there was no significant difference between treated patients and control patients in rates of long-term abstinence. This systematic review did not address the question of whether combining pharmaceutical and counseling interventions produces higher quit rates. However, patients who report using tobacco should receive at least a brief counseling intervention and an offer of medication.

Hormonal Contraceptives and Weight Gain

Clinical Question

Do combination hormonal contraceptives cause weight gain?

Evidence-Based Answer

There is no causal relationship between combination contraceptives and weight gain.

Practice Pointers

Many women and physicians believe that weight gain is associated with combination hormonal contraceptives. The weight gain could be the result of water retention, increased muscle mass, or increased fat deposition. To test this perception, Gallo and colleagues performed a systematic review of randomized controlled trials. They included studies of at least three menstrual cycles’ duration that compared combination contraceptives with placebo or other drugs, dosages, regimens, or study lengths. They found three placebo-controlled trials, none of which found a significant difference in weight gain between groups. The largest of these studies, with 473 patients, found a difference of less than 1 lb after six months. There was also no difference between groups in discontinuation of the contraceptives because of weight gain. Furthermore, most of the studies comparing two contraceptive regimens did not show differences in weight gain.

When patients are reluctant to take combination contraceptives because they fear weight gain, physicians can tell them that it is true that women gain weight with the pill and the patch. However, they also gain weight when they don’t use these products. Physicians can direct them to the excellent resources on healthy lifestyles that have been developed by the National Institutes of Health.1 The “Aim for a Healthy Weight” program has an interactive Web site on diet and exercise for patients (http://www.nhlbi.nih.gov/health/public/heart/obesity/lose_wt/).