Bupropion and nortriptyline are effective adjuncts in the treatment of tobacco dependency. Both have been proved to improve abstinence rates compared to placebo. However, in the trials that studied the effectiveness of these agents, participants received psychotherapy or had extensive contact with the project's staff, including physician reinforcement for smoking cessation, multiple episodes of brief counseling, and group meetings. All of these methods were helpful during the trials but do not meet guidelines from the Agency for Health Care Policy and Research (now the Agency for Healthcare Research and Quality), which state that the practice-based management for smoking cessation should include one to three brief physician follow-up visits and perhaps a referral to a smoking cessation group. The impact of psychologic intervention in combination with antidepressant therapy in smoking cessation is unknown. Hall and colleagues studied the effectiveness of antidepressant therapy and psychologic intervention on smoking cessation alone and in combination.

Persons who smoked at least 10 cigarettes per day were recruited for the study through advertisements. Those who met the inclusion criteria were randomized into one of six groups. This was a two (medical management versus psychologic intervention) by three (bupropion versus nortriptyline versus placebo) clinical trial. Medical management consisted of four sessions of five to 20 minutes with physicians who provided basic information and answered questions. The psychologic intervention consisted of five 90-minute group sessions with counselors educated at the master's degree level.

The medication arm of the study used nortriptyline titrated to a therapeutic serum level of 50 to 150 ng per mL. Bupropion was started at 150 mg per day for three days, then increased to 300 mg per day. Assessments, which included patient interviews, expired carbon monoxide measurements, and urinary cotinine levels, were made at 12, 24, 36, and 52 weeks. Smoking cessation rates were based on both patient information and laboratory confirmation.

An analysis of the six groups found no significant differences in baseline variables. Early abstinence rates for the bupropion and nortriptyline groups were equal and significantly higher than those of the placebo groups. Intense psychologic intervention had better abstinence rates than routine medical management. The combination of intense psychologic intervention and medication did not substantially improve abstinence rates over rates for either intervention alone. Minimal side effects were reported in the medication portion of the study; the number of side effects reported by the nortriptyline group was only slightly higher than the number reported by the placebo group, and rates between the bupropion and placebo groups were equal. The one-year abstinence rates for all interventions were the same as those for placebo.

The authors conclude that bupropion and nortriptyline improve abstinence rates in smokers, and that psychologic intervention produces higher abstinence rates than routine medical management. However, the combination of antidepressant medications and psychologic intervention is not more effective than use of antidepressants alone.

editor's note: Recent advances in the understanding of nicotine addiction have provided physicians with multiple treatment strategies to assist patients with smoking cessation. The addition of nortriptyline as an adjuvant therapy in smoking cessation has provided physicians with a less expensive alternative to bupropion. The study by Hall and colleagues demonstrates that there is no difference in the effectiveness of bupropion, nortriptyline, and extensive psychologic intervention on smoking cessation rates. The authors also noted that at the end of the study period, all cessation rates were similar to those of placebo. This finding demonstrates the need for follow-up after the initial success of smoking cessation to maintain abstinence. The challenge is not only to assist our smoking patients to stop but also to stay tobacco free.—K.E.M.