Evidence-Based Reviews

Beating nicotine: Medication algorithm helps teens quit

Current Psychiatry. 2007 October;6(10):65-74

References

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Cotinine can be tested in serum, saliva, or urine. Serum testing can be expensive and may require shipping samples to a specialized laboratory for processing. Testing saliva or urine is less expensive and may be conducted in an office. Cotinine testing in teens who use NRT may be unreliable because the nicotine in these products will be metabolized to cotinine and yield a positive result.

CASE CONTINUED: Wanting to quit

Michael was placed on a 21-mg transdermal nicotine patch, which greatly reduced his craving and irritability. He expressed an interest in quitting smoking. Given Michael’s depressive symptoms, bupropion SR was initiated to treat his depression and assist with smoking cessation.

Treatment options

Optimal smoking cessation treatment includes a combination of medication and behavioral counseling.¹⁶

Clinical Point

Nicotine gum and transdermal nicotine patch appear to be moderately effective for adolescent smokers

Pharmacologic treatments. FDA-approved medications for adult smoking cessation include NRT—available as a gum, inhaler, nasal spray, lozenge, or transdermal patch—bupropion SR, and varenicline. Although not FDA-approved for patients younger than age 18, NRT and bupropion SR have been evaluated for smoking in adolescents.

NRT helps smokers by reducing nicotine withdrawal symptoms during cessation. Only nicotine gum and transdermal nicotine patch have been studied in adolescents. Results are modest at best, although in some studies including behavioral treatments may have obscured any medication effect (Table 1).^17-20

Bupropion SR. How bupropion SR helps patients stop smoking is not completely clear. Three studies have evaluated bupropion SR in adolescents; 2 had positive results, but all 3 had important limitations (Table 2).^21-23

One of the 2 positive studies included only 16 patients and had an open-label design.²² The second—a larger randomized, placebo-controlled trial²³—found that bupropion SR improved nicotine abstinence compared with placebo at 6 weeks, but this effect did not last after subjects stopped taking the drug.

The third bupropion SR study used 150 mg/d (the recommend adult dose is 300 mg/d) and had poor medication adherence.²¹ The difference in abstinence rate compared with placebo was not statistically significant.

Clinical Point

Two of 3 studies of bupropion for younger smokers had positive results but all 3 had important limitations

Other medications. Varenicline—a partial nicotine receptor agonist recently approved for adult smoking cessation—has not been studied in adolescents. Nortriptyline, doxepin, selegiline, clonidine, and mecamylamine have shown promise in adult smokers but are not approved for smoking cessation and require further study, especially in young smokers.^24-27

Pharmacotherapy risks. NRT can cause nicotine overdose symptoms, such as rapid heart rate or nausea, especially if used while smoking. Transdermal NRT can cause a local reaction at the application site and can cause burns if worn while undergoing magnetic resonance imaging.²⁸

Adverse effects associated with bupropion SR include a small risk of seizure, weight loss, and insomnia. This drug is contraindicated for patients who:

have a seizure disorder
have ever been diagnosed with bulimia or anorexia nervosa
are taking other bupropion formulations.

Patients should not take bupropion SR during abrupt discontinuation of alcohol or sedatives or within 14 days of taking a monoamine oxidase inhibitor.²⁹

Table 1

Can the nicotine patch help teens quit smoking?

Authors	Study population	Study design	Abstinence rate
Smith et al, 1996¹⁷	13- to 17-year-olds (N=22) who smoked ≥20 cpd	8 weeks of open-label treatment with transdermal NRT plus behavioral counseling and group support	14% at 8 weeks, 4.5% at 3 and 6 months
Hurt et al, 2004¹⁸	13- to 17-year-olds (N=101) who smoked ≥10 cpd	6 weeks of open-label treatment with transdermal NRT plus self-help material and brief individual counseling if requested	11% at 6 weeks, 5% at 6 months
Hanson et al, 2003¹⁹	13- to 19-year-olds (N=100) who smoked ≥10 cpd	10 weeks of double-blind treatment with transdermal NRT or placebo plus CBT and contingency management	20% (active) vs 18% (placebo); not statistically significant
Moolchan et al, 2005²⁰	13- to 17-year-olds (N=120) who smoked ≥10 cpd	12 weeks of double-blind treatment with: transdermal NRT+placebo gum nicotine gum+placebo patch or placebo gum+placebo patch Concurrent CBT	17.7% (active transdermal NRT)* vs 6.5% (active gum) vs 2.5% (placebo only)
*P=0.04 for transdermal NRT vs placebo
CBT: cognitive-behavioral therapy; cpd: cigarettes per day; NRT: nicotine replacement therapy

Table 2

Teen smoking cessation: Evidence for bupropion SR

Authors	Study population	Study design	Abstinence rate
Upadhyaya et al, 2004²¹	12- to 19-year-olds (N=16, 11 of whom had ADHD) who smoked ≥5 cpd	7 weeks of open-label treatment with bupropion SR, 150 mg bid, with brief smoking cessation counseling	31.3% after 4 weeks of medication
Killen et al, 2004²²	15- to 18-year-olds (N=211) who smoked ≥10 cpd	9 weeks of double-blind treatment with bupropion SR, 150 mg/d, or placebo; subjects received 8 weeks of transdermal NRT and group skills training	23% (active) vs 28% (placebo) at 10 weeks; 8% (active) vs 7% placebo) at 26 weeks; not statistically significant
Muramoto et al, 2005²³	14- to 17-year-olds (N=312) who smoked ≥6 cpd	6 weeks of double-blind treatment with bupropion SR, 150 mg/d; 150 mg bid; or placebo, with CBT and motivational enhancement	16.9% (150 mg bid) vs 10.3% (150 mg/d) vs 6.7% (placebo) at 6 weeks* No differences at 26 weeks
ADHD: attention-deficit/hyperactivity disorder; CBT: cognitive-behavioral therapy; cpd: cigarettes per day; NRT: nicotine replacement therapy
*P=0.019 for 150 mg bid vs placebo