Non-nicotine pharmacotherapy for smoking cessation

Most smokers present to primary caregivers having tried unsuccessfully to quit smoking on their own multiple times. The first level of treatment offered should be appropriate behavioral support and first line pharmacotherapy, nicotine replacement, or bupropion, depending on the patient's preferences, nicotine dependence and medical history. Bupropion is the only available first line, non-nicotine medication with clear efficacy for treatment of nicotine dependence. Bupropion stabilizes the neurochemistry of nicotine craving and withdrawal by way of norepinephrine and dopamine modulation. It is more effective than one leading over-the counter nicotine transdermal system in a multi-center trial at the end of treatment and long- term follow up. There are advantages in the non-addicting effect of bupropion: highly acceptable adverse event profile lower cost than nicotine replacement and the option of using it while preparing for cessation and during the brain's withdrawal period of neurochemical readjustment to a nicotine free environment. Other promising non-nicotine agents have not shown consistent or long term success. Clearly it is prudent to use appropriate treatment to optimize underlying psychiatric disorders during smoking cessation. The relevant questions to ask are how do these agents theoretically help with long-term abstinence? We lack the evidence-based guidelines to assist us in selecting the appropriate treatment for individuals at present. If the brain's reward pathway by way of dopamine and withdrawal symptom control by way of norepinephrine are the keys to subduing nicotine addiction for an individual smoker, then better agents targeting these mechanisms clearly are needed. The goal is to match the reason why people smoke with the behavior therapy, social support, and medications that will best substitute for the smoker's needs of tobacco use, improve their long-term quit rates and reduce the consequences of tobacco related diseases. Tailoring treatment to the smoker's needs appears to be the next frontier for research on nicotine dependence treatment.