Articles for Our Patients ~ Keith Kusunis, M.D.

Cancer Prevention - Take Medicine to Stop Smoking

Author: Keith Kusunis, M.D. • Language: ENG

There are three main drugs to help people quit smoking:
1. bupropion (Zyban, Wellbutrin, Aplenzin) 2. varenicline (Chantix) 3. nicotine replacement (nicotine replacement can be added to either bupropion or varenicline)

All forms of bupropion and varenicline are prescription only, while many nicotine products are over-the-counter, so no prescription is needed. I usually like to recommend starting bupropion while planning to quit, and then adding nicotine replacement when actually off cigarettes.
I would like to focus on bupropion for this article. Bupropion was originally studied as an antidepressant. During these trials clinicians noticed that people on bupropion seemed to smoke less. Trials were then performed to confirm this and Zyban is now the brand of bupropion that is FDA approved for smoking cessation.
Some people resist taking bupropion because it’s a “mind drug.” Bupropion does work by increasing dopamine levels in the brain. The funny thing is that exercise, nicotine, food, and other pleasurable activities also release dopamine in the brain. The reason cigarettes are so addicting is that it takes only seven seconds for nicotine to get from the lungs to the brain to release those happy chemicals.
The important difference between bupropion and cigarettes are the side effects. The most common side effects of bupropion are decreased appetite, anxiety and insomnia. The most common side effects of cigarettes are decreased appetite, anxiety, insomnia and also stroke, cancer, and death. As I tell my patients, “my drug is better than your drug.”
When starting cigarettes, there are side effects in the beginning, including cough and nausea. With continued use, these side effects go away and instead are replaced by the positive psychiatric effects of nicotine. When starting bupropion, some people may also notice some side effects. With just a few days of use, these side effects also usually go away. However, it can take weeks or even months for the person to get the full benefits of bupropion - improved mood, improved concentration, and possible weight loss. This delay of effect is one reason why bupropion and other antidepressants are not addicting.
The FDA approved method of using Zyban brand of sustained release bupropion is to take 150 mg. every morning for three days, then 150mg. twice a day for seven to 12 weeks. The cigarettes are stopped one or two weeks after starting bupropion.
There are a couple of modifications to the FDA approved dosing method which are helpful. The larger 200 mg. size of sustained-release bupropion twice a day would likely be more effective in larger people.
Also, many people have some underlying depression that put them at risk for starting to smoke and continuing to smoke. So why only use the bupropion for seven to 12 weeks? Depending on the information source, the minimum length of time to treat depression is six to 12 months. The current recommendation is that if the depression is recurrent, the treatment should be forever—like the treatment of high blood pressure, glaucoma, diabetes, etc. I believe that long term bupropion is a good idea, as many people start smoking again months or years after they quit—usually during a time of stress or sadness.
People with a seizure disorder and people with liver or kidney failure should use smaller doses of bupropion, or not use it at all. The liver and kidneys remove bupropion from the body. Bupropion can lower the seizure threshold.
The cheapest U.S. source of 150 mg. bupropion sustained-release that I found during a limited internet search was 67cents per pill at Costco online. The immediate-release tablets are a little cheaper, but are not frequently used as they have a greater risk of seizures than the sustained-release pills. As one would expect, the once a day extended-release tablets are the most expensive, and less likely to be covered by insurance.

Other conditions treated with bupropion:
• Attention Deficit Disorder (ADD) - Some people unknowingly are using cigarettes to treat their ADD. If one has ADD, extra dopamine in the brain helps improve concentration. Unfortunately, cigarette smoke also contains carbon monoxide which decreases oxygen supply to the brain and decreases ones ability to concentrate. So again, it is better to increase your dopamine levels with bupropion and exercise than with nicotine. And bupropion is one of the medications regularly used for adult ADD.
• Seasonal Affective Disorder (SAD) - Bupropion is also used to treat seasonal affective disorder—the condition where a person becomes depressed every winter.
• Bipolar Disorder - bipolar disorder used to be called manic depression. Bupropion is sometimes used to help the depression component.
• Obesity - a combination pill of extended-release bupropion 360mg plus naltrexone 48 mg. is in final phase III trials as a diet pill. Naltrexone is FDA approved to help maintain sobriety during the treatment of alcoholism.