ATTUD Journal Club Postings

New Cochrane Reports on Pre-operative Treatments and Antidepressant Treatment

A new Cochrane meta-analysis examined 13 trials of pre-operative smoking cessation treatment.  Intensive treatment (e.g. 4 sessions prior to surgery plus medications) increased abstinence at the time of surgery (OR = 10.8) and long-term cessation after the surgery (OR = 3.0). Brief treatment increased abstinence slightly at the time of surgery (OR = 1.3) but not over the long term. The trials also showed intensive treatment substantially decreased the incidence of surgical complications (OR = 0.42). These results are consistent with those among other groups of smokers who have good medical reasons to stop smoking (e.g. those with COPD or pregnant) but have not done so; i.e., intensive treatments are needed. This is probably because not stopping smoking despite clear evidence it’s harming you is probably a marker of increased addiction and thus briefer treatments are not effective. Interestingly, one exception to this may be cardiovascular problems.

A second Cochrane meta-analysis updated an earlier one on the efficacy of anti-depressants (disclosure – I was first author of this analysis). The new analysis found 24 new studies and found the prior conclusions still held; i.e., a) bupropion and nortriptyline are effective but SSRIs are not, b) bupropion is not more effective than single NRT and c) adding bupropion to NRT does not increase quit rates. The new conclusion was that bupropion was inferior to varenicline (OR = 0.68). So the real question is when would one use bupropion rather than varenicline. One could say that since bupropion is an antidepressant one should prefer it with smokers with past or current depression. However, that bupropion is more effective than NRT or varenicline in such smokers has not been shown, plus early studies suggest varenicline has anti-depressant effects. Also, one could say to use bupropion with smokers with a psychiatric problem because varenicline has  been associated with psychiatric adverse events. However, bupropion has the same “black box” warning about suicides as varenicline, plus 3 very large observational studies have found that, if anything, the rates of psychiatric adverse events are less with varenicline than with bupropion. So I am at a loss as to when to use bupropion and would invite suggestions on this.