• Stop-smoking medications do reduce cravings, studies show

    Two common medications used by smokers trying to give up tobacco work by acting on the brain to reduce nicotine cravings. That’s what researchers found in two recent studies reported in the Archives of General Psychiatry. Functional magnetic resonance imaging (fMRI) of the brain was used in the studies to document how both bupropion (Zyban, Wellbutrin) and varenicline (Chantix®) reduced activity in the brain’s ventral striatum and medial orbitofrontal cortex – areas that affect cravings and rewards. Both studies were done at the Center for the Study of Addictions at the University of Pennsylvania.


    Smokers who were treated with bupropion had reduced activity in the areas of the brain that control cravings compared to those treated with the placebo.


    Antidepressant affects brain activity

    The first study looked at bupropion. Originally developed as an antidepressant and marketed as Wellbutrin, bupropion is now also prescribed as the stop-smoking aid Zyban. While this medication is effective in helping reduce cravings in smokers, it is not known exactly how it works.

    To assess how this drug influences brain activity, researchers enrolled 30 smokers who were randomly assigned to eight weeks of treatment with either bupropion or a placebo. Patients were given fMRIs before and after treatment, during which they watched 18 cigarette-related (actors smoking in a variety of settings) and nine neutral (no smoking cues) videos. During each 45-second video, participants were told to either allow their cravings or to resist cravings; they then voted on the strength of those cravings.

    Smokers who were treated with bupropion had reduced activity in the areas of the brain that control cravings compared to those treated with the placebo. They also reported significantly lower cravings than did those who received the placebo, corresponding to the changes in the brain activity shown with the fMRI scans.

    Similar results with varenicline

    Varenicline, or Chantix, is different from bupropion because it both reduces the symptoms of nicotine withdrawal and decreases the psychological reinforcement or reward from nicotine use. This study looked at 22 smokers who were thinking about quitting smoking but who were not in the process of quitting. The smokers were randomly assigned to a three-week regimen with either varenicline or a placebo. Before and after treatment, each smoker had fMRIs during rest as well as while watching smoking-cue videos.


    Researchers found that the brain’s reaction to the smoking cues was reduced after three weeks of treatment with varenicline; self-reported cravings were also significantly less.


    When compared to the placebo group, researchers found that the brain’s reaction to the smoking cues was reduced after three weeks of treatment with varenicline; self-reported cravings were also significantly less. Researchers also found that use of varenicline activated an area of the brain that evaluates the rewards associated with the smoking stimulus, helping to blunt the brain’s response to the smoking cues, thus aiding the smoker in determining appropriate actions. None of the participants quit smoking as a result of this study, but those on varenicline smoked fewer cigarettes than those on the placebo.

    Which works best?

    Neither of these studies looked at which medication worked best at reducing cravings and reward. Rather, they only looked at how each compared with a placebo treatment. However, a British study reported in the 2008 issue of Psychopharmacology found that varenicline was better than bupropion at reducing cravings, as well as in ratings of satisfaction and psychological reward; bupropion was more effective than the placebo.

    Neither drug helped reduce the physical symptoms associated with withdrawal from tobacco, such as restlessness, insomnia or increased appetite.

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Page last updated: 5/22/2014 4:15:46 PM
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    What the news means for you

    Tobacco addiction: A chronic disease – not a bad habit

    Audrey Darville, ARNP
    Tobacco Cessation

    Wright, Heather, MDRecent studies such as these that use functional magnetic resonance imaging (fMRI) to see how the brain reacts to certain stimuli demonstrate that tobacco use is not just a habit. In fact, it is a chronic disease that impacts and changes our brain chemistry and function in very specific ways. These studies help explain how medications such as Zyban/Wellbutrin (bupropion) and Chantix® (varenicline) help reduce a person’s craving for tobacco and the psychological reward associated with smoking; they also demonstrate how images of smoking can prompt that craving.

    Such studies lend credence to the fact that we need to take a more comprehensive approach in treating tobacco dependence as a chronic medical disease. There is a tendency to “medicalize” the treatment of tobacco use by just giving someone a pill and thinking that’s all that we need to do. We don’t do that with any other chronic disease. When we treat diabetes or high cholesterol, we may give a patient medicine, but we also teach them about making positive lifestyle changes and offer support. That’s the sort of approach we need for tobacco addiction.

    It’s not about willpower

    There is a pervasive notion that quitting is about willpower. Family members often question in frustration why their loved ones can’t just give up smoking. Based on fMRI studies, we can see that the physiological changes in the brain caused by tobacco use are similar to those caused by heroin and cocaine addiction.


    “There are two parts to quitting: quitting and staying quit. Staying quit is the challenge.” 


    When I lead support groups, I talk about just how powerful this addiction is so that family members can be more understanding and supportive of the person trying to quit – that’s very important. I also talk about what types of cues can trigger those cravings, how to avoid those cues and what’s available to help reduce cravings. We know from a study reported recently in Biological Psychiatry that people differ in their reaction to smoking-related cues as measured by fMRIs. If we can identify those most vulnerable to smoking relapses as a result of being exposed to “triggers,” we can better tailor smoking cessation treatments to improve success rates, thus helping to reduce smoking-related deaths.

    Quitting may take several tries

    There are two parts to quitting: quitting and staying quit. Staying quit is the challenge. People quit for two weeks, six months, even five years, and then they get into a situation that sparks the craving and awakens the receptors in their brain, and they get started again. They are frustrated, and there is a tendency to feel like a failure. They are ashamed to admit to their physician that they’ve relapsed and need help quitting again.

    The American Lung Association estimates the average person tries to quit four times – and as many as eight times – before successfully overcoming tobacco addiction. Seventy percent of smokers want to quit. Of those who try to quit “cold turkey” without some sort of help, it’s estimated that only 5 to 8 percent are successful.

    Most people do best when they use a comprehensive approach that combines medication, nicotine replacement, and, if appropriate, counseling and support. Family support and understanding are key, as is talking with your health care provider about which approach is best for you.

    Quitting is a process, and if you lapse or relapse, that’s just part of the process. We have to figure out why and what triggered the relapse so we can address it – it’s different for everyone.

    Medication may help

    There are very few studies that compare treatments to each other to see which work best, but both Chantix and Zyban/Wellbutrin appear to be effective in helping to reduce nicotine cravings. Because Chantix appears to work better than Zyban/Wellbutrin on another brain mechanism – satisfaction and psychological rewards – it may be more effective for some in helping smoking cessation.

    Also helpful are nicotine replacement therapies such as nicotine gum, patches and lozenges, especially when used in combination with Zyban/Wellbutrin. You don’t use nicotine replacement products with Chantix because this medication mimics the effects of nicotine on the body, helping thwart the addictive cravings. Zyban/Wellbutrin and Chantix are available only with a prescription. Your health care provider can explain possible side effects associated with these medications. Nicotine replacement patches, gum and lozenges can be purchased at any drugstore. The Kentucky Quitline, (1-800-QUITNOW,) is a good source of information on quitting, and it’s free.

    Remember, quitting tobacco use for good takes more than a pill. Understanding how this chronic disease works and providing personalized, comprehensive treatments and support will help more people be successful in ending their dependence on nicotine.

    Audrey Darville, ARNP, is a certified tobacco treatment specialist with UK HealthCare and a member of the clinical faculty at the UK College of Nursing. She oversees inpatient and outpatient tobacco treatment and support services.

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