I have recently been surfing through the Cochrane database of systematic reviews and found references to two studies which found a benefit for smoking cessation for the antidepressant medication nortriptyline. Both studies found a benefit at 61,2months and one found a benefit 2.25 years.2 They both used objective measures of cessation. The dosing for the study by Prochazka et al was to start 10 days before the quit day with 25 mg of nortriptyline increasing to 2 capsules per day after 3 days and finally 3 capsules per day. This needs to be continued for 8 weeks after the quit day and then titrated down to zero over about 14 days. In the Hall study3 the dosing was 25 mg per day for 4 days then increased to 50 mg per day for 4 days followed by a serum test to check for blood levels and the dose increased to 75 mg/day if a therapeutic level (at the antidepressant level) was not achieved. The blood levels were repeated and an increase to 100 mg/day was made if the levels were still low. The most common dose was 100 mg per day. This was titrated down to zero after week 6.

The numbers needed to treat were about 10 patients per 1 patient to quit at 6-16 months. The advantage of nortriptyline over the unfunded buproprion is that it is fully funded by PHARMAC. Many of my patients cannot afford the initial outlay to purchase buproprion and hence are attracted to the chance to obtain a prescription for $3 (with a community services card). Many of them have already been unsuccessful with nicotine patches. My one concern over a ‘cheaper’ option is that the patients may be less committed if they do not have to pay a larger sum up front (for the buproprion). I have discussed this with many patients and they seem genuinely excited by the prospect of a cheap but effective means of smoking cessation. So far I have started 6 patients on it. Two stopped because they felt drowsy on it and as their jobs required them to drive vehicles they did not feel safe. One did not fill the prescription and 3 have maintained cessation after about 4-6 weeks.

A doctor from the National Health Committee has checked with Medsafe and their advice was that if there is a Cochrane review supporting its use then there is little risk in practitioners prescribing it. PHARMAC were also consulted and stated that it would fund nortriptyline for smoking cessation.

Associate Professor Bruce Arroll
Department of General Practice and Primary Health Care
The University of Auckland.