Pharmacology · patient case question
Which smoking cessation aid carries the greatest risk of neuropsychiatric adverse effects?
Patient case: Sedation for an anxious smoker
Patient: Male, 44 years old
Chief Complaint: “I cannot get through an appointment without something to calm me down, and I want to stop smoking.”
Background: Twenty-pack-year smoking history. No cardiac or respiratory diagnosis. He had uneventful nitrous oxide sedation two months ago. He has a history of a single seizure in adolescence, cause never established.
Vital Signs: BP 132/80 mmHg · HR 82 bpm · SpO₂ 96% on air · T 99.4°F
Findings: He attends today with a four-day upper respiratory tract infection and is completely unable to breathe through his nose.
Show answer and explanation
Correct answer: A. Bupropion
- A. CORRECT. BUPROPION — marketed as Zyban for cessation and as Wellbutrin as an antidepressant — is a noradrenaline and dopamine reuptake inhibitor. Serious NEUROPSYCHIATRIC EVENTS have been reported in patients taking it for smoking cessation: depression, suicidal ideation, suicide attempt and completed suicide. As an antidepressant it carries a boxed warning for suicidality in children, adolescents and young adults up to age 24. It also LOWERS THE SEIZURE THRESHOLD in a dose-dependent way, which makes it contraindicated in seizure disorders, in bulimia and anorexia nervosa, and in abrupt alcohol or benzodiazepine withdrawal — directly relevant to this patient's seizure history.
- B. Nasal spray delivers nicotine fastest of the replacement forms and is the most locally irritating, causing nasal and throat burning, but it does not carry bupropion's psychiatric profile.
- C. Nicotine patches deliver a slow, steady dose and are a nicotine agonist without those central effects. Their characteristic complaints are local skin reaction and vivid dreams if worn overnight.
- D. Lozenges and gum cause hiccups, dyspepsia and jaw ache. The dental instruction for nicotine gum is worth knowing: CHEW AND PARK rather than chew continuously, and avoid acidic drinks beforehand since they reduce absorption.
Note: Note the contrast with VARENICLINE, the other non-nicotine agent. It carried a similar boxed neuropsychiatric warning, which the FDA REMOVED in 2016 after the EAGLES trial found no significant excess risk. Bupropion's warning language for cessation use remains in place. Depressed mood is also a genuine symptom of nicotine withdrawal itself, which complicates attributing these events to the drug.