CHAPTER 9. TOBACCO USE 241 Patients may also express interest in techniques such as hypnosis and acupuncture. These have not been proved to be effective through randomized, controlled trials but are probably not harmful. Informed patients who wish to try these techniques should not be discouraged from doin g Pharmacologic Agents Clinicians should consider recommending over-the-counter nicotine replacement therapy or one of several prescription medications that can increase the success rate for quit attempts. Table 9.2 summarizes currentl available pharmacologic adjuvants for smoking cessation. U.S. Food ane Drug Administration(FDA)-approved pharmacotherapies recommended as first-line agents include bupropion, varenicline tartrate, nicotine gum, nicotine inhaler, nicotine nasal spray, nicotine patch, and nicotine lozenges Secondary pharmacotherapy options, not FDA-approved for use in smoking cessation but of proven benefit, include nortriptyline and oral clonidine(17, 18). A nicotine vaccine, which will prevent transfer of nicotine through the blood-brain barrier, is in early development Selection of an appropriate agent depends on patient contraindications, patient preference, cost/coverage issues, and clinician familiarity with the pharmacotherapy. Among over-the-counter options, patches offer simplicity, while lozenges or gum give patients more control over dosing schedules. All forms of nicotine replacement therapy can help patients stop smoking, almost doubling long-term success rates(19), with similar efficacy to prescription medication. The long-term use of nicotine replacement therapies does not pose a known health risk and may be helpful with smokers who report persistent withdrawal symptoms. However, use of any nicotine replacement therapy should be avoided for 1 month following myocardial infarction serious arrhythmia, or unstable angina Clinical trial data suggest that bupropion and varenicline tartrate are effective aids to smoking cessation. Bupropion can be paired safely with nicotine replacement therapy, although blood pressure may need more careful monitoring. Even when used alone, bupropion use leads to quit rates about double those achieved with the nicotine patch. The effects of bupropion go beyond antidepressant activity, but its mechanism of action in smoking cessation remains unknown. Additionally, the FDA has approved the use of bupropion sustained release for long-term maintenance. The more recently approved varenicline tartrate appears to be even more effective than ropE on Nortriptyline and clonidine have smoking cessation efficacy, and while these may produce a number of unpleasant side effects, they should be considered when FDA-approved medications are not available to patients due to cost issues