Bibliographic record
Abstract
A 48-year-old male smoker (35 cigarettes a day for 30 years) with major depressive disorder stabilized on citalopram, 40 mg once daily, wished to quit smoking. Whenever he quit “cold turkey,” he relapsed owing to intolerable anxiety and depression that twice met criteria for an acute depressive episode. His psychiatrist added bupropion SR, 150 mg twice daily. He was advised to quit within 2 weeks. His anxiety increased within a few days of quitting but resolved with a reduction in caffeine consumption. He discontinued bupropion after 12 months. He gained 1 kg, remained euthymic and had occasional mild cravings with minimal anxiety. Tobacco causes almost 48 000 premature deaths in Canada annually (Makomaski and Kaiserman, Can J Public Health 2004;95:38-44). Those with past-month psychiatric diagnoses consume 44% of all cigarettes (Lasser et al, JAMA 2000;284:2606-10). This significant association is due to a combination of genetic (e.g., P50 deficits in schizophrenia corrected by nicotine), environmental (e.g., pro-smoking policies in patient group homes) and other factors (e.g., “self-medicating behaviours” to reduce anxiety and depression; the use of cigarettes as rewards to shape behaviour). The adverse effects are amplified by obesity and metabolic changes owing to psychotropic drugs and poverty. Fortunately, there is a 50% risk reduction in coronary events within 1 year of quitting and a significant reduction in the risk of developing lung disease and cancer in the long-term. Bupropion has a large effect size in permanent smoking cessation (19 trials, odds ratio 2.06, 95% confidence interval 1.77–2.40) independent of its antidepressant effects (Hughes et al, Cochrane Database Syst Rev 2004;[4]:{type:entrez-nucleotide,attrs:{text:C31,term_id:30294550,term_text:C31}}C31), with 15% quitting permanently with minimal weight gain. It is also effective in smokers with depression and schizophrenia (Dudas and George, Essent Psychopharmacol 2005;6:158-72). Bupropion may stabilize the dopaminergic reward system and competitively antagonize nicotine at central α4β2 nicotinic receptors (Warner and Shoaib, Addict Biol 2005;10:219-31). Clinically, subjects report decreased cravings and cigarette taste aversion. Responders tend to be moderately dependent male smokers who have tried to quit previously (Hurt et al, Addict Behav 2002;27:493-507). Smokers with the low activity variant (CT/TT group) of CYP2B6 are less likely to be abstinent than are smokers with normal activity variants (CC group) (χ2 = 5.0, p < 0.02) (Munafo et al, Pharmacogenomics 2005; 6:211-23). Bupropion is safe in combination with most neurotropic drugs because it is primarily metabolized by CYP 2B6. However, dose reduction in concomitant caffeine, benzodiazepines and neuroleptic drugs (especially clozapine) may be warranted, because polyaromatic hydrocarbons present in smoke induce CYP 1A2. The induction reverses within days to weeks after smoking cessation. Doses of 150 mg or 300 mg are effective within 3 weeks, but there are no studies with higher doses. Motivated smokers may also respond after 4 weeks of therapy. Thereafter, nicotine replacement therapy may be added. Relapse is common on stopping the medication, even after a year, necessitating longer-term use in some smokers (Hays et al, Ann Intern Med 2001;135:423-33). Insomnia can be minimized by timing the second dose to be no later than 6 hours before bed. Seizures (1/2000) can be prevented by not exceeding the recommended dose and by observing contraindications. In conclusion, psychiatrists have the ability to treat smokers in their practice with a common psychiatric medication with good efficacy. Peter Selby, MBBS, CCFP, FASAM Addictions Program Centre for Addiction and Mental Health Departments of Family and Community Medicine, Psychiatry and Public Health Sciences University of Toronto Toronto, Ont.
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.000 | 0.001 |
| Meta-epidemiology (narrow) | 0.000 | 0.000 |
| Meta-epidemiology (broad) | 0.000 | 0.000 |
| Bibliometrics | 0.000 | 0.000 |
| Science and technology studies | 0.000 | 0.000 |
| Scholarly communication | 0.000 | 0.000 |
| Open science | 0.000 | 0.000 |
| Research integrity | 0.000 | 0.001 |
| Insufficient payload (model declined to judge) | 0.002 | 0.000 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".