Before this literature review, the author thought smoking cessation medications should be associated with less, not more, suicide given that NRT decreases withdrawal-induced negative affect (West & Shiffman 2001) and appears to have antidepressant effects (Salin-Pascual et al. 1996); However, the post-marketing results cited above do suggest further investigation is needed. Although the incidence of suicide appears small, one could argue that even this is problematic given that medications are not essential to smoking cessation; i.e., many smokers are able to quit without medications (Shiffman et al. 2006). On the other hand, one could argue that there are some smokers who cannot quit without medications (US Dept Health and Human Services 1988), and given the large health benefits from smoking cessation (US Department of Health and Human Services 1990b), a 1% incidence risk is acceptable. At this writing, the US FDA, (US Food and Drug Administration 2008) the European Medicines Agency (EMEA) (European Medicines Agency 2007) and the manufacturers of varenicline (Pfizer 2008) and bupropion (GlaxoSmithKline 2007) have added warnings about suicide. These warnings state smokers considering use of bupropion and varenicline should be screened for a history of psychiatric disorders and monitored closely for psychiatric AEs.
