To systematically review the evidence for the efficacy and safety of pharmacological cessation therapies in patients with cerebrovascular disease.

Recent studies demonstrated the efficacy and safety of pharmacological smoking cessation therapy for patients with heart disease. Similar data are lacking for patients with cerebrovascular disease, who pose unique safety concerns such as seizure and neuropsychiatric risks. 

We searched the Medline, Cochrane, and Clinicaltrials.gov databases to identify randomized controlled trials (RCT) and observational studies comparing varenicline, bupropion, or nicotine replacement therapy (NRT) versus non-pharmacological cessation therapies in patients with stroke. We included studies that reported rates of smoking cessation, worsening or recurrent cerebrovascular disease, seizures, or neuropsychiatric events. The quality of evidence was assessed using a structured framework. We adhered to systematic review guidelines. 

We identified 2 RCTs and 6 observational studies; 3 included ischemic stroke and transient ischemic attack, 2 subarachnoid hemorrhage (SAH), and 3 did not specify. There was substantial heterogeneity of the timing and nature of interventions, precluding meta-analysis. Pharmacological therapies were often co-administered with intensive behavioral interventions. Efficacy was assessed in 4 studies; cessation rates ranged from 33% to 66% with pharmacological therapy versus 15% to 47% without. Results were not statistically significant in any individual study. Safety data in ischemic stroke were scarce. Among patients with SAH, patients who received NRT in 1 study had a higher incidence of seizures (9% vs 2%; P=0.024) and delirium (19% vs 7%; P=0.006), but rates of vasospasm were not statistically different in 3 studies. 

There were insufficient high-quality data to conclusively assess the efficacy and safety of pharmacological smoking cessation therapies in patients with cerebrovascular disease. Combined with behavioral interventions, these therapies resulted in numerically higher cessation rates. The safety of these agents, particularly with respect to seizures and delirium, may warrant further study.