Deep rTMS and Varenicline for Smoking Cessation

This study will be a randomized, double-blind, sham-controlled clinical trial. Nicotine dependent participants will be recruited and randomized tor receive either active or sham rTMS intervention for 4 weeks (5 sessions/week). All participants will receive an open-label treatment of varenicline for 12 weeks and weekly counselling sessions. The aims of the study are:

• To examine the efficacy of bilateral deep rTMS to the insula on point prevalence smoking abstinence in smokers receiving varenicline treatment.
• To examine the efficacy of bilateral deep rTMS to the insula on other smoking outcomes such as craving, cigarette smoking and dependence severity.
• To examine the effect of bilateral deep rTMS to the insula on abstinence at the end of rTMS treatment and at 6-month follow up.

Abstinence will be measured by point prevalence at week 4 and 12 and prolonged continuous abstinence at week 26. This will be confirmed using plasma cotinine levels. All other measures will be done using various questionnaires such as Fagerstrom Test of Nicotine Dependence (FTND), Timeline Follow-Back (TLFB), Minnesota Nicotine Withdrawal Scale (MNWS), and Tiffany Questionnaire of Smoking Urges (T-QSU).

Inclusion criteria

• Age 18-65;
• Nicotine dependent as assessed by Diagnostic and Statistical Manual of Mental Disorders (DSM-V);
• Reported daily cigarette consumption ≥ 10 and expired carbon monoxide (CO) measurement of ≥ 10 ppm;
• Fagerstrom Test of Nicotine Dependence (FTND) ≥ 4;
• Reported motivation to quit within 30 days as assessed using the Contemplation Ladder score of ≥ 7.

Exclusion criteria

• Reported smoking abstinence in the 3 months preceding screening visit;
• Current use of other smoking cessation aids;
• Allergy and/or contraindication to varenicline or rTMS;
• Pregnancy, trying to become pregnant or breastfeeding;
• Current or recent history of cardiovascular or cerebrovascular disease and/or current hypertension;
• Current or historical evidence of suicidal behavior;
• Serious current or personal history of medical condition/disease (neurological disorders, brain lesions, multiple sclerosis, head trauma, loss of consciousness, hearing loss, etc.);
• Current, personal history or family history of seizures;
• Cognitive impairment as defined as a Mini Mental State Examination (MMSE) score <24;
• Concomitant use of medication that lowers seizure threshold