Deep Transcranial Magnetic Stimulation With the H4 Coil for Reducing Smoking Addiction in Patients With Comorbid Psychiatric Illness, Including Depression, Psychosis, and Alcohol Use Disorder

Abstract

Background: Tobacco smoking remains a leading preventable cause of morbidity and mortality worldwide. Deep transcranial magnetic stimulation (DTMS) using the H4 coil targets addiction-related circuits within the bilateral insula and prefrontal cortex and has demonstrated safety and efficacy in reducing smoking craving. However, the influence of comorbid alcohol use disorder, depression, and psychosis on smoking-cessation outcomes remains insufficiently studied. Aim: This study aimed to assess the clinical utility of H4 coil DTMS in reducing nicotine dependence among smokers with alcohol use disorder, depression, or psychosis. Materials and Methods:

This retrospective observational study included 33 nicotine-dependent patients treated with DTMS at a tertiary neuromodulation center. Participants had alcohol use disorder, major depressive disorder (MDD), psychosis, or overlapping comorbidities; all were receiving regular psychiatric treatment and underwent DTMS to reduce smoking craving. High-frequency stimulation (10 Hz) was delivered using the BrainsWay H4 coil at 120% of the resting motor threshold. Patients received two sessions daily for five consecutive days, for a total of 10 sessions, with 1800 pulses delivered over 18 minutes per session. All patients also received Motivational Enhancement Therapy and standard-dose varenicline. Nicotine dependence was assessed before and after treatment using the Fagerström Test for Nicotine Dependence (FTND). Results: The mean age of participants was 34 ± 10.34 years. Mean FTND score decreased from 7.27 ± 0.96 at baseline to 3.12 ± 1.37 after treatment, representing a mean reduction of 4.15 points and an average improvement of 56.78 ± 18.96%. Alcohol use disorder was present in 24/33 patients (72%), MDD in 14 (42%), and psychosis in 8 (24%). Hypertension and type-II diabetes mellitus were observed in 10 (30%) and 8 (24%) patients, respectively. By day 5, 24/33 patients (72%) achieved ≥50% improvement. Age and smoking duration showed moderate negative correlations with treatment response. Conclusion: H4 coil DTMS was associated with significant reductions in nicotine dependence in a real-world clinical setting. Outcomes were favourable among smokers with psychiatric comorbidities, supporting DTMS as a useful adjunct to comprehensive smoking-cessation programs. Alcohol use disorder was common, whereas patients with depression showed a lower response than the overall cohort. Controlled studies with long-term follow-up are warranted.