Bupropion: a new treatment for smokers
BMJ 2000; 321 doi: https://doi.org/10.1136/bmj.321.7253.65 (Published 08 July 2000) Cite this as: BMJ 2000;321:65
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EDITOR-Having established a smoking cessation service last year as
part of our Health Action Zone initiative, we have to date been gradually
increasing the volume of clients seen in our clinics through self
referrals and referrals from GPs and hospital consultants.
We have found, as described by Britton and Jarvis1, that access to the one
week's supply of free nicotine replacement therapy, for those who are
eligible, is not always sufficient to set potential quitters on the right
track and indeed the "bureaucracy can be daunting". However, not
withstanding these issues, we find our clients eager for information on
how to stop smoking and ready to use support mechanisms be they
counselling services or pharmaceutical products.
With the launch of Zyban@ (bupropion), calls to our freephone information
line have quadrupled, with most callers wanting access to the new product
which they have seen reported in the media. Our main task currently is
directing clients back to their GPs for assessment as to their suitability
for Zyban@ whilst stressing that the product should be used in conjunction
with our support service. Not surprisingly we find differing views from
GPs as to which interventions they might choose to help patients give up
smoking. We understand that GlaxoWellcome clearly state that this product
should only be prescribed to those patients who have already made a clear
commitment that they wish to give up smoking. However, we now
consistently find that GPs want their patients to access our support
service as they recognise the importance of taking patients through the
process of giving up smoking as well as the use of pharmacological
treatment.
Although the launch of Zyban@ has given us a few headaches coping with the
demand for our services, it is an opportunity we have embraced willingly.
New products and methods for smoking cessation maintain the profile of our
service, and others like them, in terms of media coverage and more
importantly in terms of health service priorities. We welcome any
opportunity to work more closely with primary care colleagues in tackling
smoking and reducing smoking related diseases.
Wendy Richardson Tobacco Control Co-ordinator
Public Health Research Unit
Coniston House
East Riding Campus
Willerby HU10 6NS
1. Britton J, Jarvis MJ Bupropion: a new treatment for smokers BMJ
2000; 321:65-66. (8 July.)
Competing interests: No competing interests
Editor - With the arrival of a new oral treatment for smokers, that
would appear to be better than what is currently available, Britton and
Jarvis quite rightly state that the challenge is now to provide widespread
accessibility to nicotine replacement and bupropion. However the first
reaction of our practice was not pleasure at a great step forward but one
of hopefulness that our Primary Care Group would find a way of helping us
limit it's prescription. I am sure that we are not alone in this
attitude.
Despite our best efforts our practice is already spending more than our
allotted prescribing budget. If we were to provide bupropion to 10% of
our practice population, (not unlikely in view of the number of patients
already making appointments to ask for it), at £86 a course, it would cost
our practice £106,250.
We have no doubt that for society at large, this would be money well
spent, with enormous health gains. Unfortunately the NHS does not work
like that. Until new money is pumped into prescribing budgets on a
regular basis, we now have to ask ourselves what we are going to have to
stop prescribing, or how we are going to limit prescribing, every time a
new, and probably more expensive drug is introduced.
This behaviour, which has been forced upon primary care clinicians, is
just one example of why we languish in the second division of health care
systems.
Richard Vautrey general practitioner
Meanwood Group Practice
548 Meanwood Road
Leeds LS6 4JN
1. Britton J, Jarvis MJ. Bupropion: a new treatment for smokers. BMJ
2000; 321:65-6. (8 July)
2. World Health Organization. World Health Report 2000-health
systems: improving performance. www.who.int/whr/
Competing interests: No competing interests
There are two randomized controlled trials supporting nortriptyline
for use in smoking cessation.
In one trial, 214 patients ages 18 to 70 who smoked 10 or more
cigarettes per day and were without current major depression were
randomized to nortriptyline (started at 25 mg qhs 10 days prior to quit
day + titrated to 75 mg/day or maximal tolerated dose, further adjusted
based on serum levels, tapered to 50 mg/day at 8 weeks) versus placebo.
There were significant reductions in several withdrawal symptoms including
anxiety/tension, anger/irritability, difficulty concentrating,
restlessness and impatience by day 8 after quit day in the nortriptyline
group. Confirmed cessation rate at 6 months was 14% versus 3% (i.e. 9
patients need to be treated with nortriptyline [NNT 9] for 1 more to stay
quit at 6 months). Frequent adverse effects included 64% dry mouth and
20% dysgeusia. (see Arch Intern Med 1998 Oct 12;158(18):2035).
Another trial found nortriptyline useful for smoking cessation in
depressed and non-depressed patients, with cognitive-behavioral therapy
helpful in patients with a history of depression. 199 cigarette smokers
(33% with history of depression, those with depression within 3 months
were excluded) were randomized to nortriptyline versus placebo for 12
weeks, and also randomized to cognitive-behavioral therapy versus control.
Biologically verified abstinence from cigarettes measured up to 64 weeks.
Nortriptyline produced higher abstinence rates than placebo independent of
history of major depressive disorder, and nortriptyline alleviated
negative affect occurring after smoking cessation. With nortriptyline
versus placebo, there was 17% versus 30% dropout rates, and 24% versus 12%
achieved continuous abstinence (NNT 8 to achieve 1 more continuous
abstinence at 64 weeks). Cognitive-behavioral therapy was effective for
patients with a history of depression. (see Arch Gen Psychiatry 1998
Aug;55(8):683).
Competing interests: No competing interests
Britton and Jarvis give a surprisingly uncritical welcome to
bupropion. Although Jorenby and colleagues [1]did find that 30% of
patients who took bupropion were still non-smokers after 12 months (point-
prevalence data), it is clear that these must have been very highly
motivated volunteers, as 12 – 15% of those who took the placebo
successfully stopped smoking. There are no studies to show that bupropion
is effective in more averagely motivated patients.
The patients in this study [1]received intensive counselling, which
comprised more than 3 hours of face-to-face counselling and 80 minutes of
telephone support over the 12 month period. It is not realistic for the
NHS to provide this level of support. The manufacturers are offering a
telephone line for patients to ring for support, but this is not likely to
be as effective in motivating and supporting patients. It is,
therefore,unlikely that these high success rates will be repeated in day-
to-day practice.
Britton and Jarvis could have pointed out that 50% of patients who
successfully stop with the aid of bupropion will relapse within 12 months
of coming off the drug.
They could also have referred in more detail to the side effect profile
and the number of patients for whom this drug will be unsuitable.
Bupropion may have a 1 in 1000 risk of inducing seizures (GlaxoWellcome
product information). This may be an acceptable risk for drugs to treat
disease, but it becomes more significant if applied to 'lifestyle' drugs.
Bupropion may well prove to be a very useful adjunct to smoking
cessation. However, I would have preferred a more balanced appraisal in a
BMJ editorial.
1. Jorenby DE, Leischow SJ, Nides MA, Rennard SI, Johnston JA,
Hughes AR, et al. A controlled trial of sustained-release bupropion, a
nicotine patch, or both for smoking cessation. N Engl J Med 1999; 340: 685
-691.
Competing interests: No competing interests
The value of numbers
The value of numbers .
EDITOR- Britton and Jarvis acknowledge bupropion as an additional
supportive treatment for smoking cessation (1). In the study of Jorenby et
al (2) cited by the authors, the abstinence rates at 12 months were 15.6%
in the placebo group, 16.4% in the nicotine–patch group, 30.3% in the
bupropion treated group. These results are different from the data
reported in the editorial.
Smoking of cigarettes has major health consequences and bupropion
will benefit some people, therefore any error in the transmission of the
abstinence rates may be harmful because the perception and the clinical
decision of physicians are greatly influenced by the reading of numbers.
As stated by Harrison (3), bupropion efficacy may be overestimated
because intensive counselling performed in the studies is not always a
realistic model for real life. Nonetheless, the experience with nicotine
replacement therapy associated with brief advice shows a 10% rate of
cessation (4).
Pooling the data from both studies mentioned by Britton and Jarvis
(2,5), an absolute benefit increase (ABI) and a NNT could be calculated
for bupropion intervention versus placebo. The comparison with the result
obtained on nicotine replacement therapy, will provide us the best answer
of the potential bupropion efficacy. In Jorenby’s study, 25/160 patients
(15.6%) were abstinent in the placebo group versus 74/244 (30.3%) in the
bupropion group at one year of follow-up. In Hurt’s study, respectively
19/153 (12.4%) and 36/156 (23.1%) were abstinent at the same follow-up
time point.
The absolute benefit increase (ABI) for the pooled data is 13.5%
(95%CI 7.5,19.5) and the rounded off NNT (1/ABI) is 8 (95%CI 5.1, 13.3).
This value is lower than the global NNT on nicotine replacement therapy,
which is 15.2 (95% CI13.7, 17) as calculated from the review of Silagy and
al (6). These numbers indicate that bupropion is significantly more
effective than nicotine replacement therapy and is a valuable help in the
cessation of smoking.
Alain Van Meerhaeghe,
Pneumologist
CHU A.Vesale, 706 route de gozée , 6110 Montigny-le- Tilleul , Belgium.
Competing interests: none declared.
Brigitte Velkeniers,
Professor of internal medecine
AZ VUB, Laarbeeklaan 101, B-1090 Brussels, Belgium.
Competing interests: none declared
1. Britton J, Jarvis MJ. Bupropion: a new treatment for smokers .
BMJ 2000; 321:65-66.
2. Jorenby DE,Leischow SJ,Nides MA,Rennard SI, Johnston JA, Hughes AR,et
al. A controlled trial of sustained release bupropion, a nicotine patch,
or both for smoking cessation. N Engl J Med 1999; 340:685-691
3. Harrison Ch. Bupropion may not be as good as editorial implies –
letters. BMJ 2001; 322:431.
4. Raw M, McNeil A, West RJ. Smoking cessation guidelines for health care
professionals. Thorax 1998; 53 (suppl 5, part 1):1-19S.
5. Hurt RD, Sachs DL, Glover ED, Offord KP, Johnston JA, Dale LC, et al.
A comparison of sustained-release bupropion and placebo for smoking
cessation. N Engl J Med 1197;337:1195-1202
6. Silagy, Munt D,Flower D,Lancaster G.Nicotine therapy for smoking
cessation. The cochrane Library, Volume (issue 1)2001
Competing interests: No competing interests