Bupropion and other non-nicotine pharmacotherapiesBMJ 2004; 328 doi: https://doi.org/10.1136/bmj.328.7438.509 (Published 26 February 2004) Cite this as: BMJ 2004;328:509
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Narrative reviews can be misleading: Bupropion for smoking cessation is not effective in patients with COPD
Since bupropion sustained release (SR) was licensed for use in
smoking cessation in the United Kingdom and the European Union, many
(mainly narrative) reviews appeared in the scientific literature. Although
a review article can be an attractive tool to guide health care decisions,
research has shown that narrative reviews are not only incomplete, but
they can also delay the identification of effective or harmful
interventions when compared with more systematic approaches to reviewing
the literature (see Jadad(1)). In other words, narrative reviews can be
Just recently, the BMJ published a narrative review on bupropion and
other non-nicotine pharmacotherapies.(2) In that review the author stated
that “no evidence exists that bupropion is any more or less effective in
any specific subgroups of smokers, such as those with a smoking related
disease”, and “bupropion has been shown to be effective in this group of
patients” (the author refers to patients with COPD). The author based
these statements on the mediate-term results of one randomised trial,
which was published in the Lancet in 2001.(3) Tashkin and colleagues
evaluated the efficacy of bupropion SR for smoking cessation in patients
with chronic obstructive pulmonary disease (COPD).(3) They concluded that
prolonged abstinence rates from weeks 4 to 26 were significantly higher in
participants receiving bupropion SR than in those taking placebo.(3) After
26 weeks, 32 (16%) smokers from the experimental group were prolonged
abstinent compared to 18 (9%) in the control group(3) (RR=1.7, 95% CI 1.2-
2.3). Based on these results, one would agree with Elin Roddy that
bupropion SR is an effective aid in helping smokers with mild to moderate
COPD quit smoking. However, prolonged abstinence rates from weeks 4 to 52
showed that the difference in efficacy between the bupropion and control
group had disappeared (21 smokers [10%] from the experimental group were
still prolonged abstinent, compared to 17 [9%] in the control group(4)
[RR=1.2, 95% CI 0.6-1.8]). These data were presented at the 8th annual
meeting of the Society for Research on Nicotine and Tobacco in the United
States (although on the poster the number of sustained quitters in the
control group was 16)(5) and were incorporated in the Cochrane Review
addressing the efficacy of antidepressants for smoking cessation(4)
(recommended for further reading by Roddy).
Since 12-month prolonged abstinence data should always be preferred
over 6-month prolonged abstinence rates, and the results of only one study
are available, the conclusion should be that so far bupropion SR is not
efficacious in promoting prolonged abstinence in patients with mild to
moderate COPD, but more studies are needed. This example illustrates that
health-care providers and other decision-makers should only rely on high
quality systematic reviews before a health-care intervention can be
(validly and reliably) judged as being efficacious.
1. Jadad AR. Randomised controlled trials. London: BMJ Books; 1998.
2. Roddy E. ABC of smoking cessation. Bupropion and other non-nicotine
pharmacotherapies. BMJ 2004; 328: 509-511.
3. Tashkin DP, Kanner R, Bailey W, Buist S, Anderson PJ, Nides MA, et al.
Smoking cessation in patients with chronic obstructive pulmonary disease:
a double-blind, placebo-controlled, randomised trial. Lancet 2001;
4. Hughes JR, Stead L, Lancaster T. Antidepressants for smoking cessation
(Cochrane Review). The Cochrane Library, Issue 2 2003.
5. Jarvis MJ, Powell SR, Marsh HS, Browning D, Aristides M, Brown A. A
meta-analysis of clinical studies confirms the effectiveness of bupropion
SR (Zyban™) in smoking cessation. 8th Annual Meeting of the Society for
Research on Nicotine and Tobacco, February 20-23 2002.
Competing interests: No competing interests
EDITOR - regarding the dicussion on bupropion,
we want to add some facts which might be relevant for clinical practice:
Most of the available data on bupropion does
not reflect “real life conditions” and therefore gives just limited answer to
the primary question: Who is interested in smoking cessation programs and who
is interested in bupropion?
In our five outpatient units in
following situation which might be similar elsewhere:
After product introduction of Zyban in August
2000, we found a “real run” for bupropion. Rejection
of prescription of bupropion due to medical reason has
resulted in “aggression” and/or “hysteria” although we have offered established
treatment with NRT and counselling instead.
At this time bupropion was internationally
heavily pushed by the manufacturer by common PR measures, mostly based on one
(!) study by Jorenby et al.
showing a very favourable outcome of bupropion in
comparison with NRT patch.
Figure 1: Percentage of patients in the outpatient units taking bupropion in the years 2000 until 2004 (n=1042)
Figure 2: Absolute Number of articles dealing with bupropion in four major Austrian newspapers from 2000 to 2004
Prescription rates in our outpatient units drop continuously(figure 1)
and PR measures in favour of bupropion have declined
to a minimum(figure 2). Patients tend to discuss possible, side effects very
intensively. Some also reject to take the drug after carefully studying the
product information storing bupropion at home.
From our experience we conclude that smokers are not the easiest
patients. Therefore they are difficult to target and it’s them who want to
decide if and which drug to take. Positive PR measures are necessary to
convince them that medication helps if they try to quit.
In addition continuous support in terms of weekly sessions during their
smoking cessation attempt is of great importance to maintain their motivation.
But also when offering them a program, it’s not certain that they attend
continuously and take medication: Approximately 20% (19.8%, n=206) just came
once to our unit to get information on the program. From the rest, 24.8%
(n=207) reject any medication (including nicotine replacement), because they
believe “it is all willpower”. However, if they participate continuously in our
outpatient program the primary success rates are encouraging.
Regarding bupropion it is a pity to have an
efficient medication, which the patients avoid to take.
J. Eckl-Dorna, MD
of Vienna & Nicotine Institute Vienna, RechteWienzeile 81/1, A 1050
Roddy E. ABC of
smoking cessation. Bupropion and other non-nicotine pharmacotherapies. BMJ
Groman E, Bayer P,
Kiefer I, Eckl-Dorna J, Schoberberger
R. Bupropion (Zyban): First
Results of an Independent Clinical Management Study. Sucht 2000;46(6):408-413.
release bupropion, a nicotine patch, or both for
smoking cessation. N Engl
J Med 1999;340(9):685-691.
 Ferry LH. The power of the press in smokers’
attempt to quit. BMJ
K. Is bupropion (Zyban)
causing deaths? Med J Aust
Competing interests: No competing interests