A comparison of sustained-release bupropion and placebo for smoking cessation
CommentIn this study, the antidepressant buproprion prescribed for 7 weeks was found to be effective in increasing the rates of abstinence from smoking, and was well tolerated. Although there was little difference between the doses of 150 mg and 300 mg daily, the authors recommend the higher dose based on its greater effect on continuous abstinence from smoking at the end of the treatment period.
Unfortunately, there was a fairly high dropout rate (between 29% and 43%). Importantly, the dropout rate decreased with increasing doses of the drug, and dropouts were automatically assumed to have resumed smoking (according to the methods section of the article). This fact could have biased the results in favor of buproprion. This issue might have been clarified had the authors reported the results in the subgroup that did not drop out, in addition to the "intention to treat" analysis of all subjects presented here.
This caveat aside, there is a great need for drugs that will help patients stop smoking, and buproprion may well turn out to be such an agent. Issues that will need to be clarified include the optimal duration of therapy, the effect of buproprion compared with and in conjunction with nicotine replacement therapy, and the role of other anti-depressant medications.
In the original version of this summary, I stated that "antidepressents are associated with a small increase in seizure risk". This is inaccurate. In fact, "bupropion used as an antidepressant is associated with a small increase in seizure risk". This has now been rectified.
According to the PDR, the risk of seizure associated with sustained release bupropion at a daily dose of 300 mg is 0.1% (1/1000). This is small, but not negligeable. Multiple precautions are recommended to reduce the seizure risk (the drug should be avoided in patients with a history of seizure, with conditions that predispose to seizures or who are taking other medications that lower seizure threshhold).
January 7, 1998
ReferencesReferences related to this article from the NLM's PubMed database.
Reader CommentsJanuary 7, 1998
In a letter to me, Dr. Richard Hurt (corresponding author of the study) points out that there was a dose-response effect throughout the treatment phase and up to one year. This was one of the major reasons the authors recommended the 300 mg dose as the best dose to be used.
Date: Sun, 15 Mar 1998
I have a question regarding the way the results were reported in this article. I don't feel point prevalence data at 12 months necessarily reflects the effects of a medication administered 10 months ago. Isn't it possible patients resumed smoking at some point during the study, and then managed to quit again "cold turkey" independant of bupropion therapy? I don't understand why continuous quit data was reported only at 6 weeks and not reported at 12 months.
In clinical practice I don't really care if my patients are able to
remain abstinent from smoking for 1 week. I want to know if therapy with
bupropion is more effective on a continuous rate for 1 year when compared
to placebo. Why were the continuous quit rates at 12 months not included??
November 19, 1998
Letters to the editor about this article were published in the February 26, 1998 NEJM. These are about the appropriate dose of buproprion and about whether the subjects were truly blinded.
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