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Since the appearance of the seminal publication on sustained release bupropion versus placebo for smoking cessation exactly 10 years ago,1 bupropion has become a mainstay of nicotine addiction therapy.2 Some concerns relating to increased risk of seizures remain, in particular as exclusion of predisposed patients may be suboptimal in general practice.3 Furthermore, the cost of about €135 or US$180 for a pack of 100 pills required for a standard course of treatment of at least 7 weeks represents a substantial barrier to wider use.4 We present data suggesting that much shorter treatments with bupropion may be as effective as standard regimens.
In a cluster randomised trial in German general care investigating the effects of practitioner education and financial incentives for the physician or cessation drug costs reimbursement for his/her patients on smoking cessation, 577 heavy smokers (10+ cigarettes/day) aged 36–75 years and willing to participate were recruited regardless of their intentions to quit.4 At the 12 month follow-up, 76 participants (13%) reported having used bupropion (Zyban) during the 1 year study period. Consistent with expectations from clinical trials,2 cotinine confirmed point prevalence of abstinence after 1 year in subjects who had taken bupropion was 26% (20/76). However, we observed that the majority of treated patients reported intake durations clearly below the recommendations. In particular, 25 (33%) and 34 (45%) reported having taken bupropion for only 1–2 and 3–4 weeks, respectively. Intriguingly, in adjusted analyses, strong and significant associations of bupropion with cessation were evident only in the two categories representing treatment clearly shorter than current standards (table 1). This was preserved when using a stricter outcome (ie, 6 months of continuous abstinence).
While the overall high odds ratios for bupropion must be seen in relation to the low abstinence rate in the reference group, we consider it a highly interesting observation that very short treatment courses appeared as effective, or more effective, as standard bupropion regimens. The established standard duration appears to be primarily based on experience from nicotine replacement therapy,1 2 and we are aware of only a single, somewhat inconclusive, attempt to systematically investigate the performance of shorter regimens, which suggested equivalence of 1 and 2 months of treatment without reporting quantitative results.5 Our own study cannot rule out some distortion of effect estimates caused by residual confounding or recall bias, although it seems unlikely that such phenomena would be the main cause for our results. Possible explanations, such as bupropion refractory patients frustratingly continuing treatment, remain speculative. Given the potential reduction in seizure risk and substantial economic benefits associated with shorter treatment at the individual and community level, we believe that evaluation of short and more affordable regimens of bupropion for smoking cessation is warranted and should be adequately addressed in randomised clinical trials.
We wish to thank the patients and physicians participating in this study. Isabel Lerch was an essential help with data acquisition.
Funding: The study was funded by the German Ministry of Education and Research within the Baden–Württemberg Research Network on Addiction, project No 01EB0113. The funding source was not involved in study design, collection, analysis or interpretation of the data, in writing of the report or in the decision to submit for publication. LPB is supported by a grant within the German Research Foundation Priority Programme “Nicotine” (SFB 1226).
Competing interests: None.