Bupropion (Zyban) in smoking cessation

Findings by SBU Alert

Version: 2

Technology and target group

Bupropion (Zyban), the first drug registered for smoking cessation that does not contain nicotine, was introduced in Sweden during 2000. Originally, bupropion is an antidepressant. It is a prescription drug, but not covered under the drug benefit. The target group for treatment with bupropion includes smokers who have not succeeded with other treatment methods for smoking cessation.

Patient benefit

The effects of bupropion, in combination with individual support, have been studied in several randomized, placebo-controlled studies. Compiling the results from the two most important studies, where followup was conducted after 1 year, shows that the rate of continually smoke-free individuals was 19% in the group that received bupropion and 9% in the placebo group. This means that ten individuals must be treated with bupropion for one person to become smoke-free. Bupropion caused moderate side effects such as mouth dryness and insomnia in a small number of study participants, and in rare cases study subjects were affected by seizures.

Economic aspects

Currently, no studies have investigated the cost-effectiveness of bupropion treatment in Sweden. The cost for the drug alone is approximately 1000 SEK per treatment cycle. In addition, the costs for physician time correspond to at least one physician visit in primary care and a varying number of other contacts with physicians or nurses for followup and support. Economic analysis based on simulation models suggests that future savings in healthcare costs to a large extent would offset the cost of treatment for smoking cessation [6,16]. A model analysis from Great Britain indicates that the average cost per life-year saved is reasonably low. The cost per QALY of adding bupropion to counselling is approximately 12 500–27 500 SEK.

Scientific evidence

The scientific evidence on the effects of bupropion, along with individual followup support in smoking cessation, is good*. However, knowledge about the cost-effectiveness of the method is poor*. Until further notice, bupropion should be considered second line treatment because of the serious, but rare, side effects.

*This assessment by SBU Alert uses a 4-point scale to grade the quality and evidence of the scientific documentation. The grades indicate: (1) good, (2) moderate, (3) poor, or (4) no scientific evidence on the subject.

This summary is based on a report prepared at SBU in collaboration with Assoc. Prof. Peter Nilsson, Malmö University Hospital and has been reviewed by Agneta Hjalmarson, Lic. Psychol., Sahlgrenska University Hospital and Bertil Johnsson, MD, Medical Products Agency.

The complete report is available in Swedish only.

Alert is a joint effort by the Swedish Council on Technology Assessment in Health Care (SBU), the Medical Products Agency, the National Board of Health and Welfare, and the Federation of Swedish County Councils.

References

1. Ascher JA, Cole JO, Colin JN, Feighner JP, Ferris RM, Fibiger HC et al. Bupropion: a review of its mechanisms of antidepressant activity. J Clin Psychiatry 1995;56:395-401.
2. Astbury C, Tonstad S, Farsang C, Manolis A, Hider A, Sweet R. Zyban is an effective and well tolerated aid to smoking cessation in smokers with cardiovascular disease. (Abstract). European Society of Cardiology, Stockholm, 2001.
3. Britton J, Jarvis MJ. Bupropion: a new treatment for smokers. BMJ 2000;321:65-66.
4. Ferry LH, Burchette RJ. Efficacy of bupropion for smoking cessation in non-depressed smokers. (Abstract). J Addict Dis 1994;13:249.
5. Ferry LH, Robbins AS, Scariatti PD et al. Enhancement of smoking cessation using the antidepressant bupropion hydrochloride (Abstract 2670). Circulation 1992;86(Suppl. 4):I-671.
6. Halpern MT, Khan ZM, Young TL, Battista C. Economic model of sustained-release bupropion hydrochloride in health plan and work site smoking-cessation programs. Am J Health Syst Pharm 2000;57:1421-9.
7. Hayford KE, Patten CA, Rummans TA, Schroeder DR, Offord KP, Croghan IT et al. Efficay of bupropion for smoking cessation in smokers with a former history of major depression or alcoholism. Br J Psychiatry 1999;174:173-8.
8. Hays JT, Hurt RD, Rigotti N, Niaura R, Gonzales D, Durcan MJ et al. A randomised controlled trial of sustained-released bupropion for pharmacological relapse prevention following smoking cessation. Ann Behav Med 2001 (in press).
9. Hays JT, Hurt RD, Rigotti NA, Niaura R, Gonzales D, Durcan MJ et al. Sustained-release bupropion for pharmacologic relapse prevention after smoking cessation. a randomized, controlled trial. Ann Intern Med 2001;135:423-33.
10. Hughes JR, Stead LF, Lancaster T. Antidepressants for smoking cessation. Cochrane Database Syst Rev 2000;(4):CD000031. Review.
11. Hurt RD, Sachs DP, 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 1997;337:1195-202.
12. 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;340:685-91.
13. Tashkin D, Kanner R, Bailey W, Buist S, Anderson P, Nides M et al. Smoking cessation in patients with chronic obstructive pulmonary disease: a double-blind, placebo-controlled, randomised trial. Lancet 2001;357:1571-5.
14. Läkemedelsverkets hemsida: www.mpa.se
15. SBU-rapport nr. 138. Metoder för rökavvänjning. Stockholm, 1998.
16. The National Institute of Clinical Excellence (NICE). A rapid and systematic review of the clinical and cost effectiveness of bupropion SR and nicotine replacement therapy (NRT) for smoking cessation. www.nice.org.uk