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Am Fam Physician. 2002;65(5):932-935

Although treatments combining behavior interventions and pharmacologic techniques have made it easier to stop smoking, they have failed to address the high relapse rate within 12 months. Behavior treatments have offered little risk reduction benefit. Bupropion, effective in smoking cessation when taken alone or used with nicotine replacement, can be taken safely for long periods of time and has been suggested as a tool to reduce relapses. Hays and associates completed a randomized, double-blind, placebo-controlled study comparing sustained-release bupropion with placebo in relapse control among persons who stopped smoking after seven weeks of bupropion therapy.

In the study, 429 participants were randomized to receive active, sustained-release bupropion (300 mg per day) or placebo for 45 weeks and were followed at regular intervals for two years after initial randomization. Information about resumption of smoking was obtained at each follow-up visit, and patients kept a diary of withdrawal symptoms. The major outcomes measured were abstinence during medication treatment, whether the abstinence was continuous, and time to first relapse.

At the end of the 45-week medication phase, the abstinence rate was significantly higher in the bupropion group. This difference continued up to six months after medication treatment ended, but it disappeared at the end of the two-year study. The median time from randomization until smoking relapse was significantly longer in the bupropion group than in the placebo group (156 days compared with 65 days). Mean weight gain was significantly higher among the placebo group than among the bupropion group. There was no difference in the number or type of adverse events reported in each group.

The authors conclude that sustained-release bupropion helps increase long-term abstinence and lengthens the time to relapse among past smokers who initially used bupropion for smoking cessation. Although the abstinence rate was not different between groups at the end of the study, persons who have recently stopped smoking might safely benefit from long-term bupropion therapy.

editor's note: Smoking cessation remains a critical goal for physicians to encourage for their patients who smoke. We should use any of the known methods, alone or in combination, to support these patients during their cessation attempts. A review of smoking cessation techniques completed by the Cochrane Tobacco Addiction Review Group concluded that behavior techniques, including individual and group counseling, showed increased stopping rates and were more effective than brief advice or usual care. A review of the few studies of aversion therapy showed little efficacy for this method of aiding smoking cessation. Self-help interventions, which have a better response rate when materials are personalized, were found as effective as brief personal advice and more effective than no intervention. All forms of nicotine replacement were noted to be effective. Anxiolytics were found ineffective, but bupropion and nor-triptyline increased stopping rates. Clonidine was found effective, but its use had some side effects. Acupuncture, hypnosis, and exercise have limited efficacy in enhancing smoking cessation rates. Our first priority is to help our patients stop smoking. More research, such as this study by Hays and associates, is needed on ways to prevent relapse once smoking cessation is accomplished.—r.s.

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