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The effectiveness of bupriopion vs. bupropion plus nicotine patch in a smoking cessation clinic
Sherman SE, Takayesu S, West P, Chapman A. The effectiveness of bupriopion vs. bupropion plus nicotine patch in a smoking cessation clinic. Paper presented at: VA HSR&D National Meeting; 1999 Feb 25; Washington, DC.
Objectives: Several research trials have examined the efficacy of bupropion. While efficacy studies such as these are helpful, they unfortunately often do not translate into effectiveness in actual clinical practice. We examined the effectiveness of bupropion vs. bupropion plus nicotine patch in the routine practice of a smoking cessation clinic. Methods: The Sepulveda VA Smoking Cessation Clinic was established in 1992 and has consistently received approximately 60 referrals/month. Patients attend seven visits over two months and receive individual counseling in a group setting from both a health educator and a clinical pharmacist. Compliance is assessed by carbon monoxide meter at each visit, and patients with repeated high readings are dropped from the clinic. Since April, 1998, we have randomly assigned all new patients to either bupropion or bupropion plus nicotine patch ('combined therapy'). Patients were assigned to only nicotine patches if they had a history of seizures or refused bupropion. We assessed how patients were doing at each visit and whether or not they were tolerating their therapy. We also determined the percent of patients who successfully completed the two-month program. No extra resources or funding were used, so that we were comparing these two regimens in routine practice. We calculated approximate direct costs of the medication and counseling for each regimen. Results: During the first four months, 231 patients were referred, of whom 140 (61%) attended at least one session. 62 patients were assigned to bupropion, 54 to combined therapy, and 22 to nicotine patches. Two patients chose not to use any pharmacologic therapy. Side effects were noted in 21 people taking bupropion (34%), 14 people taking combined therapy (26%), and 3 people taking nicotine patches (14%). 18% of patients started on bupropion were switched to another regimen (10 to nicotine patches, 1 to combined therapy), compared to 15% of patients started on combined therapy (6 to nicotine patches, 2 to bupropion), and 0% of patients started on nicotine patches. The rate of successfully completing the two-month program (by initial treatment assignment) was as follows: bupropion 13/62 (21%), combined therapy 21/54 (39%), and nicotine patch 5/22 (23%). The cost of medication and counseling for one complete two-month course was $190 for bupropion and $310 for combined therapy. Factoring in the unsuccessful patients, the cost/successful completer was approximately $447 for bupropion and $513 for combined therapy. Conclusions: We conclude that in routine practice, patients taking combined therapy tolerate it as well (when measured by side effects or treatment switching) as patients taking bupropion. The success rate appears to be higher in patients initially assigned to combined therapy, making the cost/successful completer just slightly higher for combined therapy.Impact: These data are helpful in determining what regimen to use within a smoking cessation clinic, especially since there are so few trials of combination therapy. We are continuing to accrue approximately 40 patients/month, which will allow us to more precisely compare these two regimens. We do not yet have data on long-term abstinence to determine whether the relapse rate differs by initial treatment assignment