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Bupropion may not be as good as editorial implies
EDITOR–Britton and Jarvis give a surprisingly uncritical welcome to bupropion.[1] Although Jorenby et al did find that 30% of patients who took bupropion were still non-smokers after 12 months (point prevalence data), these volunteers must have been highly motivated as 12-15% of those who took the placebo successfully stopped smoking.[2] There are no studies showing that bupropion is effective in more averagely motivated patients.

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The patients in Jorenby et al’s study received intensive counselling, which comprised more than three hours of face to face counselling and 80 minutes of telephone support over the 12 months. It is not realistic for the NHS to provide this level of support. The manufacturers are offering a telephone line for patients to ring for support, but this is not likely to be as effective in motivating and supporting patients. The high success rates reported by Jorenby et al are therefore unlikely to be repeated in day to day practice.
Britton and Jarvis could have pointed out that half of patients who successfully stop smoking with the aid of bupropion will start again within 12 months of coming off the drug. They could also have referred in more detail to the side effect profile and the number of patients for whom the drug will be unsuitable. Bupropion may have a 1 in 1000 risk of inducing seizures (product information from GlaxoWellcome, the manufacturer of the drug). This may be an acceptable risk for drugs to treat disease but is less so for lifestyle drugs.
Bupropion may well prove to be a useful adjunct to smoking cessation, but I would have preferred a more balanced appraisal in a BMJ editorial.
Christopher Harrison general practitioner Barlow Medical Centre, Manchester M20 6TR charrison@doctors.org.uk
Competing interests: None declared.
[1] Britton J, Jarvis MJ. Bupropion: a new treatment for smokers BMJ 2000;321:65-6. (8 July.)
[2] 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.
Drug is almost identical in structure to diethylpropion, a controlled drug
EDITOR–Britton and Jarvis’s editorial on bupropion does not mention that the drug is an amphetamine derivative.[1] It is almost identical in structure to diethylpropion hydrochloride, which is a controlled (schedule 3) drug because of its supposed potential for misuse. Bupropion has been released in the United Kingdom on the strength of only two American clinical trials financed by the manufacturer. Many patients to whom it will be given will have addictive personalities. Shouldn’t the Medicines Control Agency rethink its decision?
When I asked the agency to explain the discrepancy regarding the classifications of the two drugs I was referred to the Home Office, whose advisers said that because bupropion is not a stimulant it need not be classified like diethylpropion. As the drugs are so similar in structure it would be surprising if one was a stimulant and one not. Certainly, dose related stimulation of the central nervous system occurs with bupropion in animals.[2] Both drugs come in a crushable tablet form, which facilitates parenteral misuse.
Drugs do not have to be stimulants for people to become dependent on them (for example, ethanol and diazepam), and not all stimulants give rise to dependency (only a few people say that caffeine withdrawal is a serious problem). And not all sympathomimetic drugs are stimulants (the appetite suppressant phenylpropanolamine, a sister sympathomimetic to bupropion and diethylpropion, is sold over the counter in the United States).
If bupropion is not a stimulant why does GlaxoWellcome’s product monograph list insomnia as its commonest side effect (occurring in just under half of patients)? And if it has none of the anorexigenic properties of the amphetamines why was the 11th congress on tobacco or health in Chicago on 6-11 August 2000 told that smokers taking bupropion gain less weight than those taking placebo (this information was also contained in the two clinical trials)?
A mass of evidence indicates that diethylpropion is safe and efficacious,[3] yet the Medicines Control Agency has made no objections to the European Commission’s current attempts to delicense it. Bupropion is being foisted on an unsuspecting British public with little evidence that it works much better than placebo.[4] The recommended dose of bupropion is much greater than that of diethylpropion. I suspect that a politically correct antismoking drug, however poorly researched and ineffective, will always be given the benefit of the doubt compared with a politically incorrect slimming drug, however safe and effective.
Herbert G Kinnell medical adviser Berkshire Diet Centre, Reading, Berkshire RG1 1SN
Competing interests: None declared.
[1] Britton J, Jarvis MJ. Bupropion: a new treatment for smokers BMJ 2000;321:65-6. (8 July.)