Bupropion Fails to Aid Hospitalized Smokers with Heart Disease

Smoking and nicotine dependence increase rates for heart disease in the general population. Among those with heart disease, continued smoking increases mortality rates. Targeting smoking cessation efforts at those with heart disease (secondary prevention)is an important clinical challenge.
 

Most of the research data related to drugs for smoking cessation come from subjects recruited from the general population. Both bupropion (Zyban)and varenicline (Chantix)are FDA-approved drugs for smoking cessation in the United States. There is limited data of the safety and effectiveness of these two compounds in those with heart disease.

Dr. David Planer and colleagues from Israel recently published a randomized clinical trial of smokers admitted to the hospital with acute coronary syndrome (myocardial infarction or unstable angina). Subjects in this study were required to have the intent to stop smoking. Subjects received either placebo or bupropion sustained release 300 mg daily. All subjects also received five sessions of smoking cessation counseling from a nurse or physician. These counselors had some previous experience in smoking cessation and received additional training from a smoking cessation counselor prior to the trial.

Unexpectedly, bupropion failed to provide an additional increase in abstinece compared to placebo with the following rates noted at several study time points (Bupropion Bold followed by (Placebo) rates:

• 3 months: 44% (43%)
• 6 months: 37% (42%)
• 12 months: 31% (33%) 

What is striking about these outcome comparisons in the rate of placebo response. The authors note nicotine dependence has one of the lowest rates of placebo response with studies commonly reporting placebo response rates as low as 10% at one year. It is possible that the effect of physician or nurse directed counseling at the time of hospitalization (when motivation may be highest)is quite powerful. This may be the most important finding from the study and provide impetus for more wide spread adoption of this strategy in clinical settings.

Interestingly, one predictor of smoking cessation at one year in this study was undergoing a cardiac procedure (angiography or coronary artery bypass graft) during the hospitalization (odds ratio 4.2, p value=.02). The authors hypothesize that undergoing an invasive procedure may potentiate the psychological distress of the hospitalization and increase motivation for smoking cessation to limit the risk of future procedures and hospitalizations. Previous outcome studies in alcoholism have found that a serious medical problem related to drinking (and the need to be abstinent to address this medical problem) is one of the strongest predictors of alcohol abstinence.

I think this study can not be interpreted to mean there is no place for bupropion in smoking cessation in those hospitalized with coronary artery disease. Coronary artery disease patients hospitalized in facilities with smoking cessation counseling resources may be better off with initiaion of bupropion or another smoking cessation drug. The study did find bupropion to be safe and generally well tolerated in this population. Bupropion might be a reasonable choice for smokers who experience depression in the course of the heart disease.

Physicians should see this study as an example of the power of their words and efforts in smoking cessation. Strongly urging smoking cessation in a place and time where it is most likely to be effective is crucial. Missing such opportunities may contribute to continued progression of heart disease and other smoking-related medical problems.

Photo of Cattle Egret from Maui Hawaii Courtesy of Yates Photography
Planer, D., Lev, I., Elitzur, Y., Sharon, N., Ouzan, E., Pugatsch, T., Chasid, M., Rom, M., & Lotan, C. (2011). Bupropion for Smoking Cessation in Patients With Acute Coronary Syndrome Archives of Internal Medicine DOI: 10.1001/archinternmed.2011.72