Bupropion for Smoking Cessation in Patients Hospitalized With Cardiovascular Disease: A Systematic Review and Meta-analysis of Randomized Controlled Trials

doi:10.1016/j.cjca.2013.09.014

Canadian Journal of Cardiology

Volume 29, Issue 12, December 2013, Pages 1704-1711

https://doi.org/10.1016/j.cjca.2013.09.014 Get rights and content

Abstract

Background

Smoking remains the most important modifiable risk factor for secondary prevention of cardiovascular events. We therefore performed a meta-analysis to determine the efficacy and safety of bupropion therapy started in-hospital for smoking cessation in patients with cardiovascular disease (CVD).

Methods

We systematically searched the medical literature to identify randomized controlled trials (RCTs) of in-hospital initiation of bupropion therapy for smoking cessation in patients with CVD. RCTs reporting smoking abstinence at 6 or 12 months were included.

Results

Three RCTs, including 773 patients, were included in our analyses. Participants were predominantly men (range of means, 69.0%-83.8%), and the majority were hospitalized with acute coronary syndrome (ACS) (range of means, 66%-100%). Treatment duration ranged from 8-12 weeks. At the end of treatment, bupropion was associated with a significant increase in point prevalence abstinence (relative risk [RR], 1.21; 95% confidence interval [CI], 1.02-1.45) but not continuous abstinence (RR, 1.19; 95% CI, 0.97-1.45). However, bupropion was not associated with a significant increase in point prevalence abstinence (RR, 1.17; 95% CI, 0.92-1.48) or continuous abstinence (RR, 1.16; 95% CI, 0.90-1.50) at 12 months. The results of the pooled analysis for major adverse cardiac and cerebrovascular events were inconclusive (RR, 1.28; 95% CI, 0.93-1.78).

Conclusions

We found that bupropion improved abstinence over placebo at the end of treatment but that this effect did not persist at 12 months. Because of inconsistent reporting of safety data, the safety profile of bupropion therapy in this patient population remains unclear.

Résumé

Introduction

Le tabagisme demeure le facteur de risque modifiable le plus important dans la prévention secondaire des événements cardiovasculaires. Nous avons donc réalisé une métaanalyse pour déterminer l’efficacité et l’innocuité du traitement par bupropione introduit à l’hôpital pour l’arrêt du tabagisme chez les patients ayant une maladie cardiovasculaire (MCV).

Méthodes

Nous avons cherché systématiquement la littérature médicale pour identifier les essais cliniques aléatoires (ECA) sur l’introduction du traitement par bupropione à l’hôpital pour l’arrêt du tabagisme chez les patients ayant une MCV. Les ECA rapportant l’abstinence tabagique à 6 ou à 12 mois ont été inclus.

Résultats

Trois (3) ECA, comprenant 773 patients, ont été inclus dans nos analyses. Les participants étaient de manière prédominante des hommes (étendue des moyennes, 69,0 %-83,8 %), et la majorité a été hospitalisée pour un syndrome coronarien aigu (SCA; étendue des moyennes, 66 %-100 %). La durée du traitement a varié de 8 à 12 semaines. À la fin du traitement, la bupropione a été associée à une augmentation significative de la prévalence ponctuelle de l’abstinence (risque relatif [RR], 1,21; intervalle de confiance [IC] à 95 %, 1,02-1,45), mais non de l’abstinence continue (RR, 1,19; IC à 95 %, 0,97-1,45). Cependant, la bupropione n’a pas été associée à une augmentation significative de la prévalence ponctuelle de l’abstinence (RR, 1,17; IC à 95 %, 0,92-1,48) ou de l’abstinence continue (RR, 1,16; IC à 95 %, 0,90-1,50) à 12 mois. Les résultats de l’analyse groupée des événements cardiaques et cérébrovasculaires indesirables majeurs ont été non concluants (RR, 1,28; IC à 95 %, 0,93-1,78).

Conclusions

Nous avons observé que la bupropione améliorait l’abstinence par rapport au placébo à la fin du traitement, mais que cet effet ne persistait pas à 12 mois. En raison de l’inconstance des rapports sur les données d’innocuité, on ignore le profil d’innocuité du traitement par bupropione chez cette population de patients.

Section snippets

Search strategy

We systematically searched the MEDLINE, EMBASE, and Cochrane Library databases from inception to August 12, 2012. Our search was not restricted by language or population to avoid excluding potentially relevant articles. We did, however, limit our search to studies conducted in humans. Our search strategy included the following keywords and Medical Subject Heading (MeSH) terms: smoking, smoking cessation, nicotine, tobacco, bupropion, Zyban, cardiovascular disease, coronary artery disease,

Description of included studies

A total of 773 patients, 381 patients receiving bupropion and 392 receiving placebo, were included in the analyses (Table 1). The treatment period varied across the 3 studies. All patients in the included studies received adjunct behavioural interventions. The intensity of these interventions varied across studies. The study by Rigotti et al. included an intense, multicomponent intervention,¹⁴ consisting of prevention counseling, videotapes, self-help material, and a chart prompt for physicians

Discussion

Our meta-analysis was designed to examine the efficacy and safety of in-hospital administration of bupropion therapy for patients with CVD. We found that bupropion improved abstinence over placebo at the end of treatment, but this effect did not persist at 12 months. Because of inconsistent reporting of safety data, the safety profile of bupropion therapy in this patient population remains unclear.

Previous studies have suggested that the period immediately after an admission for CVD may be a

Conclusions

Our study was designed to examine the long-term efficacy and safety of in-hospital administration of bupropion therapy in patients with CVD. We found that bupropion improved abstinence over placebo at the end of treatment but that this effect did not persist at 12 months. Because of inconsistent reporting of safety data, the safety profile of bupropion therapy in this patient population remains unclear.

Acknowledgements

M.J.E. had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. S.M.G. performed the analyses and drafted the manuscript. All authors contributed to the design and critical revision of the manuscript for intellectual content.

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Clinical Practice Guideline of Spanish Society of Pneumology and Thoracic Surgery (SEPAR) on Pharmacological Treatment of Tobacco Dependence 2023
2023, Archivos de Bronconeumologia
There are multiple systematic reviews and meta-analyses on the efficacy and safety of pharmacological treatments against nicotine dependence. However, there are few guidelines to answer frequent questions asked by a clinician treating a smoker. Therefore, the aim of this paper is to facilitate the treatment of tobacco addiction.
12 PICO questions are formulated from a GLOBAL PICO question: “Efficacy and safety of pharmacological treatment of tobacco dependence”. A systematic review was carried out to answer each of the questions and recommendations were made. The GRADE (Grading of Recommendations, Assessment, Development and Evaluation) system was used to grade the certainty of the estimated effects and the strength of the recommendations.
Varenicline, nicotine replacement therapy (NRT), bupropion and cytisine are more effective than placebo. Varenicline and combined nicotine therapy are superior to the other therapies. In smokers with high dependence, a combination of drugs is recommended, being more effective those associations containing varenicline. Other optimization strategies with lower efficacy consist of increasing the doses, the duration, or retreat with varenicline. In specific populations varenicline or NRT is recommended. In hospitalized, the treatment of choice is NRT. In pregnancy it is indicated to prioritize behavioral treatment. The financing of smoking cessation treatments increases the number of smokers who quit smoking. There is no scientific evidence of the efficacy of pharmacological treatment of smoking cessation in adolescents.
The answers to the 12 questions allow us to extract recommendations and algorithms for the pharmacological treatment of tobacco dependence.
Smoking Cessation After Surgery and Midterm Outcomes of Surgical Revascularization
2020, Annals of Thoracic Surgery
Citation Excerpt :
This implies that cardiologists and cardiac surgeons should pay special attention to the CS status of their patients and should take advantage of an evidence-based approach for smoking cessation. These approaches include brief clinical interventions (eg, a physician taking 10 minutes or less to deliver advice and assistance about quitting), counseling (eg, individual, group, or telephone counseling), behavioral cessation therapies (eg, training in problem-solving), treatments with more person-to-person contact and intensity, and pharmacotherapy (eg. nicotine replacement or other drugs like bupropion or varenicline),16,19-23 and psychosocial support.24 One of the major strengths of our study is its large sample size.
Although multiple studies have reported the devastating effect of cigarette smoking (CS) on short-term outcomes of patients who underwent coronary artery bypass grafting surgery (CABG), its effect on long-term outcomes is still questionable. We aimed to evaluate the long-term outcomes of CS cessation after CABG surgery.
This retrospective cohort study included all patients who underwent isolated CABG at our center between 2007 and 2016 and were cigarette smokers either just before or at the time of surgery. Patients were stratified into those who continued CS and those who were persistently CS abstinent after CABG. The endpoints of the study were 5-year mortality and 5-year major adverse cardiovascular and cerebrovascular events.
Of 28,945 patients who underwent isolated CABG, 9173 current cigarette smokers (93.5% men; mean age, 58.6 years) met our selection criteria and were included in the final analysis. Of these 3302 patients (40.0%) continued CS after surgery and 5688 patients were persistently abstinent. Multivariable survival analysis demonstrated that CS cessation after CABG, adjusted for major coronary risk factors, could reduce the 5-year mortality by 35% (hazard ratio, 0.65; 95% confidence interval, 0.54-0.77; P < .001) and 5-year major adverse cardiovascular and cerebrovascular events by 18% (hazard ratio, 0.82; 95% confidence interval, 0.74-0.92; P = .001).
Our study shows that CS abstinence after CABG significantly reduces long-term mortality and number of major adverse events. As a result, patients who smoke should be encouraged to participate in CS cessation programs after CABG surgery.
Smoking Cessation in Patients With Acute Coronary Syndrome
2018, American Journal of Cardiology
Citation Excerpt :
Overall, the absence of detectable treatment effects with bupropion may be due to a combination of small sample sizes and the increased motivation of patients to quit smoking after an acute cardiovascular event.5 However, the pooling of these data across trials in a 2013 meta-analysis30 found no significant difference in long-term abstinence between bupropion and placebo. Although this finding represents a small sample size, the available evidence suggests that bupropion may not be effective for smoking cessation in patients hospitalized after ACS.
Over 30% of the nearly 1 million North Americans hospitalized annually with an acute coronary syndrome (ACS) are smokers. Despite a substantially increased risk of morbidity and mortality, 2/3 of patients who quit smoking after ACS return to smoking within 1 year. To summarize the evidence of smoking cessation in patients hospitalized after ACS, we systematically reviewed all randomized controlled trials of pharmacologic and behavioral smoking cessation therapies in patients with ACS. In addition, we reviewed the clinical considerations surrounding the use of smoking cessation therapies, including their broad mechanisms of action and possible alternative treatments, including cardiac rehabilitation programs and electronic cigarettes. A total of 7 randomized controlled trials met our inclusion criteria (4 pharmacotherapies and 3 behavioral therapies). In pharmacologic trials, only varenicline increased point prevalence abstinence at 12 months. Behavioral interventions produced significantly improved abstinence rates at 6 and 12 months. However, these studies had substantial limitations affecting their generalizability. Overall, currently available smoking cessation therapies are limited in their efficacy in patients hospitalized after ACS. Because of the relative scarcity of data and the urgency of establishing clinical guidelines, there is a critical need to continue examining the efficacy and safety of smoking cessation interventions in patients hospitalized after ACS.
Guidelines for the Treatment of Smoking in Hospitalized Patients
2017, Archivos de Bronconeumologia
Citation Excerpt :
Interestingly, 2 of these studies were performed in patients who had been admitted for acute cardiovascular disease (myocardial ischaemia), and no short or long-term adverse cardiovascular effects appeared in the group of subjects that used bupropion, compared to the group that received standard care.18,19 These data were confirmed in a recent metaanalysis and in a new randomized, controlled clinical trial.20,21 A recent randomized, double-blind, controlled clinical trial examined the efficacy of a smoking treatment programme in a group of smokers who received intensive counselling for smoking cessation during admission, followed by continued counselling with automated interactive voice response telephone calls after discharge, as well as the treatment of their choice for a period of 3 months (NRT, bupropion or varenicline).
Between 15 and 27% of patients admitted to Spanish hospitals are smokers. Hospitalization is an ideal time for a smoker to decide to quit.
We performed a MEDLINE search of controlled, randomized or observational studies associated with helping hospitalized patients quit smoking, published between January 1, 2002 and September 30, 2015. On the basis of the results of those studies, we have issued some recommendations for the treatment of smoking in hospitalized patients. The recommendations were drawn up according to the GRADE system. Offering the smoker psychological counselling and prolonging follow-up for at least 4 weeks after discharge is the most effective recommendation for helping hospitalized patients to quit.
Entre el 15 y el 27% de los pacientes que ingresan en los hospitales españoles son consumidores de tabaco. La hospitalización es un momento idóneo para que el fumador se plantee el abandono del tabaco.
Se ha realizado una búsqueda bibliográfica en MEDLINE entre el 1 de enero de 2002 y el 30 de septiembre de 2015, de estudios, controlados y aleatorizados u observacionales, relacionados con la ayuda para dejar de fumar a pacientes ingresados en el hospital. Basándose en los resultados de dichos estudios se han emitido unas recomendaciones para el tratamiento del tabaquismo en pacientes hospitalizados. Las recomendaciones han sido formuladas de acuerdo con el sistema GRADE. Ofrecer al fumador asesoramiento psicológico más tratamiento farmacológico mientras está ingresado en el hospital y prolongar el seguimiento durante al menos 4 semanas después del alta es la recomendación más efectiva para ayudar a dejar de fumar a los pacientes ingresados.
The impact of smoking on long-term outcome of patients with premature (≤35 years) ST-segment elevation acute myocardial infarction
2015, American Heart Journal
Citation Excerpt :
A meta-analysis24 of 10 smoking cessation intervention studies in coronary patients showed a 50% increase in quitting rate with intervention. More recent studies have shown a higher success rate in quitting smoking with pharmacologic smoking cessation interventions,26 although recent studies questioned the effectiveness of bupropion for smoking cessation in post-AMI patients.27,28 In our study, there was an in-hospital smoking cessation counseling, but after discharge, there was no specific smoking cessation program as part of a rehabilitation program.
There are few data regarding the long-term prognosis of young survivors of acute myocardial infarction (AMI). We explored the long-term outcome in individuals who had sustained a premature ST-segment elevation AMI.
We recruited 257 consecutive patients who had survived their first AMI ≤35 years of age. Patients were followed up for up to 18 years. Clinical end points included all major adverse coronary events (MACE): cardiac death, readmission for acute coronary syndrome, arrhythmias, or coronary revascularization due to clinical deterioration.
The most prevalent risk factor at presentation was smoking (93.7%). Follow-up data were obtained from 237 patients (32.2 ± 3.7 years old). The median follow-up period was 9.1 years. During follow-up, 139 (58.6%) patients reported continuation of smoking. Ninety-one (38.4%) patients had recurrent MACE (13 deaths, 59 acute coronary syndromes, 2 arrhythmias, and 17 revascularizations). Multivariable Cox regression analysis showed that persistence of smoking, left ventricular ejection fraction (LVEF), and reperfusion therapy (fibrinolysis or primary coronary angioplasty) were independent predictors of MACE after adjustment for conventional risk factors. Continuation of smoking remained an independent predictor for MACE after additional adjustments for LVEF (hazard ratio 2.154, 95% CI 1.313-3.535, P = .002) or reperfusion treatment (hazard ratio 2.327, 95% CI 1.423-3.804, P = .001). Harrell c statistic showed that the model with persistent smoking had the best discriminatory power compared with models with LVEF or reperfusion treatment.
In the era of statins and reperfusion treatment, continuation of smoking is the strongest independent long-term predictor for recurrent MACE in young survivors of premature AMI.
Stimulant mechanisms of cathinones - Effects of mephedrone and other cathinones on basal and electrically evoked dopamine efflux in rat accumbens brain slices
2014, Progress in Neuro-Psychopharmacology and Biological Psychiatry
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Bupropion is also considered to have low abuse liability in humans where most studies do not see significant changes in behaviour, subjective liking or physiology (see review by Lile and Nader, 2003). Bupropion is an antidepressant, now used mostly for smoking cessation (Grandi et al., 2013) and has been extensively examined neurochemically using microdialysis. Our data, showing a 4-fold increase in dopamine efflux are in broad agreement with microdialysis studies where bupropion was administered acutely to the rat dorsal striatum (Santamaria and Arias, 2010).
Mephedrone, an erstwhile “legal high”, and some non-abused cathinones (ethcathinone, diethylpropion and bupropion) were tested for stimulant effects in vitro, through assessing their abilities to increase basal and electrically evoked dopamine efflux in rat accumbens brain slices, and compared with cocaine and amphetamine. We also tested mephedrone against cocaine in a dopamine transporter binding study.
Dopamine efflux was electrically evoked and recorded using voltammetry in the rat accumbens core. We constructed concentration response curves for these cathinones for effects on basal dopamine levels; peak efflux after local electrical stimulation and the time-constant of the dopamine decay phase, an index of dopamine reuptake. We also examined competition between mephedrone or cocaine and [¹²⁵I]RTI121 at the dopamine transporter.
Mephedrone was less potent than cocaine at displacing [¹²⁵I]RTI121. Mephedrone and amphetamine increased basal levels of dopamine in the absence of electrical stimulation. Cocaine, bupropion, diethylpropion and ethcathinone all increased the peak dopamine efflux after electrical stimulation and slowed dopamine reuptake. Cocaine was more potent than bupropion and ethcathinone, while diethylpropion was least potent. Notably, cocaine had the fastest onset of action.
These data suggest that, with respect to dopamine efflux, mephedrone is more similar to amphetamine than cocaine. These findings also show that cocaine was more potent than bupropion and ethcathinone while diethylpropion was least potent. Mephedrone’s binding to the dopamine transporter is consistent with stimulant effects but its potency was lower than that of cocaine. These findings confirm and further characterize stimulant properties of mephedrone and other cathinones in adolescent rat brain.

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Systematic Review/Meta-analysisBupropion for Smoking Cessation in Patients Hospitalized With Cardiovascular Disease: A Systematic Review and Meta-analysis of Randomized Controlled Trials

Abstract

Background

Methods

Results

Conclusions

Résumé

Introduction

Méthodes

Résultats

Conclusions

Section snippets

Search strategy

Description of included studies

Discussion

Conclusions

Acknowledgements

Am J Cardiol

Am Heart J

Am J Med

J Am Coll Cardiol

Respir Med

Defining and setting national goals for cardiovascular health promotion and disease reduction: the American Heart Association's strategic Impact Goal through 2020 and beyond

Circulation

Smoking cessation for the secondary prevention of coronary heart disease

Cochrane Database Syst Rev

Effect of smoking cessation on mortality after myocardial infarction: meta-analysis of cohort studies

Arch Intern Med

Smoking status and risk for recurrent coronary events after myocardial infarction

Ann Intern Med

Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline

Risk of serious adverse cardiovascular events associated with varenicline: a systematic review and meta-analysis

CMAJ

Risk of cardiovascular serious adverse events associated with varenicline use for tobacco cessation: systematic review and meta-analysis

BMJ

Bupropion SR for smoking cessation in smokers with cardiovascular disease: a multicentre, randomised study

Eur Heart J

Systematic Review/Meta-analysis
Bupropion for Smoking Cessation in Patients Hospitalized With Cardiovascular Disease: A Systematic Review and Meta-analysis of Randomized Controlled Trials