Combination Smoking Cessation Therapy Increases Abstinence Rates in Teens

Deborah Brauser

November 02, 2009

November 2, 2009 ( UPDATED November 11, 2009 ) (Honolulu, Hawaii) — A combination of bupropion standard release (SR) and contingency management (CM) can lead to increased rates of smoking cessation in adolescents, at least in the short term, and is superior to either of the treatments alone or placebo, according to a new study presented here at the American Academy of Child & Adolescent Psychiatry 56th Annual Meeting.

"There is a real need for evidence-based treatments for nicotine-dependent adolescents, especially since most adult smokers started smoking as adolescents," lead author Kevin M. Gray, MD, child and adolescent psychiatrist, and assistant professor at the Medical University of South Carolina in Charleston, told Medscape Psychiatry.

Dr. Kevin Gray

"What we found in our study was that basically, the combination treatment of bupropion SR and [CM] beat the single treatments, at least in the acute setting, for smoking cessation in adolescents."

First Study of Combination Therapy

Although past studies have suggested a potential role for bupropion SR and for CM as treatments for smoking cessation, no prior studies have assessed the combined effects of these interventions.

"There isn't really a lot of encouraging data to date in terms of how to treat adolescent smokers," reported Dr. Gray. "So we wanted to look, in a very structured way, at a combination of medication and psychosocial treatment, as well as each treatment alone."

In this study, Dr. Gray and his team evaluated these effects in a 6-week active treatment trial, with a final posttreatment follow-up at 12 weeks.

They enrolled 134 adolescent smokers 14 to 21 years old who were randomly assigned to 1 of 4 treatment arms:

  • Bupropion SR 150 mg twice daily, as tolerated (n = 36)

  • Bupropion SR (same dosage) plus CM (n = 37)

  • Placebo plus CM (n = 29)

  • Placebo only (n = 32)

The CM consisted of escalating cash compensation reinforcement, based on biologically verified abstinence at twice-weekly visits during the treatment period.

"In addition, all participants selected a quit date within the first 2 weeks of treatment, giving a 2-week grace period before we started recording results," said Dr. Gray.

The main outcome was a 7-day biologically verified (through urine cotinine) point prevalence abstinence evaluated weekly.

Odds of Abstinence Tripled

The final results revealed that bupropion SR plus CM was significantly superior to the placebo for abstinence rates during all active treatment points (odds ratios [OR], 5.9 for week 1 [after the 2-week grace period], 3.3 for week 2, 4.1 for week 3, and 3.6 for week 4; P < .05 for all). However, the treatment only had an OR of 1.8 at follow-up.

Those treated with the bupropion SR plus CR combination were also found to have significantly greater abstinence rates vs bupropion alone at weeks 1 (OR, 2.5), 2 (OR, 3.0), and 4 (OR, 4.1), but not at week 3 or follow-up.

In addition, the bupropion SR plus CM group was deemed superior to the placebo plus CM group at weeks 1 (OR, 5.3), 2 (OR, 5.3), and 3 (OR, 3.7), but not at week 4 or at follow-up.

"Results support the efficacy of bupropion SR and [CM] for smoking cessation in adolescents," said Dr. Gray. "This combined treatment was well tolerated and acutely efficacious, more than tripling the odds of abstinence throughout active treatment, making it one to watch, at least in the short-term."

However, he reported that limitations included participant retention limiting the power to detect between-group differences, particularly at later time points.

"Further work is obviously needed to determine the long-term efficacy of this treatment approach," said Dr. Gray.

He suggested that future studies should consider incorporating a larger sample size, a longer course of active treatment, and "added techniques to enhance participant retention in order to attain adequate power for long-term treatment comparisons."

Important Public Health Implications

"I think this study is very well conducted and the results are very interesting," said Dr. Ivan Montoya, MD, MPH, acting deputy director of the Division of Pharmacotherapies and Medical Consequences of Drug Abuse at the National Institute on Drug Abuse in Bethesda, Maryland.

"The fact that they found that bupropion [SR] plus contingency management is so advantageous in terms of efficacy in this population, particularly in adolescents, is a very important result and has important public health implications," said Dr. Montoya, who was not involved in the study.

"Based on these results, I would recommend that clinicians who treat adolescents who smoke consider using bupropion plus [CM] as the first-line treatment," he added. "There is no question that there was a very synergistic effect between the medication and the intervention."

Dr. Montoya said that it can be challenging to conduct smoking cessation studies in adolescents, "so it's really an accomplishment that they did this one with such a large sample size."

Next, he would like to see how varenicline, another medication that has been approved for smoking cessation, compares with bupropion in this patient population.

Dr. Gray and Dr. Montoya have disclosed no relevant financial relationships.

American Academy of Child & Adolescent Psychiatry 56th Annual Meeting: Abstract 2.26. Presented October 28, 2009.

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