New smoking cessation guidelines are published this month in Thorax. They recommend that amfebutamone (bupropion, Zyban) and nicotine replacement therapies (NRT) should be available on the National Health Service.
The guidelines, funded by the Health Development Agency, state that pharmacists can be effective in aiding smoking cessation by providing a structured package of behavioural support and NRT.
At a press conference on November 21, one of the authors of the guidelines, Dr Ann McNeill (freelance public health consultant) said that the guidelines summarised the most up-to-date scientific evidence for smoking cessation and aimed to help health professionals be more effective in helping patients to quit. She said that the guidelines "emphasise the importance of effective pharmacological treatments such as bupropion and nicotine replacement therapies and recommend that both should be available on the National Health Service”. She added that they "stress the importance and effectiveness of advice and support from health professionals, such as doctors and pharmacists, and recommend how this support can be optimised”.
Details of the guidelines were discussed by Professor Robert West (guidelines co-author and professor of psychology, St George's hospital, London) at a smoking cessation workshop following the press conference.
NRT was an effective aid for smoking cessation in smokers of more than 10 cigarettes a day but there was little evidence of differences between NRT products overall, he said. NRT appeared to be safe in most cases of cardiovascular disease, but approval was needed from a patient's physician if the disease was acute or poorly controlled. The guidelines state that, in pregnancy, the effects of NRT on the foetus are unknown but that it is almost certainly safer than smoking. Professor West said that NRT should only be used in pregnancy if it was known that the woman would not stop smoking without it.
Evidence for amfebutamone was included in the updated guidelines. There was data to suggest that it was an effective aid to smoking cessation but this was limited to medium to heavy smokers who also received behavioural support. The drug had a small risk of serious adverse events, including a risk of seizures broadly similar to other antidepressants of one in 1,000.
According to the guidelines, there was insufficient evidence to recommend either amfebutamone or NRT over the other. The guidelines state: "They are both effective and cost-effective life-
preserving treatments and making one available on the NHS and the other not available on the NHS is unreasonable and likely to cause problems in the delivery of services where only NRT or only bupropion is available.”
In terms of combination therapies, it appeared that combining a nicotine patch with other forms of NRT was more effective than a patch alone and was safe. Insufficient evidence meant that no recommendation could be made on the use of NRT and amfebutamone in combination.
An earlier edition of the smoking cessation guidelines was published in 1998. The new guidelines were not designed to replace the original ones but to provide clarification and detail and to include new evidence, Professor West said. The guidelines have been endorsed by the Royal Pharmaceutical Society (Thorax 2000;55:987).
Coinciding with the publication is the launch of a World Health Organisation (WHO) campaign to encourage smokers to seek professional help when they want to quit. The WHO campaign is based on posters that will be distributed for display in pharmacies and surgeries. The posters depict images on the theme of quitting smoking and contain the words "if you want to stop smoking, ask how”.