To the Editor: Sustained-release bupropion is reported to be superior to placebo for smoking cessation in smokers without a current psychiatric illness (1). We report a case of successful smoking cessation in a man with schizophrenia in which sustained-release bupropion was used in addition to clozapine.
Mr. A was a 41-year-old man with a 20-year history of chronic, undifferentiated schizophrenia who had smoked three to five packs of cigarettes a day for 11 years. Two years of individual cognitive behavioral and motivational enhancement treatment resulted in only transient, limited reduction in cigarette use. In the 3 months preceding Mr. A’s trial of sustained-release bupropion, he brought 100–157 empty cigarette packs per month to the clinic; the carbon monoxide in his expired air was 54 ppm. Nicotine replacement therapy was contraindicated because of multiple cardiovascular risk factors, combined with inability to reliably agree to reduce cigarette use while using nicotine replacement therapy. One week after starting sustained-release bupropion, at a dose of 150 mg/day, he reported that he no longer had such a strong urge to smoke and stopped smoking entirely; 3 months later, the carbon monoxide in his expired air measured 3 ppm. During this period, his clozapine dose was gradually decreased from 550 to 300 mg/day, and he reported less sedation and drooling and appeared more alert and less disheveled. His psychotic symptoms remained under control, his weight remained unchanged, and he began his first paying job in 18 years. He discontinued the sustained-release bupropion after 7 months and remained abstinent from smoking at 11 months.
The prevalence of smoking in schizophrenic patients is 74%–92% (2, 3). In published reports of smoking cessation trials in schizophrenia, the 6-month cessation rate was only 12%–13% with group therapy alone (4) or in combination with nicotine reduction therapy (5). Patients with schizophrenia may have more difficulty with smoking cessation for various reasons. Smoking lowers serum medication levels and reduces parkinsonian side effects (3). More fundamentally, nicotine has been shown to modulate both dopaminergic and glutamatergic transmission and may also improve cognitive deficits and negative symptoms by this mechanism. Any intervention that improves smoking cessation in patients with schizophrenia warrants further investigation because it has important public health implications and may improve our understanding of the role of nicotine in schizophrenia.