We think that Shaun Holt, Richard Beasley, and colleagues’ response regarding bupropion for smoking cessation (http://www.nzma.org.nz/journal/118-1217/1544/)1 still deserves an answer, as we are unaware of any evidence that bupropion is cost-effective compared with nortriptyline.

We agree with the raft of evidence, cited by the authors, that smoking cessation treatments can be highly cost-effective compared with other options for health spending. However, evidence does not yet extend to comparing bupropion with nortriptyline.

The one head-to-head trial2 showed no significant difference between nortriptyline and bupropion—so we don’t really know either way, which reflects uncertainty and different perspectives. Nortriptyline is neither proven as more or less effective as bupropion, nor bupropion proven as more effective than nortriptyline.

However, when nortriptyline is problematic for particular patients, bupropion as adjunctive smoking cessation treatment (versus nicotine replacement therapy alone) might be cost-effective relative to other treatments for other disease states—it would be good to see this quantified. Likewise with side effect profiles—it needs the analysis and would be worth pursuing, integrating the pharmacovigilance evidence around bupropion.3,4

We apologise for any offence, as our intent was not to personally criticise the authors. Although the discussions around the Cochrane Review5 were hindered by no mention of its evidence about nortriptyline,6 we needed to be much clearer on that point (our response missed out an important comma).

We will continue to disagree with authors’ conclusions. However, apart from price, the evidence is debatable7—this reflects different ways of looking at things, in the face of uncertainty. This will extend to other things that PHARMAC does or does not fund—where PHARMAC manages a set budget, so funding some things means not funding others. We welcome any new relevant evidence presented.

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