1. Meta-analysis of Effectiveness of First-Line Smoking Cessation Pharmacotherapies 6 Months After Quitting
Medication
Estimated OR
(95% CI)
Est. abstinence rate
Placebo
1.0
13.8
Monotherapy
Nicotine gum (6-14 weeks)
1.5 ( )
19.0 ( )
Nicotine patch (6-14 weeks)
1.9 ( )
23.4 ( )
Long-term nicotine patch (>14 weeks)
1.9 ( )
23.7 ( )
Bupropion SR
2.0 ( )
24.2 ( )
Nicotine inhaler
2.1 ( )
24.8 ( )
Varenicline (1 mg/day)
2.1 ( )
25.4 ( )
Long-term nicotine gum (>14 weeks)
2.2 ( )
26.1 ( )
High-dose nicotine patch (>25 mg)*
2.3 ( )
26.5 ( )
Nicotine nasal spray*
26.7 ( )
Varenicline (2 mg/day)
3.1 ( )
33.2 ( )
Combination therapy
Nicotine patch + inhaler**
2.2 ( )
25.8 ( )
Nicotine patch + bupropion
2.5 ( )
28.9 ( )
Nicotine patch (>14 weeks) + ad lib gum or spray*
3.6 ( )
36.5 ( )
Speaker’s Notes
This slide presents the odds ratios for efficacy of first-line therapies at six months after quitting based on meta-analyses conducted for the United States Public Health Service guideline.
Compared with placebo, all of these pharmacotherapies are more effective at reducing smoking six months after quitting, though adherence to the full duration of therapy is necessary for best results and in some cases longer duration of treatment appears to be associated with greater effectiveness, as with nicotine gum. However, it should be noted that treatment length was not specifically indicated for all studies included in this meta-analysis and may differ from that suggested in the product monographs.
The recommended dose (2 mg/day) of the 42 nicotinic acetylcholine receptor partial agonist varenicline has the highest OR (3.1 vs. placebo) of all the monotherapies evaluated, though it should be noted these ORs were derived from meta-analyses and should not be used for direct comparison
Certain combinations of first-line therapies, including long-term patch plus ad lib NRT (gum or spray), patch plus bupropion and patch plus inhaler, have also been shown to be effective and warrant consideration in patients wanting to quit smoking, particularly those who are highly dependent on nicotine or who have a history of severe withdrawal symptoms. Decisions regarding combination therapy should take into consideration patient preferences regarding adverse effects, cost, etc.
Both the patch plus gum and bupropion plus patch combinations have been approved by Health Canada. Neither the inhaler plus patch combination nor the varenicline plus NRT combination are approved in Canada. In fact, because of its mechanism of action, the addition of NRT to varenicline is not expected to result in increased efficacy.
Reference
Fiore MC et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Available at: Accessed: July 20, 2010.
OR=Odds Ratio
*Fiore MC et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Available at: Accessed: July 20, 2010. 1