Nicotine patch plus lozenge appears best for smoking cessation

November 02, 2009

In a comparison of five different smoking cessation medications, a nicotine patch plus a nicotine lozenge appears most effective at helping smokers quit, according to a report in the November issue of Archives of General Psychiatry, one of the JAMA/Archives journals.

"Many smokers have successfully quit using a variety of smoking cessation pharmacotherapies, yet there is little direct evidence on the relative efficacies of these different pharmacotherapies," the authors write as background information in the article. "Without such evidence clinicians and smokers lack a strong empirical basis for recommending or selecting among them."

Megan E. Piper, Ph.D., of the University of Wisconsin Center for Tobacco Research and Intervention, Madison, and colleagues conducted a randomized clinical trial of smoking cessation therapies involving 1,504 adults. All had smoked at least 10 cigarettes a day during the previous six months and were motivated to quit. Participants were randomly assigned to one of six treatment groups: nicotine lozenge alone, nicotine patch alone, bupropion alone, patch plus nicotine lozenge, bupropion plus nicotine lozenge or placebo. Bupropion treatment began one week before a designated quit date and continued for eight weeks; all other treatments were taken for eight to 12 weeks after the quit date. All participants also received six individual counseling sessions.

Smoking rates were assessed one week, eight weeks and six months after the quit date. When all the treatments were compared at the six-month point, only the individuals in the patch plus nicotine lozenge group were more successful in quitting than those taking placebo. Smokers using a patch and nicotine lozenge were also more likely to have quit at seven days and tended to have other more positive outcomes, such as a longer period of time before relapsing. In addition, this combination along with the patch alone were most effective at helping people achieve at least one day of abstinence from smoking, an important stepping stone to successful quitting.

Previous research has combined the patch with other nicotine replacement therapies, such as gum, nasal spray or an inhaler. "The present results suggest that the nicotine lozenge can also be effective as an adjuvant [additional treatment] to the nicotine patch," the authors write. "The key seems to be that an ad libitum, or as needed, agent must be paired with the patch; simply using higher patch doses does not seem to augment outcomes to the same degree." The lozenge, though effective with the patch, did not appear to work any better than placebo when used alone.

All of the interventions appeared safe and well tolerated, the authors note. Only four of 1,504 participants withdrew from the study for medication-related reasons.

"These findings plus recent meta-analyses published in the 2008 Public Health Service Guideline Update suggest that a combination pharmacotherapy comprising the nicotine patch and an ad libitum nicotine replacement therapy should be routinely considered for use as a smoking cessation treatment," the authors write. "In addition, this study illustrates that after more than 20 years the patch remains a highly efficacious pharmacotherapy for helping people quit smoking."
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(Arch Gen Psychiatry. 2009;66[11]:1253-1262. Available pre-embargo to the media at www.jamamedia.org.)

Editor's Note: This research was conducted at the University of Wisconsin-Madison and was supported by a grant from the National Institute on Drug Abuse and a grant from the General Clinical Research Centers Program of the National Center for Research Resources. Dr. Piper was supported by an Institutional Clinical and Translational Science Award, University of Wisconsin-Madison. Medication was provided to patients at no cost under a research agreement with GlaxoSmithKline. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.

The JAMA Network Journals

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