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Pharmacotherapies for smoking cessation: a meta-analysis of randomized controlled trials

From the Divisions of Cardiology and Clinical Epidemiology (Eisenberg, Filion, Yavin, Mottillo), Sir Mortimer B. Davis Jewish General Hospital and McGill University; the Department of Epidemiology, Biostatistics and Occupational Health (Eisenberg, Filion, Joseph, Paradis, Pilote), McGill University; the Division of Clinical Epidemiology (Filion, Bélisle, Joseph, Pilote), McGill University Health Centre; Agence de la santé et des services sociaux (Gervais), Direction de santé publique; Centre de recherche (O'Loughlin) and Division of Cardiology (Rinfret), Centre hospitalier de l'Université de Montréal; the Department of Social and Preventive Medicine (O'Loughlin), University of Montreal; and the Division of Internal Medicine (Pilote), McGill University Health Centre, Montréal, Que.

Correspondence to: Dr. Mark J. Eisenberg, Divisions of Cardiology and Clinical Epidemiology, Sir Mortimer B. Davis Jewish General Hospital, Ste. A-118, 3755 Cote Ste-Catherine Rd., Montréal QC H3T 1E2; fax 514 340-7564; mark.eisenberg{at}mcgill.ca

Background: Many placebo-controlled trials have demonstrated the efficacy of individual pharmacotherapies approved for smoking cessation. However, few direct or indirect comparisons of such interventions have been conducted. We performed a meta-analysis to compare the treatment effects of 7 approved pharmacologic interventions for smoking cessation.

Methods: We searched the US Centers for Disease Control and Prevention's Tobacco Information and Prevention database as well as MEDLINE, EMBASE and the Cochrane Library for published reports of placebo-controlled, double-blind randomized controlled trials of pharmacotherapies for smoking cessation. We included studies that reported biochemically validated measures of abstinence at 6 and 12 months. We used a hierarchical Bayesian random-effects model to summarize the results for each intervention.

Results: We identified 70 published reports of 69 trials involving a total of 32 908 patients. Six of the 7 pharmacotherapies studied were found to be more efficacious than placebo: varenicline (odds ratio [OR] 2.41, 95% credible interval [CrI] 1.91–3.12), nicotine nasal spray (OR 2.37, 95% CrI 1.12–5.13), bupropion (OR 2.07, 95% CrI 1.73–2.55), transdermal nicotine (OR 2.07, 95% CrI 1.69–2.62), nicotine tablet (OR 2.06, 95% CrI 1.12–5.13) and nicotine gum (OR 1.71, 95% CrI 1.35–2.21). Similar results were obtained regardless of which measure of abstinence was used. Although the point estimate favoured nicotine inhaler over placebo (OR 2.17), these results were not conclusive because the credible interval included unity (95% CrI 0.95–5.43). When all 7 interventions were included in the same model, all were more efficacious than placebo. In our analysis of data from the varenicline trials that included bupropion control arms, we found that varenicline was superior to bupropion (OR 2.18, 95% CrI 1.09–4.08).

Interpretation: Varenicline, bupropion and the 5 nicotine replacement therapies were all more efficacious than placebo at promoting smoking abstinence at 6 and 12 months.

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