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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 (2009;66:1253-1262).


"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," wrote the authors, led by Megan E. Piper, PhD, of the University of Wisconsin Center for Tobacco Research and Intervention. "Without such evidence clinicians and smokers lack a strong empirical basis for recommending or selecting among them."


The randomized clinical trial of smoking-cessation therapies included 1,504 adults, all of whom 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, considered to be an important stepping stone to successful quitting.


Previous research, a news release notes, 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 to the nicotine patch," Dr. Piper and her colleagues said.


"The key seems to be that an ad libitum 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, with only four of 1,504 participants withdrawing 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 researchers concluded.


"In addition, this study illustrates that after more than 20 years the patch remains a highly efficacious pharmacotherapy for helping people quit smoking."