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Evidence summaries

Combined Nicotine Replacement Therapy for Smoking Cessation

Combination therapy with a patch and a rapid delivery form of nicotine replacement therapy increases abstinence compared with monotherapy in smoking cessation. Level of evidence: "A"

Summary

A Cochrane review [Abstract] 1 included 9 studies with a total of 4664 subjects. Combining a nicotine patch with a rapid delivery form (gum, nasal spray, inhaler) of nicotine replacement therapies (NRT) was more effective than a single type of NRT (RR 1.34, 95% CI 1.18 to 1.51; 9 trials, n=4664).

In a RCT 2 a total of 1346 patients (from 12 clinics) attending a routine primary care appointment, were randomly assigned to 5 active pharmacotherapies: 3 monotherapies (nicotine patch, nicotine lozenge, and bupropion hydrochloride sustained release) and 2 combination therapies (patch + lozenge and bupropion + lozenge). Patients were referred to a telephone quit line for cessation counselling. Medication was free. Six-month self-reported abstinence rates were: bupropion 16.8%; lozenge 19.9%; patch 17.7%; patch + lozenge 26.9%; and bupropion + lozenge 29.9%. Combination therapies were clearly superior to all of the monotherapies.

Another Cochrane review [Abstract] 2 included a network meta-analysis of 12 treatment-specific reviews (267 studies) involving 101804 participants. NRT was superior to placebo (odds ratios (OR) 1.84; 95% credible interval (CredI) 1.71 to 1.99, 119 trials). Varenicline was superior to single forms of NRT (OR 1.57; 95% CredI 1.29 to 1.91; indirect comparison), but was not more effective than combination NRT (OR 1.06; 95% CredI 0.75 to 1.48; indirect comparison). Combination NRT also outperformed single formulations. The four categories of NRT performed similarly against each other, apart from 'other' NRT, which was marginally more effective than NRT gum (OR 1.21; 95% CredI 1.01 to 1.46; indirect comparison).

Another Cochrane review [Abstract] 4 included 68 trials with a total of 43 327 subjects. Combination NRT (fast-acting form + patch) results in higher long-term quit rates than single form (RR 1.27, 95% CI 1.17 to 1.37; I²=12%; 16 studies, n=12 169). 21 mg patches are more effective than 14 mg (24-hour) patches (RR 1.48, 95% CI 1.06 to 2.08; 1 study, n=537).

A review and meta-analysis 5 included 19488 smoking subjects. The combination of medication and behavioral counseling was associated with a quit rate of 15.2% over 6 months compared with a quit rate of 8.6% with brief advice or usual care. Combining a nicotine patch with other NRT products was more effective than use of a single NRT product. Combining drugs with different mechanisms of action, such as varenicline and NRT, had increased quit rates in some studies compared with use of a single product. The combination of a clinician's brief advice to quit and assistance to obtain tobacco cessation treatment is effective when routinely administered to tobacco users in virtually all health care settings.

Date of latest search: 2023-11-06

    References

    • Stead LF, Perera R, Bullen C et al. Nicotine replacement therapy for smoking cessation. Cochrane Database Syst Rev 2012;(11):CD000146 (Last assessed as up-to-date: 19 September 2012). [PubMed]
    • Smith SS, McCarthy DE, Japuntich SJ et al. Comparative effectiveness of 5 smoking cessation pharmacotherapies in primary care clinics. Arch Intern Med 2009;169(22):2148-55. [PubMed]
    • Cahill K, Stevens S, Perera R et al. Pharmacological interventions for smoking cessation: an overview and network meta-analysis. Cochrane Database Syst Rev 2013;(5):CD009329. [PubMed]
    • Theodoulou A, Chepkin SC, Ye W et al. Different doses, durations and modes of delivery of nicotine replacement therapy for smoking cessation. Cochrane Database Syst Rev 2023;6(6):CD013308.[PubMed]
    • Rigotti NA, Kruse GR, Livingstone-Banks J et al. Treatment of Tobacco Smoking: A Review. JAMA 2022;327(6):566-577. [PubMed]

Primary/Secondary Keywords