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Combination Therapies for Smoking Cessation

A Hierarchical Bayesian Meta-Analysis
  • Sarah B. Windle
    Affiliations
    Division of Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital/McGill University, Montreal, Quebec, Canada
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  • Kristian B. Filion
    Affiliations
    Division of Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital/McGill University, Montreal, Quebec, Canada

    Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada
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  • Joseph G. Mancini
    Affiliations
    Division of Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital/McGill University, Montreal, Quebec, Canada
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  • Lauren Adye-White
    Affiliations
    Division of Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital/McGill University, Montreal, Quebec, Canada
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  • Lawrence Joseph
    Affiliations
    Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada

    Division of Clinical Epidemiology, McGill University Health Centre, Montreal, Quebec, Canada

    Research Institute, McGill University Health Centre, McGill University, Montreal, Quebec, Canada
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  • Genevieve C. Gore
    Affiliations
    Schulich Library of Science and Engineering, McGill University, Montreal, Quebec, Canada
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  • Bettina Habib
    Affiliations
    Division of Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital/McGill University, Montreal, Quebec, Canada
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  • Roland Grad
    Affiliations
    Herzl Family Practice Centre, Jewish General Hospital, Montreal, Quebec, Canada

    Department of Family Medicine, McGill University, Montreal, Quebec, Canada
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  • Louise Pilote
    Affiliations
    Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada

    Division of Clinical Epidemiology, McGill University Health Centre, Montreal, Quebec, Canada

    Division of General Internal Medicine, McGill University Health Centre, Montreal, Quebec, Canada
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  • Mark J. Eisenberg
    Correspondence
    Address correspondence to: Mark J. Eisenberg, MD, MPH, Divisions of Cardiology and Clinical Epidemiology, Jewish General Hospital/McGill University, 3755 Côte Ste-Catherine Road, Suite H-421.1, Montreal, Quebec, Canada H3T 1E2
    Affiliations
    Division of Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital/McGill University, Montreal, Quebec, Canada

    Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada

    Division of Cardiology, Jewish General Hospital, Montreal, Quebec, Canada
    Search for articles by this author
Published:September 09, 2016DOI:https://doi.org/10.1016/j.amepre.2016.07.011

      Context

      Treatment guidelines recommend the use of combination therapies for smoking cessation, particularly behavioral therapy (BT) as an adjunct to pharmacotherapy. However, these guidelines rely on previous reviews with important limitations. This study’s objective was to evaluate the efficacy of combination therapies compared with monotherapies, using the most rigorous data available.

      Evidence acquisition

      A systematic review and meta-analysis of RCTs of pharmacotherapies, BTs, or both were conducted. The Cochrane Library, Embase, PsycINFO, and PubMed databases were systematically searched from inception to July 2015. Inclusion was restricted to RCTs reporting biochemically validated abstinence at 12 months. Direct and indirect comparisons were made in 2015 between therapies using hierarchical Bayesian models.

      Evidence synthesis

      The search identified 123 RCTs meeting inclusion criteria (60,774 participants), and data from 115 (57,851 participants) were meta-analyzed. Varenicline with BT increased abstinence more than other combinations of a pharmacotherapy with BT (varenicline versus bupropion: OR=1.56, 95% credible interval [CrI]=1.07, 2.34; varenicline versus nicotine patch: OR=1.65, 95% CrI=1.10, 2.51; varenicline versus short-acting nicotine-replacement therapies: OR=1.68, 95% CrI=1.15, 2.53). Adding BT to any pharmacotherapy compared with pharmacotherapy alone was inconclusive, owing to wide CrIs (OR=1.17, CrI=0.60, 2.12). Nicotine patch with short-acting nicotine-replacement therapy appears safe and increases abstinence versus nicotine-replacement monotherapy (OR=1.63, CrI=1.06, 3.03). Data are limited concerning other pharmacotherapy combinations and their safety and tolerability.

      Conclusions

      Evidence suggests that combination therapy benefits may be less than previously thought. Combined with BT, varenicline increases abstinence more than other pharmacotherapy with BT combinations.
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