There is a great deal of evidence that smoking cessation medications increase the success of a quit smoking attempt.1–4 The 2008 Update to the Public Health Service (PHS) Treating Tobacco Use and Dependence Clinical Practice Guideline found that five nicotine replacement therapies (NRT’s) and two non-nicotine replacement first-line pharmacotherapies (bupropion SR, varenicline) reliably increase abstinence rates relative to a placebo control.1 However, less is known about the relative efficacies of these medications. This limitation is due, in part, to a lack of clinical trials that provide “head-to-head” comparisons of different pharmacotherapies within the same study. Cessation studies of individual medications differ in myriad respects which makes it difficult to gauge effectiveness across treatments, even when the individual studies contain a placebo control for the medication. Meta-analyses that attempt to account for interstudy differences may yield conclusions that conflict markedly with large-scale head-to-head trials.5 Without evidence based on head-to-head comparisons, clinicians and smokers lack a strong empirical basis for recommending or selecting from amongst the available smoking cessation medications. Finally, the small number of studies offering head-to-head comparisons yield some conflicting evidence.6, 7
