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Stevens S. Smith, PhD; Danielle E. McCarthy, PhD; Sandra J. Japuntich, PhD; Bruce Christiansen, PhD; Megan E. Piper, PhD; Douglas E. Jorenby, PhD; David L. Fraser, MS; Michael C. Fiore, MD, MPH; Timothy B. Baker, PhD; Thomas C. Jackson, MD

Arch Intern Med. 2009;169(22):2148-2155.

Background  Randomized efficacy clinical trials conducted in research settings may not accurately reflect the benefits of tobacco dependence treatments when used in real-world clinical settings. Effectiveness trials (eg, in primary care settings) are needed to estimate the benefits of cessation treatments in real-world use.

Methods  A total of 1346 primary care patients attending routine appointments were recruited by medical assistants in 12 primary care clinics. Patients were randomly assigned to 5 active pharmacotherapies: 3 monotherapies (nicotine patch, nicotine lozenge, and bupropion hydrochloride sustained release [SR]) and 2 combination therapies (patch + lozenge and bupropion SR + lozenge). Patients were referred to a telephone quit line for cessation counseling. Primary outcomes included 7-day point prevalence abstinence at 1 week, 8 weeks, and 6 months after quitting and number of days to relapse.

Results  Among 7128 eligible smokers (10 cigarettes per day) attending routine primary care appointments, 1346 (18.9%) were enrolled in the study. Six-month abstinence rates for the 5 active pharmacotherapies were the following: bupropion SR, 16.8%; lozenge, 19.9%; patch, 17.7%; patch + lozenge, 26.9%; and bupropion SR + lozenge, 29.9%. Bupropion SR + lozenge was superior to all of the monotherapies (odds ratio, 0.46-0.56); patch + lozenge was superior to patch and bupropion monotherapies (odds ratio, 0.56 and 0.54, respectively).

Conclusions  One in 5 smokers attending a routine primary care appointment was willing to make a serious quit attempt that included evidence-based counseling and medication. In this comparative effectiveness study of 5 tobacco dependence treatments, combination pharmacotherapy significantly increased abstinence compared with monotherapies. Provision of free cessation medications plus quit line counseling arranged in the primary care setting holds promise for assisting large numbers of smokers to quit.

Trial Registration  clinicaltrials.gov Identifier: NCT00296647

Author Affiliations: Department of Medicine and Center for Tobacco Research and Intervention (CTRI), University of Wisconsin School of Medicine and Public Health, Madison (Drs Smith, Japuntich, Christiansen, Piper, Jorenby, Fiore, Baker, and Jackson and Mr Fraser); and Department of Psychology, Rutgers, The State University of New Jersey, Piscataway (Dr McCarthy).

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