Windle Sarah B, Filion Kristian B, Mancini Joseph G, Adye-White Lauren, Joseph Lawrence, Gore Genevieve C, Habib Bettina, Grad Roland, Pilote Louise, Eisenberg Mark J
Division of Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital/McGill University, Montreal, Quebec, Canada.
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.
Am J Prev Med. 2016 Dec;51(6):1060-1071. doi: 10.1016/j.amepre.2016.07.011. Epub 2016 Sep 9.
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.
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.
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.
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.
治疗指南推荐采用联合疗法来戒烟，尤其是将行为疗法（BT）作为药物疗法的辅助手段。然而，这些指南依赖于以往有重要局限性的综述。本研究的目的是利用现有最严格的数据，评估联合疗法与单一疗法相比的疗效。
对药物疗法、行为疗法或两者结合的随机对照试验进行了系统综述和荟萃分析。从创刊至2015年7月，对Cochrane图书馆、Embase、PsycINFO和PubMed数据库进行了系统检索。纳入标准仅限于报告12个月时经生化验证的戒烟情况的随机对照试验。2015年，使用分层贝叶斯模型对各疗法进行了直接和间接比较。
检索到123项符合纳入标准的随机对照试验（60774名参与者），并对其中115项试验（57851名参与者）的数据进行了荟萃分析。与其他药物疗法与行为疗法的组合相比，伐尼克兰联合行为疗法能提高更多的戒烟成功率（伐尼克兰与安非他酮比较：比值比[OR]=1.56，95%可信区间[CrI]=1.07，2.34；伐尼克兰与尼古丁贴片比较：OR=1.65，95%CrI=1.10，2.51；伐尼克兰与短效尼古丁替代疗法比较：OR=1.68，95%CrI=1.15，2.53）。由于可信区间较宽（OR=1.17，CrI=0.60，2.12），将行为疗法添加到任何药物疗法中与单独使用药物疗法相比，结果尚无定论。尼古丁贴片与短效尼古丁替代疗法联合使用似乎是安全的，与尼古丁替代单一疗法相比能提高戒烟成功率（OR=1.63，CrI=1.06，3.03）。关于其他药物疗法组合及其安全性和耐受性的数据有限。
有证据表明联合疗法的益处可能比之前认为的要少。与行为疗法联合使用时，伐尼克兰比其他药物疗法与行为疗法的组合能提高更多的戒烟成功率。
