Discussion
psychiatric comorbidity, psychiatric illness
This randomized clinical trial found that adaptive treatment was more efficacious than standard treatment for daily smokers recruited from a smoking cessation clinic and allowed to choose between varenicline and nicotine patches. Additionally, the results suggest that adaptive treatment with extended (4-week) precessation varenicline may be more effective than standard varenicline treatment starting 1 week before the target quit date. This study contributes to the existing literature, which thus far only supports the use of adaptive treatment using precessation nicotine patches and has not assessed smokers in clinical settings. The trial used a clinical population with minimal exclusion criteria so that findings might be more readily generalizable to smokers seen in a clinical setting. A component of this trial’s design was allowing participants to select their medication. Another important element was to use minimal exclusion criteria, such that only 31% of screened participants were excluded from the trial. This resulted in a study sample with rates of psychiatric comorbidity (30.8%) similar to that in US smokers (35%).An important perspective on trial outcomes is provided by studies showing that varenicline plus bupropion was more effective than varenicline alone with continuous 12-week postquit smoking abstinence between groups (OR, 1.89; 95% CI, 1.07-3.35; To our knowledge, this is first trial that tested adaptive smoking cessation treatment in a clinical population with minimal exclusion criteria. As such, our best estimates for smoking abstinence in the standard treatment group were derived from randomized trials that used more restrictive eligibility criteria, eg, excluding smokers with physical or psychiatric illness.