For the video version of this post, click here. Quitting smoking is really hard. It’s frustrating for smokers and for their doctors. And I need to come clean and admit that when varenicline (Chantix) came out I was excited to have one more weapon in my anti-smoking armamentarium. After all, the gums, lozenges, and patches didn’t seem to work very well, but here was this new drug – a pill – that initially boasted quit rates as high as 40%. Compare that to 8% with placebos.

Even compared to the nicotine patch, varenicline seemed better, with one study showing quit rates of 26% versus 20% at one year. Of course, patients had some interesting side-effects, but smoking must be worse than vivid nightmares, right?

Recent studies have suggested that combination nicotine replacement therapy, with a patch to give some basal nicotine and lozenges to curb cravings, might be the better strategy.

Now a study appearing in the Journal of the American Medical Association finally pits the drug against a fair competitor. Researchers randomized around 1000 smokers to treatment with 12 weeks of a nicotine patch alone, a patch plus lozenges, or varenicline. The big question was what percent of those would stay quit at 14 weeks after all interventions stopped.

And I’ll skip right to the punchline. Patch: 23%, Varenicline 24%, patch plus lozenge 27%. There were no statistically significant differences between any of these numbers. Out at 1 year? 20% stayed quit across the board. The winner appears to be… nobody.

To me, more interesting than the intervention results was the analysis of factors that would predispose to quitting. Some were no surprise – if someone else was smoking in the home, your chance of quitting was 22% instead of 27% in a smoke-free home.  But there was a pretty large discrepancy in quit rates based on whether or not you smoked menthols. 30% of standard cigarette smokers stayed quit, compared to just 19% of minty cigarette smokers.

Now, we may be tempted to tell our patients – "use whatever you like". But maybe the guidepost should be their tolerance of adverse events – as these were significantly different between the treatment strategies.  Hate itching, hives, and hiccups? Avoid the patch. Hate nausea, vomiting, and vivid dreams? Stay away from varenicline.

Actually, you know what's even easier? Stay away from cigarettes in the first place.