To the Editor.
—In their meta-analysis of transdermal nicotine patch clinical trials, Dr Fiore and colleagues1 reviewed the efficacy of this therapy compared with placebo patches, with a major emphasis on the relationship of counseling with patch use. Studies were categorized by intensity levels of counseling, and quit rates between "low counseling" and "high counseling" studies were compared. The authors report, "[t]here was no indication that low-intensity or high-intensity counseling resulted in greater efficacy of the nicotine patch in relation to placebo patch," and subsequently advocate a minimal counseling approach with initial transdermal nicotine patch use. There are several problems inherent in using this meta-analysis to arrive at such a conclusion, including two potential sources of bias.First, performing a subgroup analysis for counseling intensity requires comparisons between studies, not across studies. Subjects in this meta-analysis were not randomly exposed to counseling of varying intensity. Given the likelihood that
Swartz SH. Using the Nicotine Patch to Stop Smoking. JAMA. 1995;273(3):181. doi:10.1001/jama.1995.03520270015007