In this issue of Thorax Aubin and colleagues1 report a further trial from the Varenicline Phase III Programme (see page 717). The trials supporting registration contrasted bupropion with varenicline in a double placebo design.2 3 This study examines the efficacy of varenicline against nicotine replacement therapy (NRT). In many countries, including the UK, bupropion is rarely used and NRT is the predominant treatment offered in general practices and in specialist smoking cessation clinics. It is not practical to obtain placebo NRT, so this trial was of an open-label design. This publication follows a study by Stapleton et al4 with historical controls which showed that varenicline is superior to NRT in achieving abstinence and in reducing withdrawal phenomena such as urges to smoke and withdrawal symptoms.

Varenicline is licensed for smoking cessation around the world, but in the UK the National Institute for Health and Clinical Excellence (NICE) makes decisions about whether the benefits from licensed medications are worth the costs and therefore whether such interventions can be used in the National Health Service (NHS). NICE approved varenicline in 2007,5 but many local primary care organisations have limited the use of varenicline by making it a second-line treatment choice. The main reason given is the lack of trial data against the key competitor, NRT, but many have felt that the main reason was actually cost. Varenicline costs slightly more per treatment course than NRT or bupropion and considerably more than nortriptyline, an effective6 but unlicensed medication. The trial by Aubin and colleagues showing that varenicline is more effective than NRT and the trials of varenicline versus bupropion mean that varenicline must be considered a first-line choice in smoking cessation treatment. The recently published NICE guidance on smoking cessation affirmed this view,7 and it should be …