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However, a major question for TMS remains: does brain state affect clinical response?<\/jats:p><\/jats:sec>Objective<\/jats:title>To quantify the association between symptom provocation and clinical response to TMS for OCD and nicotine dependence, the only Food and Drug Administration\u2013cleared TMS indications with symptom provocation.<\/jats:p><\/jats:sec>Data Sources<\/jats:title>PubMed, CINAHL, Embase, PsycInfo until August 30, 2024.<\/jats:p><\/jats:sec>Study Selection<\/jats:title>Randomized clinical trials of TMS for OCD or nicotine dependence with a clinical outcome. Of 600 studies identified, 71 met inclusion criteria.<\/jats:p><\/jats:sec>Data Extraction and Synthesis<\/jats:title>Data extraction was completed independently by 2 extractors and cross-checked by a third. Standardized mean difference (SMD) and SE were estimated via Hedges g<\/jats:italic> and synthesized data in a 3-level random-effects meta-analysis. Study data were analyzed from August 2023 to March 2025.<\/jats:p><\/jats:sec>Main Outcomes and Measures<\/jats:title>Primary outcomes were clinical response measures.<\/jats:p><\/jats:sec>Results<\/jats:title>A total of 71 studies met inclusion criteria and included 3246 participants (mean [SD] age; 37.8 [8.0] years; mean [SD] percentage female, 44.1% [17.2%]). Included in the meta-analysis were 63 studies with 2998 participants. For OCD studies, active TMS was associated with better clinical response than sham both with (SMD\u2009=\u2009\u22120.51; 95% CI, \u22120.96 to \u22120.07; P<\/jats:italic>\u2009=\u20090.04) and without (SMD\u2009=\u2009\u22120.29; 95% CI, \u22120.40 to \u22120.17; P<\/jats:italic>\u2009&amp;lt;\u2009.001) symptom provocation. For nicotine use, active TMS was associated with better clinical response than sham when used with (SMD\u2009=\u2009\u22120.56; 95% CI, \u22121.12 to 0; P<\/jats:italic>\u2009=\u2009.05) but not without (SMD\u2009=\u2009\u22120.35; 95% CI, \u22120.74 to 0.04; P<\/jats:italic>\u2009=\u2009.08) symptom provocation. For OCD studies, the estimated expected added effect of provocation was SMD\u2009of\u2009\u22120.22 (95% CI, \u22120.65 to 0.20; P<\/jats:italic>\u2009=\u2009.22). In nicotine studies, the estimated expected added effect of provocation was SMD\u2009of\u2009\u22120.21 (95% CI, \u22121.00 to 0.58; P<\/jats:italic>\u2009=\u2009.57).<\/jats:p><\/jats:sec>Conclusions and Relevance<\/jats:title>Results of this systematic review and meta-analysis suggest that symptom provocation may enhance clinical response to TMS for OCD and nicotine dependence. 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