The pros and cons of transdermal nicotine therapy

To review current knowledge of the efficacy, safety and cost of transdermal nicotine therapy for smoking cessation.

1. Published and unpublished reports of randomised, double-blind trials of at least 12 weeks' duration, in smokers motivated to cease smoking, identified by a search of the MEDLINE database, article and book bibliographies, Current contents, and by a request to the Medical Department of Ciba-Geigy (Australia) Ltd. 2. A clinical trial of 1500 smokers using transdermal nicotine (S Gourlay, unpublished data).

Transdermal nicotine more than doubles the success rates of smoking cessation attempts in motivated subjects who smoke at least 10-15 cigarettes per day (odds ratio 12 months after quitting, 2.3; 95% confidence interval, 1.6-3.4). Application site reactions are not uncommon (erythema or burning < or = 16%, transient itch < or = 50%) and cause discontinuation of therapy in up to 10% of subjects. Sleep disturbance due to nocturnal nicotine absorption occurs in up to 13% of subjects when patches are worn overnight. Smoking or nicotine chewing gum used concurrently with transdermal nicotine could raise peak nicotine levels but is unlikely to adversely affect individuals with established tolerance to nicotine. Smoking and (theoretically) nicotine replacement therapies should be avoided in pregnancy or patients with unstable coronary artery disease. In such patients, the risk-benefit ratio of nicotine replacement therapies may be favourable for nicotine-dependent smokers unable to cease smoking by alternative methods.

Transdermal nicotine is an effective smoking cessation therapy for motivated, nicotine-dependent smokers. As most smokers can cease smoking on their own, and the patches are costly, they should be recommended only for smokers who are unable to quit by simpler means and those likely to suffer severe nicotine withdrawal symptoms.