Nicotine replacement therapy can help motivated patients stop smoking, but long-term abstinence is a more difficult goal. Patient preference, which often guides the choice of a particular type of treatment, does not improve the outcome of nicotine replacement therapy. Lerman and associates compared the efficacy of transdermal nicotine with nicotine nasal spray to identify patient characteristics that might predict treatment outcomes.

These two forms of nicotine replacement therapy were chosen because of their differing pharmacodynamics, with transdermal preparations offering a slow nicotine administration with a four- to six-hour steady state, while the nasal spray more closely mimics the immediate nicotine peak achieved with smoking cigarettes. Healthy, treatment-seeking smokers were enrolled in a randomized, open-label, eight-week clinical trial of transdermal nicotine (Nicoderm CQ, 21 mg, tapering after four weeks) versus nicotine nasal spray (Nicotrol, 1.0-mg dose given as 0.5-mg spray in each nostril with a maximum of five doses per hour, tapered after four weeks) for smoking cessation. All patients received seven sessions of standarized behavioral group therapy. Smoking status was assessed by telephone, first at the end of treatment (eight weeks after the target quit date), and again six months after the target quit date.

The transdermal nicotine group achieved a higher prolonged abstinence rate through the end of treatment (62.5 percent) compared with the nicotine nasal spray group (44.5 percent). Six months later, abstinence rates were not significantly different in the two groups (28.5 versus 24.5 percent). No serious adverse events were reported. White, nonobese smokers with low to moderate levels of nicotine dependence had a better response to transdermal nicotine.

The authors conclude that pretreatment patient characteristics may help in the individualization of nicotine replacement therapy. Transdermal nicotine is a more effective treatment in white, nonobese smokers who have low nicotine dependence, while nicotine nasal spray is more beneficial in obese smokers who are highly nicotine dependent and members of minority groups.