Combination nicotine replacement therapy for smoking cessation - Rationale, efficacy and tolerability

Currently available nicotine replacement therapy (NRT) medications provide effective treatment for tobacco dependence, typically doubling success rate s compared with placebo. A strategy for further improving the efficacy of N RT is to combine one medication that allows for passive nicotine delivery ( e.g. transdermal patch) with another medication that permits ad libitum nic otine delivery (e.g. gum, nasal spray, inhaler). The rationale for combinin g NRT medications is that smokers may need both a slow delivery system to a chieve a constant concentration of nicotine to relieve cravings and tobacco withdrawal symptoms, as well as a faster acting preparation that can be ad ministered on demand for immediate relief of breakthrough cravings and with drawal symptoms. This article reviews 5 published studies that have examined the effectivene ss of combination NRT compared with monotherapy in providing withdrawal rel ief and smoking cessation, and examines other factors relevant to the promo tion of combination NRT for treating tobacco dependence. The data show that there are conditions under which combinations of NRT pro ducts provide greater efficacy in relieving withdrawal and enabling cessati on than monotherapy, but the findings are not robust and additional researc h is warranted to better understand the magnitude and generality of the ben efits of combination therapy. There are also regulatory and commercial obst acles that must be considered. Nonetheless. combination NRT has the potenti al to provide effective treatment of tobacco dependence in persons whose de pendence is refractory to currently available treatments.