Considerable benefits accrue from stopping smoking in older patients. Reversal of the short term cardiovascular adverse effects of smoking is rapid. Long term risk reduction appears to occur as a result of decreased life-time exposure to tobacco smoke. The pharmacology of nicotine has not been studied in older patients but is unlikely to change in clinically important ways with advancing age. Nicotine replacement doubles long term success rates, compared with placebo, among younger smokers of > or = cigarettes per day. There is no reason to believe its efficacy should be less among older smokers. Transdermal nicotine is the replacement therapy of choice in older patients because of once-daily administration and good tolerability. Approximately half of the users of transdermal nicotine smoke concurrently with treatment. It is unlikely that concurrent smoking or high doses of nicotine replacement therapy will adversely effect healthy patients. While it is generally believed that patients with unstable coronary heart disease may be at risk from concurrent smoking during nicotine replacement therapy, it is unclear whether this risk is greater than the risk of smoking alone. Nicotine replacement therapy is a logical approach for motivated, older smokers who are unable to stop smoking by simpler means. Results can be augmented by including other interventions, such as counselling and follow-up support.