What is the most appropriate smoking cessation strategy for a 54-year-old man with a 40 pack-year history of smoking, hypercholesterolemia, and taking daily pravastatin and as-needed acetaminophen with codeine, who is scheduled for an elective inpatient rotator cuff repair and wants to quit smoking?

From the Guidelines

The most appropriate smoking cessation strategy for this 54-year-old hospitalized patient is nicotine replacement therapy (NRT). NRT is the preferred option for inpatient smoking cessation because it effectively manages withdrawal symptoms during hospitalization, has minimal drug interactions, and can be immediately implemented. For this patient with a significant 40 pack-year smoking history, NRT can be provided through patches (21 mg/24 hours initially for heavy smokers), supplemented with short-acting forms like gum or lozenges for breakthrough cravings. This approach addresses both baseline nicotine needs and acute cravings. NRT works by providing controlled nicotine doses to reduce withdrawal symptoms while avoiding the harmful chemicals in cigarette smoke. While bupropion and varenicline are effective options, they typically require pre-hospitalization initiation and have more potential drug interactions, as noted in studies such as 1 and 1. Gabapentin and lorazepam are not indicated for smoking cessation. The hospital stay for rotator cuff surgery provides an excellent opportunity to initiate cessation with NRT, which can then be continued after discharge as part of a comprehensive cessation plan. According to the most recent guidelines, such as 1, combining pharmacologic therapy and behavior therapy is the most effective approach and leads to the best results for smoking cessation, with NRT being one of the most effective pharmacotherapy agents.

Some key points to consider in the management of this patient's smoking cessation include:

• The importance of a comprehensive approach that includes both pharmacologic and behavioral components, as emphasized in 1 and 1.
• The selection of NRT as a first-line treatment due to its efficacy and safety profile, especially in a hospital setting where close monitoring is possible, as discussed in 1 and 1.
• The potential for NRT to be used in combination with other therapies, such as counseling, to enhance quit rates, as suggested by 1.
• The need for ongoing support and follow-up to help the patient maintain abstinence and manage any challenges that arise during the quit process, as recommended in 1 and 1.

Overall, the use of NRT as part of a comprehensive smoking cessation strategy is supported by the evidence and guidelines, including those from 1, 1, and 1, and is appropriate for this patient given his significant smoking history and current hospitalization for rotator cuff surgery.

From the FDA Drug Label

Varenicline tablets are indicated for use as an aid to smoking cessation treatment.

Patients should be treated with varenicline tablets for 12 weeks.

For patients who have successfully stopped smoking at the end of 12 weeks, an additional course of 12 weeks treatment with varenicline tablets is recommended to further increase the likelihood of long-term abstinence

The most appropriate smoking cessation strategy for the patient while he is in the hospital is varenicline 2.

• Key points:
  • Varenicline is indicated for smoking cessation treatment
  • Treatment should last for 12 weeks, with an optional additional 12 weeks for patients who successfully quit smoking
  • Varenicline can be used for patients who are motivated to quit smoking and are provided with additional advice and support.

Note: The patient's history of hypercholesterolemia and use of pravastatin and acetaminophen with codeine do not appear to be directly relevant to the choice of smoking cessation strategy.

From the Research

Smoking Cessation Strategies

The patient in question has a 40 pack-year history of smoking and is motivated to quit due to his upcoming hospitalization for rotator cuff repair. Considering his history and the hospital setting, the most appropriate smoking cessation strategy should be effective, safe, and suitable for his situation.

Evidence-Based Options

• Nicotine Replacement Therapy (NRT): Studies 3, 4, 5 have consistently shown that NRT is effective in achieving long-term smoking abstinence. It works by replacing nicotine from cigarettes, reducing withdrawal symptoms, and helping resist the urge to smoke. Various forms of NRT, such as gum, transdermal patches, nasal spray, inhalers, and tablets, have been found to be effective.
• Pharmacotherapy: In the context of hospitalized patients, pharmacotherapies like NRT, varenicline, and bupropion have been studied. Evidence 6 suggests that NRT and varenicline can help more patients quit smoking than a placebo or no medication, with NRT having high-certainty evidence and varenicline having moderate-certainty evidence due to imprecision.

Considerations for Hospitalized Patients

• Interventions Initiated in Hospital: Studies 6, 7 indicate that initiating smoking cessation interventions during hospitalization can be effective, especially when these interventions include counseling and continue for more than a month after discharge.
• Combination Therapy: While there is evidence supporting the use of NRT and other pharmacotherapies, the effectiveness of combination therapy (e.g., NRT plus counseling) in hospitalized patients is also noteworthy, as it may offer additional benefits in quit rates.

Conclusion Not Allowed, Direct Answer

Given the evidence and the context of the patient's hospitalization, the most appropriate smoking cessation strategy would likely involve nicotine replacement therapy (D), as it is supported by high-certainty evidence for its effectiveness in achieving long-term smoking abstinence, including in hospitalized patients. However, it's also important to consider the patient's overall health status, potential interactions with other medications (like pravastatin and acetaminophen with codeine), and his history of hypercholesterolemia when selecting a smoking cessation strategy.