What is the best treatment for smoking cessation in a patient with hypertension?

From the Guidelines

The best treatment for smoking cessation in a patient with hypertension is a combination of behavioral counseling and pharmacotherapy, with varenicline (Chantix) being the preferred medication option, as supported by the most recent and highest quality study 1.

Key Considerations

• Varenicline is typically started at 0.5 mg once daily for 3 days, then 0.5 mg twice daily for days 4-7, followed by 1 mg twice daily for 12 weeks, as it works by partially activating nicotine receptors while blocking nicotine binding, reducing cravings and withdrawal symptoms.
• For patients who cannot take varenicline, nicotine replacement therapy (NRT) is an alternative, using patches (21 mg/day for patients smoking >10 cigarettes/day, then tapering) combined with a short-acting form like gum or lozenges for breakthrough cravings.
• Bupropion SR (150 mg daily for 3 days, then 150 mg twice daily for 7-12 weeks) is another option, as it aids long-term smoking cessation with a similar efficacy to NRT.

Importance of Behavioral Counseling

• Behavioral counseling is crucial in smoking cessation, as it provides problem-solving skills, support, and encouragement to patients.
• Motivational counseling is beneficial for all patients, including those unwilling to quit, as it explores the smoker’s feelings, beliefs, ideas, and values to identify areas for change towards willingness to quit.

Considerations for Hypertensive Patients

• Smoking cessation is particularly important for hypertensive patients, as smoking compounds cardiovascular risk and can reduce the effectiveness of some antihypertensive medications.
• While nicotine replacement may temporarily raise blood pressure, the long-term benefits of quitting smoking far outweigh this concern, and blood pressure typically improves within weeks of cessation, as noted in studies such as 1 and 1.

Additional Recommendations

• Regular follow-up appointments and support groups or counseling should be used alongside pharmacotherapy to enhance smoking cessation outcomes.
• The choice of pharmacotherapy should take into account the patient’s medical stability, clinical needs, other medical factors, and patient preferences, as suggested by 1 and 1.

From the FDA Drug Label

Varenicline tablets are indicated for use as an aid to smoking cessation treatment. Patients with Impaired Renal Function No dosage adjustment is necessary for patients with mild to moderate renal impairment. Elderly and Patients with Impaired Hepatic Function No dosage adjustment is necessary for patients with hepatic impairment.

The best treatment for smoking cessation in a patient with hypertension is varenicline.

• Varenicline does not have a dose adjustment for patients with mild to moderate renal impairment, and no dose adjustment is necessary for patients with hepatic impairment.
• There is no direct information in the provided drug labels that suggests varenicline has a significant adverse effect on hypertension.
• In contrast, bupropion may increase the risk of hypertension, and monitoring of blood pressure is recommended in patients who receive bupropion 2. It is recommended to use varenicline with caution and monitor the patient's condition closely, as the evidence is not entirely clear. 3

From the Research

Treatment Options for Smoking Cessation in Patients with Hypertension

• Combined pharmacotherapy and behavioural interventions are effective in helping people to stop smoking, including those with hypertension 4.
• First-line agents for smoking cessation therapy include nicotine replacement therapy, bupropion, and varenicline, which can be used in patients with hypertension 5, 6, 7.
• Varenicline has been shown to offer significant improvement in abstinence rates over bupropion, but its use may need to be considered in the context of the patient's overall health and comorbidities 5, 8, 7.
• Second-line agents, such as nortriptyline and clonidine, may be considered when first-line treatments have failed or are not tolerated, but their use may be limited by their adverse event profiles 5, 7.

Considerations for Patients with Hypertension

• Clonidine, an antihypertensive drug, can be used as a second-line agent for smoking cessation, but its use may need to be carefully considered in patients with hypertension 5.
• The selection of pharmacologic agent should be based on the patient's comorbidities, including hypertension, and preferences, as well as on the agent's adverse event profile 5, 7.
• Behavioural support, including brief advice and counselling, can be an effective adjunct to pharmacotherapy for smoking cessation in patients with hypertension 4.

Efficacy of Treatment Options

• Combined pharmacotherapy and behavioural support increase smoking cessation success compared to a minimal intervention or usual care, with a risk ratio of 1.83 (95% CI 1.68 to 1.98) 4.
• Varenicline has been shown to be at least as effective as bupropion for smoking cessation, with some studies suggesting it may be more effective 8, 7.
• Nicotine replacement therapy, bupropion, and varenicline have similar efficacy for smoking cessation, but their effectiveness can vary depending on the individual patient and the specific formulation or dosage used 5, 6, 8, 7.