What is the recommended smoking cessation treatment for a patient with hypertension, a history of childhood seizures, and previous unsuccessful attempts with nicotine gum and patches, who is scheduled for hip replacement surgery in five months?

Recommended Smoking Cessation Treatment

Sustained-release bupropion should NOT be recommended for this patient due to his history of childhood seizures, which is an absolute contraindication; instead, varenicline combined with intensive behavioral counseling is the optimal choice. 1

Critical Contraindication: Bupropion and Seizure History

• Bupropion is contraindicated in patients with a history of seizures, as it lowers the seizure threshold and can precipitate new or worsening seizures 1, 2
• The FDA drug label explicitly warns that varenicline should be used cautiously in patients with seizure history, but bupropion carries a more severe restriction given its known seizure risk (approximately 0.1% in general populations, higher in those with predisposing factors) 1, 3
• Care must be taken when prescribing bupropion with any condition or medication that can lower seizure threshold 2

Primary Recommendation: Varenicline

Varenicline is the first-line medication for this patient, achieving the highest abstinence rates (33.2% at 6 months) compared to other monotherapies, with an odds ratio of 3.1 versus placebo 4

Dosing Strategy for Varenicline

• Start varenicline 1-2 weeks before the quit date 4, 1
• Days 1-3: 0.5 mg once daily 4, 1
• Days 4-7: 0.5 mg twice daily 4, 1
• Weeks 2-12: 1 mg twice daily 4, 1
• A flexible dosing option allows self-titration between 0.5 mg/day minimum and 1 mg twice daily maximum to reduce side effects while retaining efficacy 4

Treatment Duration

• Minimum 12 weeks of therapy for the initial quit attempt 4
• An additional 12 weeks of treatment (total 24 weeks) is recommended for successful quitters to increase likelihood of long-term abstinence, which is particularly important given the upcoming hip replacement surgery in 5 months 4, 1
• Schedule follow-up within 2 weeks of starting medication to assess efficacy and side effects 4

Essential Behavioral Counseling Component

All pharmacotherapy must be combined with intensive behavioral counseling for optimal results, as combination approaches are superior to either alone 4

• Provide at least 4 counseling sessions, with greatest effect seen in 8+ sessions totaling 91-300 minutes of contact 5
• Effective counseling includes practical problem-solving skills training, identifying high-risk situations (such as pre-operative stress), developing coping strategies, and providing social support 5
• Even brief counseling (5-10 minutes) significantly improves outcomes 4

Safety Considerations for This Patient

• Hypertension is not a contraindication to varenicline; the patient's well-controlled hypertension on hydrochlorothiazide does not preclude its use 1
• Patients should be monitored for neuropsychiatric adverse events including mood changes, anxiety, and agitation, though these are rare 1
• Instruct the patient to use caution driving or operating machinery until they know how varenicline affects them 1
• The patient should reduce alcohol consumption until they know whether varenicline affects their tolerance 1

If Varenicline Fails: Next Steps

Should varenicline prove ineffective, the next best option is combination NRT (long-term nicotine patch >14 weeks + short-acting NRT such as gum or lozenge), which achieves 36.5% abstinence at 6 months versus 23.4% for patch alone 5, 4

• For this patient who smokes one pack daily, start with a 21 mg/24-hour patch combined with 4 mg nicotine gum (8-12 pieces per day as needed for cravings) 5
• Combination NRT nearly doubles cessation success compared to monotherapy and is safe even in patients with cardiovascular disease 5

Surgical Timing Advantage

• Starting varenicline now provides 5 months before surgery, allowing for the recommended 24-week treatment course to be completed well before the hip replacement 4, 1
• Smoking cessation at least 4-8 weeks before surgery significantly reduces perioperative complications, making this timeline ideal for optimizing surgical outcomes 4