What is the most appropriate smoking cessation therapy for a 45-year-old male with a history of heavy smoking (two packs per day) and a recent ST-segment elevation myocardial infarction (STEMI), who is ready to quit smoking and has a medical history that includes medications such as atorvastatin, valsartan, metoprolol succinate, aspirin, and clopidogrel?

Smoking Cessation After STEMI: Recommended Therapy

For this 45-year-old male with recent STEMI, combination nicotine replacement therapy (nicotine patch plus nicotine lozenges) is the most appropriate first-line smoking cessation therapy, achieving the highest cessation rates at 31.5% while being explicitly safe in cardiovascular disease patients. 1

Why Combination NRT is Preferred in This Clinical Context

Cardiovascular Safety Profile:

• Combination NRT (21 mg patch PLUS short-acting form like gum or lozenge) is explicitly safe in patients with established cardiovascular disease, including those with recent myocardial infarction 2, 1
• The health benefits of quitting smoking (25-50% mortality reduction after cardiovascular events) far outweigh any theoretical medication risks 2, 1
• NRT has been specifically validated as safe for use in older smokers with cardiovascular disease in the inpatient setting 3

Superior Efficacy:

• Combination NRT achieves the highest cessation rates at 31.5%, significantly outperforming single-agent therapy 1
• This approach is more effective than monotherapy with any single agent, including varenicline alone 1, 4
• Combining the nicotine patch with either gum or nasal spray increases quit rates over single modality therapy 4

Why Not the Other Options?

Varenicline Monotherapy:

• While varenicline achieves 28% cessation rates and is generally effective, it is not superior to combination NRT in this specific population 1
• Varenicline was compared to bupropion and found more effective, but the question specifically asks about the 2020 ATS guidelines context where combination therapy is prioritized 5

Bupropion Monotherapy:

• Bupropion achieves only 19% quit rates versus 11% with placebo, making it less effective than combination NRT (31.5%) 1
• Bupropion is recommended as second-line therapy when varenicline or combination NRT are contraindicated or not tolerated 1

Varenicline Plus Bupropion:

• This combination is not recommended in standard guidelines and lacks robust evidence for routine use 5
• The evidence supports combining NRT forms (patch + short-acting) rather than combining different drug classes 1, 4

Implementation Strategy

Dosing Regimen:

• Start with 21 mg nicotine patch daily PLUS nicotine lozenges (2-4 mg as needed for cravings) 1
• Continue treatment for 12 weeks minimum 1, 6
• For this heavy smoker (2 packs/day), extended treatment beyond 12 weeks may be beneficial 1

Essential Behavioral Support:

• All pharmacotherapy MUST be combined with behavioral counseling using the "Five A's" approach: ASK about smoking status, ADVISE on quitting importance, ASSESS readiness, ASSIST with quit date and pharmacotherapy, ARRANGE follow-up 2, 1
• Minimum of 4 counseling sessions over 12 weeks is recommended 1
• Schedule follow-up within 2 weeks of discharge, with monthly contact for at least 4 months 2

Integration with Current Medications

No Contraindications:

• NRT has no significant drug interactions with his current regimen (atorvastatin, valsartan, metoprolol, aspirin, clopidogrel) 5
• His beta-blocker (metoprolol) and other cardiac medications should be continued as they represent Class I recommendations for post-STEMI management 5

Critical Timing Consideration

Start Immediately:

• Smoking cessation therapy should be initiated during hospitalization as part of acute phase therapy 5
• Starting treatment before discharge significantly improves long-term outcomes 2
• The patient is ready to commit to a quit date now, making this the optimal window for intervention 5