Varenicline and Clinician Counseling
For this 63-year-old man with failed over-the-counter nicotine replacement therapy, remote childhood seizures (no longer requiring treatment), and upcoming hip surgery, you should recommend varenicline combined with intensive behavioral counseling. 1
Why Varenicline Is the Optimal Choice
- Varenicline is specifically recommended as first-line therapy when previous NRT has failed, achieving 6-month abstinence rates of approximately 28% versus 12% with placebo (relative risk 2.27) 1, 2
- The patient has already failed with both over-the-counter nicotine gum and patches, making combination NRT a less attractive option since he has already tried the individual components 1
- Varenicline demonstrates superior efficacy compared to bupropion SR (relative risk 0.68 favoring varenicline), making it the preferred non-NRT option 2
Why Bupropion Is Contraindicated
- Bupropion SR is absolutely contraindicated in patients with any history of seizure disorder, even if remote and no longer requiring medication 1
- The NCCN guidelines explicitly state that both varenicline and bupropion should be avoided in patients with brain metastases due to increased seizure risk—this same caution applies to any seizure history 1
- This eliminates options c and d from consideration 1
Why Behavioral Counseling Is Essential
- Combining pharmacotherapy with behavioral counseling increases 6-month abstinence from approximately 8% to 14% (relative risk 1.82) 2
- Pharmacotherapy alone yields approximately 18% abstinence, whereas adding behavioral support improves this to 21% 2, 3
- At least 4 counseling sessions totaling 91-300 minutes of contact should be provided, with the greatest benefit seen in 8 or more sessions 1, 2
- A perioperative smoking cessation program with varenicline and counseling achieved 42.4% abstinence at 12 months versus 26.2% with brief advice alone in surgical patients 4
Specific Treatment Protocol
- Varenicline dosing: Start with 0.5 mg once daily for 3 days, then 0.5 mg twice daily for 4 days, then target dose of 1 mg twice daily for a minimum of 12 weeks 1
- Timing for surgery: Initiate treatment now to allow maximum preoperative cessation time; smoking cessation should occur as far in advance of hip surgery as feasible, though the 5-month window is adequate 1
- First follow-up: Schedule within 2 weeks of starting varenicline to assess adherence, manage side effects (particularly nausea), and provide continued counseling 1
- Counseling content: Include practical problem-solving, identification of high-risk situations, development of coping strategies, and social support 1, 2
Important Caveats
- Nausea is the most common side effect of varenicline, occurring in 24-31% of patients; this can be managed with dose adjustments or antiemetics if needed 1, 5
- Nicotine withdrawal symptoms typically peak within 1-2 weeks of quitting and then subside—encourage continued therapy through brief slips 1
- The patient's hypertension and occasional albuterol use are not contraindications to varenicline 1
- Preoperative smoking cessation reduces postoperative morbidity in surgical patients, making this intervention particularly valuable given the upcoming hip replacement 1
Why Not Varenicline Alone (Option A)
- Varenicline monotherapy without structured counseling is substantially less effective than the combination approach 2, 3, 4
- The 5 A's strategy (Ask, Advise, Assess, Assist, Arrange) has been a cornerstone of evidence-based smoking cessation since 1996 and should not be omitted 1
- Brief physician advice alone (approximately 3 minutes) results in only small increases in quit rates compared to comprehensive counseling 1
The answer is B: varenicline and clinician counseling.