A 25-year-old graduate student comes to the student health clinic for a routine physical examination. He has been concerned about his health since a close friend died in a motor vehicle collision several weeks ago, but he has otherwise felt well. Medical history reveals no major problems except for a recent history of bulimia. The patient has smoked a pack of cigarettes daily for the past 7 years. He tried varenicline for smoking cessation but did not like the way it made him feel and stopped the medication. He currently takes no medications. The patient's mother has asthma and his father died of a heart attack at age 56. Physical examination is unremarkable, and vital signs are normal. At the end of the visit, he asks for assistance with smoking cessation. In addition to proper counseling and support, which of the following would be considered an appropriate first-line treatment for smoking cessation in this patient?

Question

A 25-year-old graduate student comes to the student health clinic for a routine physical examination.  He has been concerned about his health since a close friend died in a motor vehicle collision several weeks ago, but he has otherwise felt well.  Medical history reveals no major problems except for a recent history of bulimia.  The patient has smoked a pack of cigarettes daily for the past 7 years.  He tried varenicline for smoking cessation but did not like the way it made him feel and stopped the medication.  He currently takes no medications.  The patient's mother has asthma and his father died of a heart attack at age 56.  Physical examination is unremarkable, and vital signs are normal.  At the end of the visit, he asks for assistance with smoking cessation.  In addition to proper counseling and support, which of the following would be considered an appropriate first-line treatment for smoking cessation in this patient?

Quizplus · Accepted Answer

Explanation: Nicotine replacement therapy (NRT), varenicline, and bupropion are the 3 available FDA-approved, first-line pharmacological treatments for smoking cessation. NRT replaces the nicotine from tobacco to decrease nicotine withdrawal and aid in smoking cessation. It can be delivered in multiple ways (ie, transdermal patch, gum, lozenge, inhaler, nasal spray). The combination of the transdermal patch and gum or lozenge is commonly used to control both shorter- and longer-term nicotine withdrawal symptoms and would be appropriate for this patient. The other first-line options are: Varenicline, an alpha-4 beta-2 nicotinic acetylcholine receptor partial agonist, can diminish nicotine cravings. Despite earlier concerns, varenicline does not appear to increase the risk of suicidality or depression compared with placebo. It has been associated with an increased risk of cardiovascular events in patients with preexisting cardiovascular disease. The antidepressant bupropion, a norepinephrine-dopamine reuptake inhibitor, is an effective smoking cessation aid. However, it is contraindicated in patients with seizures or in any patient who may have active bulimia, such as this patient (Choice B). All treatments should be combined with counseling and supportive therapy. (Choice A) Acamprosate is a first-line medication for alcohol use disorder, not for smoking cessation. (Choice C) Buspirone is an anti-anxiety medication. There is limited evidence that it may be of benefit as a short-term adjuvant for smoking cessation, but it is not approved by the FDA for this indication. (Choice D) Electronic cigarettes provide nicotine in an aerosolized form. Dosing can be inconsistent and they have not been shown to have clear efficacy for smoking cessation. They are not approved by the FDA, and should not be considered for first-line treatment. (Choice E) Selective serotonin reuptake inhibitors (eg, fluoxetine) have not been found to be effective for smoking cessation. Educational objective: Nicotine replacement therapy, varenicline, and bupropion are first-line treatments for smoking cessation. They should be used in conjunction with counseling and supportive therapy. References: An update on the pharmacotherapeutic interventions for smoking cessation. (http://www.ncbi.nlm.nih.gov/pubmed/27267498) Nicotine replacement therapy for smoking cessation. (http://www.ncbi.nlm.nih.gov/pubmed/23152200) Pharmacotherapy for smoking cessation: pharmacological principles and clinical practice. (http://www.ncbi.nlm.nih.gov/pubmed/23488726)

A 25-Year-Old Graduate Student Comes to the Student Health Clinic