Board Review

A 45-year-old man is evaluated during a routine examination. He is interested in quitting smoking. He has a history of seizures but has not had a seizure in 15 years and discontinued his seizure medication 4 years ago. He also has hypertension. His only medication is amlodipine.

Physical examination is unremarkable.

Which of the following will most likely give this patient the greatest chance of success in quitting smoking?

A) Bupropion

B) Electronic cigarettes

C) Nicotine replacement patches

D) Varenicline

Answer: D - Varenicline

Objective: Recommend appropriate pharmacologic treatment for smoking cessation.

Key Point

Varenicline is more effective in achieving smoking cessation than bupropion or single-agent nicotine replacement therapy but not more effective than combination nicotine replacement therapy.

Varenicline will most likely give this patient the greatest chance of success in quitting smoking. A recent Cochrane meta-analysis showed that varenicline increased the odds of quitting smoking compared with placebo (OR, 2.88; 95% CI, 2.40-3.47). Although concerns have been raised regarding varenicline use and an increase in cardiovascular events, the FDA noted that the benefits outweigh potential risks in terms of cardiovascular risk.

Varenicline is more effective than bupropion (OR, 1.59; 95% CI, 1.29-1.96). Additionally, there is also concern that bupropion can lower seizure threshold and thus would not be the best option for this patient who has a history of seizures. Both varenicline and bupropion also have FDA warnings highlighting the risk of serious neuropsychiatric symptoms in patients using these medications.

Electronic cigarettes (E-cigarettes) may not be effective in reducing smoking cessation rates. In a recent randomized controlled superiority trial, adult smokers were randomly assigned to nicotine E-cigarettes, nicotine patches, or placebo E-cigarettes (no nicotine), with low-intensity behavioral support. At 6 months, the risk difference for nicotine E-cigarettes versus nicotine patches was 1.51 (95% CI, 2.49-5.51); for nicotine E-cigarettes versus placebo E-cigarettes, 3.16 (95% CI, -2.29-8.61). There was insufficient statistical power to conclude superiority of nicotine E-cigarettes to patches or to placebo E-cigarettes. Currently, the role of E-cigarettes in smoking cessation is uncertain.

Varenicline was also found to be more effective than the nicotine patch (OR, 1.51; 95% CI, 1.22-1.87) and nicotine gum (OR, 1.72; 95% CI, 1.38-2.13), and the nicotine inhaler, spray, tablets, or lozenges (OR, 1.42; 95% CI, 1.12-1.79) all used as single agents. Varenicline was not more effective than combination nicotine replacement therapy (OR, 1.06; 95% CI, 0.75-1.48) such as the combination of a rapid-onset nicotine replacement product (for example, nicotine spray or inhaler) with a long-duration nicotine replacement product (for example, a nicotine patch).

Cahill K, Stevens S, Perera R, Lancaster T. Pharmacological interventions for smoking cessation: an overview and network meta-analysis. Cochrane Database Syst Rev. 2013 May 31;5:CD009329. Link Out