A 65-Year-Old Woman with Moderate Chronic Obstructive Pulmonary Disease and Hypertension

A 65-year-old woman with moderate chronic obstructive pulmonary disease and hypertension comes to the office for dyspnea that occurs when she walks more than 2 or 3 blocks.  The dyspnea is not new and she has a chronic cough.  The patient has a 40-pack-year smoking history and wants to know if there is anything she can do to stop.  "I want to be done with these damn cigarettes."  She briefly tried nicotine replacement therapy and cognitive-behavioral therapy for smoking cessation but found them to be only partially helpful.  The patient also has a history of bipolar disorder and a chronic eating disorder.  Her last episode of depression was a year ago.  Medications include albuterol, salmeterol, fluticasone, and hydrochlorothiazide.  She takes no psychiatric medications.
The patient is afebrile.  Blood pressure is 138/88 mm Hg and pulse is 94/min.  Physical examination shows decreased breath sounds and expiratory wheezes, which are not new.
Which of the following is the most appropriate next step in management of this patient's smoking?

A) Offer aggressive behavioral support and reevaluate in 4-6 weeks
B) Offer behavioral support and bupropion
C) Offer behavioral support and varenicline
D) Offer varenicline in combination with nicotine replacement therapy
E) Prescribe short-acting nicotine replacement therapy

Correct Answer:

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