A patient wishing to quit smoking is already taking varenicline (Chantix). What additional intervention should be recommended?

Correct answer: D. Behavioural counselling

• A. Adding bupropion to varenicline is not standard practice. Both act centrally, the combination increases neuropsychiatric and seizure risk, and evidence of added benefit is limited.
• B. Medication alone leaves a substantial part of the intervention undone. The behavioural component is what supports the patient through the triggers and lapses that pharmacotherapy does not address.
• C. Nicotine replacement combined with varenicline is used in some specialist settings but is not the routine recommendation, and it raises the frequency of nausea and other side effects.
• D. CORRECT. Pharmacotherapy and behavioural counselling work through different mechanisms and their effects are additive — combining them produces substantially higher abstinence rates than either alone. Varenicline addresses the neurochemistry by partially agonising the α4β2 nicotinic receptor, reducing both craving and the reward from smoking. Counselling addresses the behavioural triggers, habits and coping strategies that medication cannot touch. Every major guideline recommends offering both, and counselling is the appropriate addition when the patient is already on effective pharmacotherapy.

Note: The 5 A's: Ask, Advise, Assess, Assist, Arrange. The dental visit is a genuinely effective cessation opportunity — you have visible evidence of harm in front of the patient (staining, periodontal breakdown, leukoplakia) and a natural recall interval for follow-up.