For a 42-year-old woman with a smoking history of 2 packs daily and a first cigarette within 15 minutes of waking, what is the most appropriate initial treatment?

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The selection of varenicline as the most appropriate initial treatment for this patient is grounded in several clinical considerations. The patient's smoking history, which includes a high level of dependence indicated by smoking two packs a day and taking her first cigarette within 15 minutes of waking, classifies her as having a significant nicotine addiction.

Varenicline is a nicotine receptor partial agonist that helps reduce withdrawal symptoms and cravings by stimulating nicotine receptors in the brain while simultaneously blocking nicotine from binding to these receptors. By initiating treatment with a low dose of 0.5 mg daily for the first three days before increasing to the standard therapeutic dose, varenicline offers a tailored approach that can help address both the psychological and physiological aspects of nicotine dependence.

Moreover, clinical guidelines often recommend varenicline as the first-line pharmacotherapy for smoking cessation due to its efficacy and safety profile. It has been shown to double the chances of successful cessation compared to placebo, making it especially suitable for patients with a high degree of dependence.

In contrast, while nicotine replacement therapies (NRTs) such as patches and gum are effective for many smokers, they do not provide the same kind of receptor activity modification that varenicline does, particularly for someone with such a strong smoking

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