Medications to help people quit smoking are typically recommended as an early intervention, and over the past several years these have included nicotine replacement such as a patch or gum, or sustained release buproprion (zyban), and now chantix, with evidence supporting it as a leading effective option, as described in my prior post. The FDA has also approved these options for smoking cessation. Specifically, chantix is approved for people who have not received prior treatment to help them quit smoking, or in those who have tried another method unsuccessfully. Still, this is a treatment that is indicated for patients who possess the motivation. There are people who can quit smoking without the assistance of medication, and medication without an underlying commitment to smoking cessation is not likely to be successful.

The most advocated way to pursue smoking cessation successfully is to set a quit date that is a week after starting chantix. During that first week, the dose of chantix is gradually increased from 0.5 mg by mouth once daily for the first 3 days, then twice daily for the next 4 days, and then the full dose of 1 mg by mouth twice daily after the first week, which should coincide with the target quit date. The gradual dose escalation can help reduce nausea, which is typically mild to moderate but can occur in 30-50% of people and tends to be worse when starting right at the full dose. In addition, nausea can be reduced by taking chantix with food. Still, some patients may continue to have nausea, and in such cases it may be best to drop the dose down to 1 mg daily and then consider trying to get back up to 1 mg twice daily later.

In keeping with patients needing to have the motivation to quit and not just a medication to treat the issue, ongoing counseling and encouragement by the medical team and/or others can help. These periodic discussions don’t need to be prolonged, but there is an association of more discussion/encouragement with better success with smoking cessation (guidelines here). There’ s value as well in telephone-based support (abstract here), which is offered by some programs.

There are some limitations and safety concerns with chantix. In addition to nausea, insomnia, abnormal dreams, headhaches, and GI side effects other than nausea (indigestion, constipation, diarrhea, gas) can also occur in about 10-22% of patients, which is only slightly more than the rates with a placebo. About 12% of patients in the clinical trials with chantix stopped it early because of problematic side effects, most commonly nausea. For patients who start chantix but can’t tolerate it, or are taking it but can’t maintain motivation to quit, it’s possible to discontinue chantix immediately: no taper is required.

Chantix also shouldn’t be given to pregnant or lactating women now, since we don’t know about safety to the fetus or infant in this population yet. It’s excreted in the urine after going through the kidneys, so liver function isn’t really an issue, but patients with significant kidney problems are recommended to have a dose reduction. However, routine dose reductions aren’t required for older patients with reasonable kidney function. Because chantix is excreted primarily without being metabolized by the body, it doesn’t typically have interactions with other medications.

There have also been several high profile reports about psychiatric symptoms associated with chantix, which are rare and and can range from agitation to depression to suicidality to worsening of a patient’s underlying psychiatric problems if they have them (alert here). However, it’s not entirely clear that the chantix is a direct contributor, since smoking itself and nicotine withdrawal can increase risk of suicidal behavior. This is still controversial and uncommon to rare, but family and friends who know the patient should be aware of this possibility and alert a doctor about any observed behavioral changes, ideally also stopping chantix until the situation is clarified. Of note, chantix hasn’t been tested in patients with severe psychiatric disorders, so it’s important to be cautious about potentially using it in patients who may be at considerably higher risk for significant psychiatric probems. And until the effect on driving and operating heavy machinery can be clarified, the FAA prohibits pilots and air-traffic controllers from taking chantix.

Of note, chantix has really been studied only as a single agent approach, and while it may be possible to combine it with zyban or nicotine replacement, we don’t have evidence to confirm the safety of this strategy yet, so it isn’t recommended.

So just to summarize, the US Public Health Service in its clinical practice guidelines recommends considering chantix as an option for a first approach to smoking cessation, and other countries also have similar guidelines. However, this is in conjunction with behavioral support, and it’s to be directed to people who are motivated to quit smoking. Even with several tools, smoking cessation is a challenge, but chantix is one more valuable tool for many patients.