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How varenicline works

Tobacco contains nicotine. When you smoke, nicotine is absorbed through your lungs into your blood. When nicotine reaches your brain it can cause feelings of pleasure, often leading to nicotine addiction.

When you stop smoking you may experience a variety of symptoms such as craving a cigarette, feeling restless, a change in mood, or trouble sleeping. For most people who stop smoking these withdrawal symptoms are worse in the first few days to a couple of weeks, then they reduce in strength and frequency.

Varenicline works by attaching to the same receptors in the brain as nicotine, reducing the pleasurable feelings experienced when using nicotine-containing products. Varenicline increases the likelihood you will stop smoking, but also allows a gradual reduction in nicotine dependence. Compared with nicotine replacement therapy, where the body remains addicted to nicotine, varenicline has the additional benefit of weaning you off nicotine.

How to use varenicline

Varenicline tablets are taken twice daily, usually for 12 or 24 weeks.

The dose is built up over a week, starting 1-2 weeks before target stop smoking date:

Varenicline schedule of treatment to reduce nicotine cravings

Days of treatment	Dosage and frequency
Days 1-3	0.5mg once a day
Days 4-7	0.5mg twice a day
Day 8 onwards	1mg (or 2 x 0.5mg) twice a day

The dose can be reduced to 0.5mg twice a day if the higher dose is not tolerated.

An alternative version of the varenicline treatment schedule which you may find easier to follow (from the National Centre for Smoking Cessation and Training).

The complete course is for 12 weeks. It can be repeated for a further 12 weeks if there are still significant withdrawal symptoms.

If smoking resumes after 12 weeks, or whilst taking the treatment, then this is a smoking relapse and you should stop taking varenicline. A further course may be repeated when you decide to try and stop again. Further attempts may be more successful if the longer course of 24 weeks is used.

Forgotten dose - DO NOT make up for the missed dose by taking more than the maximum daily dose, but resume at the normal daily dose.

Accidental overdose - if too much varenicline is taken in error, seek medical advice.

Pregnancy and breastfeeding

Varenicline should not be used if you are pregnant or breastfeeding as the effects on your baby are unknown.

Every cigarette contains more than 4,000 chemicals, many of which are dangerous. Smoking during pregnancy can restrict the essential oxygen supply; harming your unborn baby. In many areas of the UK there are specialist NHS services to assist pregnant women to stop smoking. It is advisable to speak to your midwife or doctor for advice.

• NHS - Stop smoking in pregnancy
• RCOG - Smoking and pregnancy patient information

Cautions

A caution does not mean that a medicine cannot be used. It means the risks should be assessed by an appropriately trained clinician, and monitoring for worsening of an existing medical condition may be required.

Cardiovascular disease - you may take varenicline, but if you develop any worsening symptoms, particularly chest pain indicating angina, heart attack, or symptoms of a stroke, you must stop taking varenicline and seek emergency medical assistance.

Dr Fox cannot supply varenicline if you have the following conditions:

• Psychiatric illness.
• Active depression.
• Seizures, epilepsy, or a condition that makes you more likely to have a seizure.
• Renal failure/severe kidney disease - you will likely need a reduced dose and monitoring by your usual GP.

When the course of varenicline has ended, some people experience poor sleep and/or low mood/depression for a few days. The chance of this occurring can be reduced by lowering the dose gradually before stopping treatment. To do this, once the course has been completed, reduce to 0.5mg twice a day for a week, then 0.5mg once a day for a week. Additional 0.5mg tablets can be purchased to do this.

It is rare but possible to feel suicidal after stopping varenicline; if this occurs you must seek medical advice immediately.

Driving and skilled tasks

When starting this medication you should ensure you do not experience dizziness or sleepiness before driving.

Possible side effects of varenicline

Varenicline is usually well tolerated, however the following side effects are most commonly reported:

• Nausea.
• Nose or throat inflammation.
• Difficulty sleeping, abnormal dreams.
• Headache.

For more detail about potential varenicline side effects, see the patient information leaflet supplied with varenicline.

Varenicline interaction with other medicines

There are no significant interactions between varenicline and other medications.

Do not take other stop-smoking medicines at the same time as varenicline, especially nicotine replacement in the form of gums, tablets, sprays, and patches. Nicotine and varenicline attach to the same receptors in the brain and may block each other's actions.

If you take theophylline, warfarin, or insulin, you should consult your GP before simply stopping smoking, as the dose of these medications may need adjusting.

There are some reports of increased susceptibility to alcohol whilst taking varenicline.

Alternative stop smoking treatments

In the UK several treatments are available to help you to quit smoking in addition to varenicline.

Cytisine: 25-day course, prescription-only tablet used to reduce nicotine cravings during quit smoking attempts. Available from Dr Fox.

Nicotine replacement therapy (NRT): transdermal patch, gum, lozenge, nasal spray, inhalator & mouth spray. Use of a longer-acting transdermal patch in combination with a faster-acting gum, lozenge, or inhalator is called 'combination NRT' and is more effective than using a single product. Used in approximately 15% of quit attempts in the UK. Available over the counter from pharmacies and some supermarkets.

Nicotine vapes (e-cigarettes) allow you to inhale nicotine in a vapour rather than smoke. They are generally more effective than NRT. People who use vapes to stop smoking are still experiencing the addictive effects of nicotine and therefore tend to continue to use them for months or years after stopping smoking tobacco. Used in approximately 35% of quit attempts in the UK. Available over the counter from pharmacies and some supermarkets.

Bupropion (Zyban) is licensed for use in the US as an antidepressant and as a stop smoking aid. Zyban is available only on prescription. Used in less than 1% of quit attempts in the UK.

Dr Fox does not supply Zyban, NRT, or nicotine vapes.

For more information see the NHS Stop smoking treatments and Using e-cigarettes to stop smoking advice.

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Improving your chances of quitting

If you are mindful, notice your cravings and find strategies to manage them that work for you, you are more likely to succeed in your quit smoking attempt. Here are some hints and tips for you to consider:

• Make a quit plan - think ahead about ways you will manage your cravings if and when they happen. Choose a quit date, stick to it, and seek support from family, friends, and colleagues.
• Know your triggers – cravings and thoughts about smoking can be triggered by the people you spend time with, the places you go, and the situations you encounter. Avoid your triggers, at least temporarily, after you quit to help lessen your cravings and give you time to build confidence and skills for remaining smokefree.
• Distract yourself – practice mindfulness and remember your reasons for quitting. Quitting smoking is great for your health, the health of those around you, and your bank account! Calculate how much money you will save per week/per year and what you could spend your money on instead.
• Get text message support – SMS text the keyword CRAVE to 47848 to get 24/7 immediate support whenever you have a craving, or text QUIT to 47848 to sign up for SmokefreeTXT, a 6 to 8 week program of daily text message support, tips, and encouragement.
• Use the free Smokefree.gov quitSTART app – track your cravings and understand your smoking patterns with one of the Smokefree.gov apps.

If you don't manage to quit 1st time, or if you relapse, then try again having learned from your previous experience. To read more use this link: Managing Nicotine Withdrawal (Smokefree.gov).

Managing nicotine cravings and increased appetite

Cravings are powerful urges to smoke for which there may be triggers, e.g. stressors, situations where you would usually smoke, seeing others smoking. You are more likely to give in to cravings if your inhibitions are reduced, e.g, by drinking alcohol or using recreational drugs.

Nicotine can also reduce your appetite, therefore stopping smoking may inadvertently increase your appetite. If you choose to eat as an alternative to smoking, you may gain weight. Suggestions for keeping your hands and mouth busy are:

• Have to hand a 'fiddle toy'.
• Drink water if you are tempted to eat between meals which also keeps you hydrated.
• Take a short walk or do 5 minutes exercise which also good for your general health.
• Further information: Manage Weight Gain After Quitting (Smokefree.gov).