Chantix (varenicline) for Smoking Cessation

For any psychiatrist, the following is a very common scenario.

I am seeing Frank, a 45 year old man, who is afflicted with schizophrenia. He has been smoking heavily since he was a teenager. Though Frank has heard many times that smoking is bad for him, in all kinds of ways, he has never given much thought to quitting, until now. It might be his recent health changes, the death of a relative, the high cost of a pack of cigarettes, the hassles of finding a place where he can smoke in peace, or some combination of these. Whatever the cause, he is willing to discuss smoking cessation, and smoking cessation aids, for the first time. We talk about the options (one of my favorite words): going cold turkey (commonly done, not very effective for most people), bupropion, nicotine replacement in all it’s forms (gum, patches, lozenges, inhaler, nasal spray), and Chantix. As we go over the pros and cons, I point out that Chantix is the most effective at helping people quit (I use the brand name rather than the generic name varenicline since most people know it as Chantix and it is not yet available as a generic). He is clearly interested in going with the most effective medication, and his case manager and I are excited at his intent to give it a try. But wait, doesn’t Chantix cause people to get depressed, even become suicidal and to try and kill themselves, or to hear voices? Isn’t it contraindicated for people with mental illness?

Soon after Chantix was released it became clear that it was very effective for some individuals, and was generally superior to the medications already being used. Nausea was the biggest problem.

However, not long after it’s release there were reports that it might cause depression, suicidal thoughts, suicide attempts, psychosis and other neuropsychiatric side effects. That  presented smokers and their clinicians with a dilemma.  Smoking kills and disables very large numbers of people. Chantix was the most effective treatment available. Most people do not succeed with their first, second or even third attempt at quitting. It is hard to quit and many people get discouraged.  How dangerous is Chantix? Do the benefits outweigh the risks? Is it dangerous for everybody, or just some people?

These questions generated considerable interest and study, and not just from the makers of Chantix (who have such a strong vested interest that they cannot be trusted to study the issues objectively). We have learned, among other things, that smokers as a group are more prone to depression, and are more likely to attempt and commit suicide than non-smokers. Also, that the act of quitting smoking puts a person at risk of developing depression and suicidal thoughts. The question is not is Chantix dangerous, but is taking Chantix to quit smoking more dangerous for your mental health than other ways of quitting, such as cold turkey, or with nicotine replacement therapy, or with bupropion. And we now have evidence to answer that question, and I think the answer is good news for smokers.

In a study published online on Sept. 13, 2013 in AJP in Advance, researchers from the University of Chicago and at Columbia University performed the largest analyses to date, by combining data from a number of studies that in total included more than 40,000 smokers.

The data showed that varenicline was highly associated with inducing nausea among patients, but not suicide events, depression, or aggression. Current or past psychiatric illness increased the risk of neuropsychiatric events equally among the varenicline and placebo groups. In the drug-comparison studies, the rate of neuropsychiatric events in the varenicline cohort was significantly less than in those receiving nicotine-replacement therapy. Overall, varenicline was more successful in achieving smoking abstinence than placebo or nicotine-replacement therapy.”

In plain language: Chantix was more effective than nicotine replacement and bupropion, and it was no more likely than placebo to be associated with depression, suicidal thoughts, and other neuropsychiatric effects such as hallucinations.

Getting back to the questions asked earlier: Chantix is not contra-indicated in those with a current or past history of mental illness. The evidence at this point, and there is now good data to guide treatment decisions, is that Chantix is more effective than nicotine replacement and bupropion, and possibly even safer. And, it is no more dangerous than taking no medication when trying to quit smoking and a lot more effective than going cold turkey.

Varenicline, Smoking Cessation, and Neuropsychiatric Adverse Events  Robert D. Gibbons, Ph.D.; J. John Mann, M.D.                Am J Psychiatry 2013;:. doi:10.1176/appi.ajp.2013.12121599

Declaration of interest: I have no financial interest in Chantix or an other product used in helping people quit smoking.

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