Varenicline for cessation from nicotine-containing electronic cigarettes

Approximately 10.8 million individuals in the United States used electronic cigarettes (e-cigarettes) in 2016.¹ Also known as e-hookahs and vapes, e-cigarettes generally have a battery, heating element, and liquid reservoir.² They usually contain the addictive drug nicotine and may have other harmful substances, including carcinogens and heavy metals. Many adults use e-cigarettes for cigarette smoking cessation, but e-cigarettes are not Food and Drug Administration (FDA) approved, and insufficient evidence exists to recommend their use for this indication.

There are 7 available FDA-approved medications for cigarette smoking cessation; these include 5 nicotine replacement therapies (NRTs), bupropion, and varenicline. Varenicline is a partial neuronal α-4 β-2 nicotinic receptor agonist whose use results in decreased craving and withdrawal symptoms. It is initiated 1 week before a patient’s cigarette quit date. It is generally taken orally at 0.5 mg daily for 3 days, with the dosage increased to 0.5 mg twice daily for 4 days and then to 1 mg twice daily thereafter. The typical duration of treatment is 12 weeks, but some patients may be candidates for 24 weeks of treatment. Potential adverse effects include nausea, headache, and vivid dreams. Precautionary prescribing warnings include suicidal ideation and depressed mood. In 2011, FDA issued a safety alert regarding the potential risk of cardiovascular events in patients with preexisting cardiovascular disease.³

Although varenicline is among the medications approved for cigarette smoking cessation, there is no established regimen for e-cigarette vaping cessation. This raises the question of what can be used for the successful management of patients who seek to quit e-cigarettes. We report a case of e-cigarette cessation using varenicline in a patient seen in a pharmacist-managed smoking cessation clinic.

The patient was a 53-year-old Caucasian man and 9/11 responder with a history of rhinitis, sinusitis, gastroesophageal reflux disease, lung nodules, and osteoarthritis. He denied any history of mental health treatment, head injuries, seizures, or atypical chest pain. He reported a 15-year history of tobacco use, smoking 1 to 1.5 packs of cigarettes per day, and a past cessation trial and failure with an NRT combination of patch and gum. The patient had switched to e-cigarettes (Logic, Princeton, NJ), vaping 2 cartridges (containing 27 mg/mL of nicotine) per day for the last 4 years.⁴ He reported a strong desire to quit e-cigarettes but denied any past pharmacotherapy trials, with the exception of NRT for his cigarette use.

The patient and clinical pharmacist agreed on varenicline therapy. The pharmacist counseled the patient about adverse effects and proper medication administration. The plan was to use varenicline for 12 weeks. Significant barriers to the patient’s vaping cessation attempt included the severity of nicotine addiction and his vaping triggers. The pharmacist provided behavioral techniques to aid in vaping cessation. The patient was seen 1 month after varenicline initiation. He reported medication adherence and denied any vaping or adverse effects except for 1 vivid dream. The patient reported that varenicline was dispensed as 0.5 mg twice daily and that the instructions for use did not include the adjustment to 1 mg twice daily. The pharmacist provided counseling about the dosage elevation regimen, and the patient professed understanding.

During his 2-month follow-up visit, he denied any vaping but reported weight gain secondary to substituting food for vaping. The pharmacist reinforced the importance of behavioral interventions to cope with triggers and choosing healthy snacks and referred the patient to a registered dietitian. The patient reported an improvement in his breathing since e-cigarette cessation. He denied adverse effects but stated that he occasionally missed the second daily dose of varenicline. The pharmacist discussed the importance of and offered techniques to improve medication adherence.

At the 3-month follow-up visit, the patient denied vaping and reported a decrease in vaping urges and triggers. He also stated that he lost 5 pounds after seeing a dietitian. He denied adverse effects but again reported forgetting occasionally to take the second daily dose of varenicline. The pharmacist reinforced the importance of adherence and the patient’s success in cessation and discussed what was planned after completion of varenicline therapy. The patient remained motivated to continue the cessation plan.

The pharmacist conducted a telephone follow-up with the patient 1 month later. He reported completion of the varenicline regimen and e-cigarette abstinence and agreed to a follow-up in 6 months.

This experience suggests that varenicline may be beneficial for nicotine-containing e-cigarette cessation. Our patient demonstrated successful cessation with a 12-week course of varenicline and behavioral counseling. Aside from 1 vivid dream, varenicline also proved to be safe. Research may determine varenicline’s role in e-cigarette cessation and indicate whether other smoking cessation medications may be effective for people who wish to quit e-cigarettes.

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