Ask the Experts: Is it helpful to use varenicline and nicotine patch together for smoking cessation?

by Marlena Parson, PMHNP-BC, Duke Smoking Cessation Program

Nicotine patch (Wikimedia Commons)

It's a well-known fact that quitting smoking can greatly improve health outcomes; yet, for some smokers, commonly used approaches to smoking cessation may not work. However, a combination therapy pairing nicotine patch and varenicline has emerged as a highly effective strategy for some individuals who want to quit smoking. I spoke with Dr. James Davis, Medical Director of the Duke Center for Smoking Cessation to find out more about the potential of this combination strategy.

Combining nicotine patch with faster-acting nicotine replacement, such as nicotine gum and nicotine lozenge is a well-established strategy, but the concept of nicotine patch with varenicline is less familiar. Please share more about the science behind this approach.

Varenicline molecule stdructure (Wikimedia Commons)

“Nicotine patch is designed to decrease symptoms of nicotine withdrawal--such as irritability and difficulty concentrating. Varenicline works differently; it blocks nicotine receptors in the brain so that nicotine from smoking can’t reach the receptor. If nicotine cannot reach the nicotine receptor, then smoking is no longer satisfying. If a person uses a nicotine patch and varenicline together, the patch decreases withdrawal symptoms and the varenicline makes smoking less satisfying. It's a nice combination of effects.”

What patient presentation would be ideal for considering this method?

“Combination varenicline-nicotine patch is almost only used in people with high nicotine dependence. Signs of high nicotine dependence include: smoking first thing when they wake up in the morning, smoking after waking up at night in order to get back to sleep, severe nicotine withdrawal symptoms, and a family history of severe addiction to cigarette smoking. Often patients with high nicotine dependence will say, 'I’ve tried everything and nothing works.” High nicotine dependence represents about 15-20% of the smoking population."

Any special considerations for providers monitoring patients during combination therapy?

“At the Duke Smoking Cessation Program, we combine varenicline-nicotine patch quite frequently. When we start this combination, we first provide education to patients on side effects. We then check in regularly to monitor for these potential side effects. The most common side effects are nausea, vivid dreams, insomnia, and dry mouth. That said, most people tolerate the combination quite well. A good approach to minimize the potential for side effects is to start one medication at a time and to start with lower doses of medications before increasing.”

Conclusion

Combining the nicotine patch with varenicline represents a powerful and effective strategy for a group of people who smoke and have high nicotine dependence. By decreasing nicotine withdrawal and decreasing the pleasurable aspects of smoking, this combination therapy significantly increases the chances of successfully quitting in patients with high nicotine dependence.

Click here to read a case report about use of combination nicotine patch and varenicline by Dr. James Davis.

Learn more about combination therapy and other effective pharmacological interventions for tobacco use treatment in our upcoming CE Short--Course Tobacco Dependence Pharmacotherapy--on December 5, 2023. Learn More or Register Now >>

About the Author

Marlena Parson, PMHNP-BC, is a psychiatric nurse practitioner with the Duke Smoking Cessation Program. She has extensive experience helping adults who are new to smoking cessation understand their treatment options. She enjoys forming long-term therapeutic alliances with her patients to help them quit tobacco use and live healthier lives.