A pragmatic review of varenicline prescribing practices

Smoking is the leading preventable cause of illness and premature death worldwide. Most tobacco users desire to quit, but few are successful. Guidelines recommend varenicline as an initial treatment recommendation to support smoking cessation.

Determine whether historic warnings preclude the use of varenicline as an initial treatment recommendation in patients with and without certain comorbidities. Appendix 1 shows the questions asked in the survey.

This study was conducted in 2 parts. Part 1 of this study was a provider survey. Part 2 was a multicenter, retrospective chart review. Survey respondents were primary care providers (PCPs) or internal medicine residents within a large health system. Patients included in the chart review had a PCP appointment between January 1, 2017, and December 31, 2020, and a diagnosis of tobacco dependence or tobacco cessation therapy prescription.

In total, 352 providers were included in survey distribution and 56 responses were received, resulting in a response rate of 16%. Most providers (77%) indicated that they would be likely to use varenicline as an initial treatment recommendation in a patient with no comorbidities. Providers indicated they would be unlikely to use varenicline in a patient with certain mental health comorbidities (43%, 43%, and 55% for patients with bipolar disorder, schizophrenia, or history of suicide attempts, respectively, with 25%, 30%, and 27% having no opinion for each group). In addition, chart review yielded data for 25,128 patients. Notably, patients with schizophrenia were found to have an odds ratio of 0.55 (95% confidence interval [CI] 0.39-0.77) to receive varenicline at any point in therapy, and patients with diabetes had an odds ratio of 2.66 (95% CI 2.22-3.19) to receive no treatment.

Historic warnings for neuropsychiatric events with varenicline may still preclude usage in patients with serious psychiatric comorbidities such as schizophrenia. In addition, patients with diabetes were less likely to receive any form of tobacco cessation therapy.