Can You Smoke While Taking Varenicline?
Yes, you can smoke while taking varenicline—in fact, the standard dosing protocol explicitly allows continued smoking during the first 1–2 weeks of treatment, with the quit date set after medication has been started. 1
Standard Varenicline Initiation Protocol
Begin varenicline 1–2 weeks before your chosen quit date, using the National Comprehensive Cancer Network (NCCN)-recommended titration schedule: 0.5 mg once daily for days 1–3,0.5 mg twice daily for days 4–7, then 1 mg twice daily starting week 2 through week 12. 1
Patients are expected to continue smoking during the initial titration period (the first 1–2 weeks) while varenicline reaches therapeutic levels and begins to reduce nicotine cravings and the rewarding effects of smoking. 1
The medication works as a partial nicotinic receptor agonist, meaning it reduces both withdrawal symptoms and the satisfaction you get from smoking, making it easier to quit when you reach your target quit date. 2
Safety of Smoking While on Varenicline
No evidence suggests that smoking while taking varenicline increases cardiovascular risk, neuropsychiatric events, or other serious adverse events. The FDA label and clinical guidelines do not list concurrent smoking as a contraindication or safety concern. 3
Large randomized controlled trials, including studies in patients with cardiovascular disease, psychiatric disorders, and HIV, have demonstrated that varenicline is safe and well-tolerated even when patients continue smoking during the initial treatment phase. 4, 5, 6
The EAGLES trial—the largest safety study of varenicline (>8,000 participants, including >4,000 with psychiatric disorders)—found no increase in neuropsychiatric adverse events, cardiovascular events, or mortality with varenicline compared to placebo or nicotine patch, regardless of smoking status during treatment. 1
What Happens If You Continue Smoking After the Quit Date?
Varenicline reduces the rewarding effects of nicotine, so cigarettes become less satisfying even if you continue to smoke. This is part of the medication's mechanism of action. 2
If you smoke after your quit date, do not stop varenicline—continue the medication and work with your healthcare provider to intensify behavioral counseling or adjust your treatment plan. 1
For patients who fail to achieve abstinence during the initial 12-week course, NCCN guidelines recommend continuing or resuming varenicline, switching to combination nicotine replacement therapy, or progressively intensifying behavioral therapy before trying other options. 1
Combining Varenicline with Nicotine Replacement Therapy (NRT)
NCCN guidelines note that blood nicotine levels from NRT are significantly lower than from smoking cigarettes, and NRT is well tolerated even when used concurrently with smoking. 7
However, combining varenicline with a nicotine patch may increase nausea, vomiting, headache, dizziness, upset stomach, and tiredness compared to using a nicotine patch alone. 3
NCCN recommends varenicline monotherapy or combination NRT as first-line treatment, reserving varenicline plus NRT for patients who fail monotherapy with either agent. 7
Key Safety Monitoring Points
Monitor for neuropsychiatric symptoms (depression, suicidal ideation, agitation, behavioral changes) throughout treatment, though large-scale trials found no significant increase in these events with varenicline. 1, 3
Discontinue varenicline immediately if you experience worsening depression, suicidal thoughts or behavior, aggression, hostility, or panic attacks, and contact your healthcare provider. 3
Common side effects include nausea (28–40%), insomnia (14%), and abnormal dreams (10–13%)—these are typically mild to moderate and diminish over time, not related to concurrent smoking. 1
Clinical Bottom Line
Smoking while on varenicline is not only safe but is the expected practice during the first 1–2 weeks of treatment. The medication is designed to be started before your quit date, allowing it to reach therapeutic levels while you continue smoking. After your quit date, varenicline will make cigarettes less satisfying and reduce cravings, but if you do smoke, continue the medication and work with your provider to optimize your cessation plan rather than stopping treatment.