The 2026 VA/DoD clinical practice guideline on tobacco use treatment was built from 19 key clinical questions, a systematic review of literature from January 2014 to December 2024, and GRADE assessment, producing 32 recommendations across 10 topic areas. Most guidance on smoking cessation tells clinicians to offer treatment; the useful part here is that it ranks the options and marks the strength of each.
Four recommendations carry strong grading and are directly actionable. Motivational interviewing to get people into treatment. FDA-approved pharmacotherapy rather than willpower. Varenicline in preference to monotherapy with any other agent. And combination nicotine replacement — a patch plus a short-acting form such as a lozenge — in preference to a single agent. Varenicline is also strongly recommended for smokeless tobacco, which is the form that matters most in India and is the one usually left out of cessation advice. Extending bupropion sustained release beyond 12 weeks is graded weak, as is nicotine replacement or varenicline for electronic nicotine delivery systems.
The recommendation worth changing a habit over is the last one: offering nicotine replacement or varenicline to people who are not planning to quit in the next 30 days. The usual practice is to assess readiness first and treat only those who say yes. This guideline, weakly, says treat anyway — pharmacotherapy increases both quit attempts and abstinence in people who had not asked for it.
- Offer varenicline first unless contraindicated, rather than starting with a patch alone.
- Where nicotine replacement is used, combine a patch with a lozenge or gum — single-agent NRT is the weaker option.
- Ask about smokeless tobacco separately; varenicline is strongly recommended for it.
- Offer pharmacotherapy to people who say they are not ready to quit, rather than deferring to the next visit.
- Varenicline supply in India has been intermittent — confirm availability locally before building a plan around it.
Why it matters
Cessation advice usually stops at readiness; this says treatment should not wait for it.
Don't overread it
This is a VA/DoD guideline developed for a largely male, American military and veteran population, and drug availability differs elsewhere.
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