The 2026 VA/DoD clinical practice guideline on tobacco use treatment carries 32 recommendations across ten topic areas, built from a systematic review of literature to December 2024 and graded by GRADE.
Four of the strong recommendations are worth carrying out of the room. Motivational interviewing to get people into treatment. Any FDA-approved pharmacotherapy over none. Varenicline over monotherapy with any other agent. And combination nicotine replacement - patch plus a short-acting form such as a lozenge - over a single agent. Varenicline is also recommended strongly for smokeless tobacco. Weaker recommendations cover extending bupropion beyond twelve weeks, varenicline for people using electronic nicotine delivery systems, and offering nicotine replacement or varenicline to people not ready to quit in the next thirty days.
That last one is the change most clinics have not made. The default is still to wait for readiness. Smokeless tobacco matters more in India than in the population this guideline was written for, and the strong varenicline recommendation for it is directly transferable. Varenicline supply in India has been intermittent; check availability locally before building a pathway on it.
- Offer varenicline first unless contraindicated, rather than nicotine replacement by default.
- If using nicotine replacement, combine a patch with a short-acting form - not a patch alone.
- Offer pharmacotherapy to people not ready to quit within 30 days, rather than waiting for readiness.
- Varenicline carries a strong recommendation for smokeless tobacco, which matters in Indian practice.
- Check local varenicline supply before writing it into a clinic pathway.
Why it matters
Most clinics still offer a patch and wait for the patient to be ready; this guideline recommends against both halves of that habit.
Don't overread it
Written for US veterans and service personnel - the evidence is general but the population and drug availability are not.
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