A work group from the US Department of Veterans Affairs and Department of Defense published a guideline on treating tobacco and nicotine use, summarised here in a synopsis. It has 32 recommendations across 10 topic areas, built from 19 key questions and a systematic review of literature to December 2024, graded with the GRADE method.
Among the strong recommendations for people who smoke are motivational interviewing to engage people in treatment, approved drug therapy, varenicline over other single agents, and combination nicotine replacement (such as a patch plus a lozenge) over a single product. Extending sustained-release bupropion beyond 12 weeks and e-cigarettes for abstinence are weak recommendations, as is offering nicotine replacement or varenicline to people not ready to quit within 30 days. Varenicline is recommended for smokeless tobacco.
The guideline was written for a US military and veteran population and for products on the US market. Smokeless tobacco is common in India, and the access and cost of varenicline here should be checked locally. Its conclusions on e-cigarettes are weak and should not be read as a general endorsement.
- Offer combination nicotine replacement, such as a patch plus a short-acting product, rather than a single product
- Consider varenicline as a first-line drug option when it is available and suitable
- Use motivational interviewing to start the conversation, even when the patient is not ready to quit
- For smokeless tobacco users, varenicline was the strong recommendation; the evidence base is narrower than for cigarettes
- Treat the e-cigarette recommendation as weak and apply local regulation and patient circumstances
Why it matters
It sets out what to prescribe, in what combination, and which options are firmly supported compared with those that are conditional.
Don't overread it
This is a US VA/DoD guideline for its own populations; other societies' recommendations may differ and have not changed because of it.
The statistics, in plain English
A strong recommendation means the work group judged benefits clearly outweigh harms for most patients; a weak one means the balance is closer and patient preference matters more. Both come from consensus informed by evidence grading, not from a single trial.
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