The 2026 US Department of Veterans Affairs and Department of Defense guideline reviewed literature to December 2024 across 19 key questions and issued 32 recommendations using GRADE. The strong recommendations are the ones to carry into clinic.
For abstinence from combustible tobacco: use motivational interviewing to get people into treatment, use an approved pharmacotherapy, prefer varenicline to monotherapy with other agents, and prefer combination nicotine replacement — a patch plus a short-acting form such as a lozenge — over a single agent. Extending bupropion sustained release beyond 12 weeks is recommended weakly. Varenicline is also strongly recommended for smokeless tobacco, which matters more here than in the guideline's own population.
The recommendation most likely to change a consultation is the weak one about patients not ready to quit. Offering nicotine replacement or varenicline to someone who does not intend to stop in the next 30 days increases both quit attempts and abstinence. That inverts the usual sequence, in which pharmacotherapy is withheld until the patient declares readiness — a gate that filters out most of the people who would benefit.
- Combination nicotine replacement means a patch for background plus a lozenge or gum for breakthrough, not two short-acting forms
- Offer pharmacotherapy to people who are not yet ready to quit, rather than waiting for a declared quit date
- Smokeless tobacco has its own strong varenicline recommendation — ask about it separately from smoking
- Where varenicline supply is uncertain, combination nicotine replacement is the recommendation that travels, and it is also strongly made
- Motivational interviewing is recommended for engagement, not as a substitute for drug treatment
Why it matters
It removes readiness to quit as a precondition for treatment, which is the assumption that keeps most tobacco users unmedicated.
Don't overread it
A guideline developed for US veteran and military populations. The evidence base is general, but the smokeless tobacco and access recommendations were framed for that setting.
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