The 2026 VA/DoD clinical practice guideline on tobacco use treatment distils 32 recommendations, and the strong ones are worth carrying into any clinic that prescribes for smokers.
For combustible tobacco, the strong recommendations are motivational interviewing to engage patients, FDA-approved pharmacotherapy as standard, varenicline in preference to other single agents, and combination nicotine replacement, such as a patch plus a lozenge, over single-agent replacement. Extending bupropion sustained release beyond 12 weeks is a weaker suggestion. The guideline also backs offering nicotine replacement or varenicline to patients who are not ready to quit in the next month, to raise quit attempts.
The actionable shift for many prescribers is to reach for varenicline first and to combine nicotine replacement rather than using a patch alone, and to treat even ambivalent smokers rather than waiting for readiness.
- Varenicline is recommended over other single-agent pharmacotherapies (strong).
- Combination nicotine replacement (for example patch plus lozenge) beats monotherapy (strong).
- Motivational interviewing to engage patients is a strong recommendation.
- Offer nicotine replacement or varenicline even to those not ready to quit within a month.
- Extending bupropion sustained release beyond 12 weeks is a weaker option.
Why it matters
It pushes against the habit of single-agent nicotine replacement and of waiting for a patient to declare readiness.
Read the rest in the app
You have read your two free briefings this month. The app carries all 27 specialties, every morning, free — and this finding is waiting in it.
Scan to keep reading on your phone. No account needed to start.
Tomorrow morning, before your first patient
One edition a day for internal medicine, written by the desk, every claim tied to its paper. Six minutes.
Get the app — free