Tobacco treatment: varenicline over single agents, combination NRT over one product

Design

Clinical practice guideline based on systematic review with GRADE

Population

Adults using tobacco or nicotine products in the VA and DoD health systems

Primary outcome

Recommendations for increasing abstinence and quit attempts

Effect

32 recommendations; strong for varenicline over other monotherapy and for combination over single NRT

The 2026 VA/DoD clinical practice guideline on tobacco use treatment, summarised in Annals, makes 32 recommendations across 10 topics, built from a systematic review of evidence from 2014 to December 2024 and graded with GRADE.

Its strong recommendations are motivational interviewing to increase engagement, approved pharmacotherapy for people trying to stop smoking, varenicline in preference to monotherapy with any other agent, and combination nicotine replacement, such as a patch with a lozenge, over a single nicotine product. It also strongly recommends varenicline for smokeless tobacco. Weaker recommendations cover extending bupropion beyond 12 weeks, electronic nicotine delivery systems, and offering nicotine replacement or varenicline to people not ready to quit within the next 30 days.

The practical shift for a physician is in the defaults: a single nicotine patch is no longer the reasonable first offer when varenicline or combination replacement is available, and a patient's unreadiness to quit is not a reason to offer nothing. This is a US guideline. In India, varenicline availability has been inconsistent and its legal status should be checked locally; nicotine gum and patches are available, and the national quitline is 1800-11-2356. The weak recommendation on e-cigarettes does not apply in India, where their sale is prohibited.

• Offer varenicline, where available, in preference to any single other cessation drug.
• Combine a nicotine patch with a short-acting form such as gum or lozenge rather than prescribing one product.
• Offer medication even to patients not ready to quit within a month, to build towards an attempt.
• Use a brief motivational interviewing approach to bring hesitant patients into treatment.
• Refer patients to the national tobacco quitline for ongoing support.

Why it matters

The single-patch default that many prescribers still use is now below the recommended standard.

Don't overread it

This is a US military and veterans guideline; its e-cigarette recommendation does not transfer to India.

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