“I tried patches. They did nothing.”
I hear that sentence most weeks, and it is almost never the end of the story. Ask three more questions and it usually turns out the patch was 14 mg, it was worn for four days, there was nothing for the sudden cravings, and nobody explained that there should have been.
That client did not fail nicotine replacement therapy. They were never shown how to use it.
Medication is still discussed too briefly in most consultations. Some clients are afraid of side effects. Some stop early because the cravings came back anyway. Some feel that using medication means they are not really quitting by themselves. And some were simply asked “do you want medication?” and said no, because that is what you say to a question you do not understand.
So the useful question for practice is not which medication has the strongest evidence. It is how medication gets explained, matched and supported in a real quit attempt.
This is a summary of where the guidance and the recent research stand on varenicline, nicotine replacement therapy, bupropion and cytisine, and what each of those means once someone is sitting in front of you.
What Medication Is Actually For
Medication does not make the emotional, behavioural and social layers of smoking disappear. It was never going to.
What it does is lower the biological pressure of withdrawal. That matters more than it sounds.
Most people do not go back to smoking because they lack insight. They go back because craving, low mood, irritability, broken sleep and a bad afternoon all arrive in the same week, and the cigarette is the fastest thing available. Medication puts a little more space between the urge and the hand.
That space is where your work happens. It is the room in which someone can use a coping plan, get to the next appointment, change a routine, delay an impulse, practise a different response.
Which gives a sentence worth saying out loud:
Medication does not quit for you. It steadies the body while you learn how to live without cigarettes.
Where the Guidance Stands
The WHO published its first clinical treatment guideline for tobacco cessation in adults in 2024. It recommends varenicline, nicotine replacement therapy, bupropion and cytisine as pharmacological options for people who smoke and want to stop. Varenicline, NRT and bupropion are named as first-line, and combination NRT — a patch plus a short-acting form — is listed as an option for anyone using NRT. The certainty is high for varenicline, NRT and bupropion, and moderate for combination NRT and cytisine (World Health Organization, 2024).
NICE updated its own guidance in February 2025 and added cytisinicline to the list of options that, combined with behavioural support, are more likely to result in someone stopping. That list now reads: cytisinicline, a combination of short-acting and long-acting NRT, varenicline, and nicotine-containing e-cigarettes. Bupropion remains prescribable but is not on it. NICE also sets a clear limit: cytisinicline is not to be offered to people aged 66 and over (National Institute for Health and Care Excellence, 2025).
The Canadian Task Force takes the same direction, recommending that people who smoke be offered evidence-based support including behavioural help, pharmacotherapy or both, with the choice made together (Canadian Task Force on Preventive Health Care, 2025).
The practical point underneath all three: medication is not an extra reserved for heavy smokers. It is a standard part of cessation care, and the work is in matching it to the person.
Varenicline: Strong Evidence, Poorly Explained
Varenicline remains one of the most effective options available. The evidence behind the WHO recommendation is high-certainty, and it puts varenicline ahead of placebo, ahead of bupropion, and ahead of single-form NRT (World Health Organization, 2024).
That does not mean every client should be on it. It means the conversation about it has to be a real one.
What people need to understand before they start:
- why it is usually started before the quit date
- that it reduces what a cigarette gives you, rather than removing the wish for one
- that cravings will still happen
- what to watch for, and when to contact the prescriber
- why finishing the course matters
The common failure is quiet and predictable. Someone expects the medication to remove every urge, has an urge in week two, and concludes it is not working. Then they stop taking it, and then they smoke.
A better sentence to hand over at the start:
This may lower the intensity of the urge and take the reward out of smoking. You will still notice cravings. They should be easier to sit through.
Craving is not failure. If nobody says that, the client will decide it is.
NRT: Not One Product, a System
Nicotine replacement therapy gets dismissed more often than anything else, usually by people who have tried it informally and badly.
The evidence is unambiguous on one point. Cochrane found high-certainty evidence that combination NRT — a patch plus a fast-acting form such as gum or a lozenge — produces higher long-term quit rates than a single form, roughly 17 to 37 percent higher, across sixteen studies and more than twelve thousand participants (Theodoulou et al., 2023).
Which makes sense the moment you picture a day. The patch is the floor under the whole day. The gum, lozenge or spray is for the moments that break through it: the coffee, the car, after dinner, the difficult phone call.
Said plainly to a client:
The patch is the background. The gum is for the moments that come through it.
So “have you tried NRT?” is not the question. These are:
- Which form did you use?
- What strength, and for how long?
- Did you have anything for sudden cravings?
- What made you stop using it?
- Did anyone explain how to combine two forms?
Nine times out of ten the answer to the last one is no.
Bupropion: Still There, With Conditions
Bupropion is still in the WHO guideline as a first-line option, and it still works. But the same guideline shows it producing lower quit rates than varenicline and lower than combination NRT, and more people leaving treatment because of side effects than with placebo (World Health Organization, 2024).
So it is not a casual suggestion. It needs a proper medication history, a contraindication check, and a prescriber who knows the person.
One question opens most of that up:
Have you ever stopped a medication because of side effects, or because it made you feel not quite yourself?
The answer tells you what to expect this time, and often prevents someone quietly stopping in week three without telling anyone.
Cytisine: Old Drug, New Attention
Cytisine has been used in central and eastern Europe for decades. What is new is the evidence behind it and the regulatory movement around it.
The ORCA-3 trial, published in 2025, gave 792 adults who smoked at least ten cigarettes a day either six weeks of cytisinicline, twelve weeks, or placebo, all with behavioural support. On the twelve-week course, 30.3 percent were abstinent in the final four weeks of treatment against 9.4 percent on placebo, and 20.5 percent against 4.2 percent were still abstinent at twenty-four weeks. Cravings dropped further than on placebo, and 1.7 percent stopped treatment because of side effects (Rigotti et al., 2025).
Treatment duration differs from the other options. NICE notes a twenty-five day course for the cytisine product licensed in the UK, against twelve weeks for varenicline. In ORCA-3 the twelve-week cytisinicline course produced higher abstinence at twenty-four weeks than the six-week course, 20.5 percent against 6.8 percent (Rigotti et al., 2025).
But availability is where this gets local. Licensing, product names, age limits and guideline status differ from country to country. NICE added cytisinicline in February 2025 and excluded people aged 66 and over. Elsewhere it may not be licensed at all (National Institute for Health and Care Excellence, 2025).
Worth watching. Always worth checking locally first.
Combining: Not Automatically Better
For NRT, combining is settled. Patch plus fast-acting beats one form alone, with high-certainty evidence behind it (Theodoulou et al., 2023).
For varenicline plus NRT, it is less tidy. A 2025 systematic review found low-certainty evidence that the combination may improve long-term quit rates compared with varenicline alone, and that it is generally well tolerated. Side effects were somewhat more common, and skin reactions notably so where a patch was used (Zhou et al., 2026).
Low certainty is not nothing, and it is not proof either. It means this is a conversation, not a default.
The question to hold in mind is not whether more is stronger. It is:
Would this person be helped by tighter craving control, or would a more complicated plan be the thing they abandon?
Medication only works if it gets taken.
What This Changes in the Room
The old question was: do you want medication?
It invites a no, because it asks someone to decide about a thing they have not been told anything about.
The better question is: what would make this attempt more survivable for you?
And then the ones underneath it:
- What happened the last time you tried?
- Did the cravings build slowly, or arrive all at once?
- Did you stop the medication early? What made you stop?
- Were you afraid of the side effects, or of something else?
- Did you decide it was not working because you still had urges?
- Do you need steady cover through the day, something for the spikes, or both?
- What would make a plan feel manageable rather than one more thing to fail at?
These turn medication from a product into a plan that belongs to the person.
What a Medication Conversation Should Cover
The aim is not to talk everyone into medication. It is to make sure nobody declines it because nobody explained it.
- how dependent this person actually is
- previous attempts, and what happened in them
- previous experience with these medications specifically
- fear of side effects, named out loud
- medical history and contraindications
- pregnancy or breastfeeding, where relevant
- mental health history, where relevant
- cost and access, which decides more than we like to admit
- prescription or over the counter
- what behavioural support runs alongside it
Prescribing sits with whoever is licensed to do it where you work. The translating does not. That part is yours.
The Short Version
Varenicline has the strongest evidence. Combination NRT beats a single form, and most people have never been shown how. Bupropion still has a place, with screening. Cytisine is worth watching, and worth checking locally before you mention it. Combining varenicline with NRT may help some people, on low-certainty evidence, and adds side effects.
None of that answers the question practitioners actually face, which is not which medication is best.
It is which support fits this person’s dependence, fears, previous attempts, medical history and ordinary Tuesday.
Medication does not replace the conversation. Used properly, it is what makes the conversation possible.
Who Wrote This
I am a registered nurse in the Netherlands, qualified in asthma and COPD, with twenty-five years in pulmonary care. I work in a hospital pulmonology outpatient clinic. I am also a smoking cessation coach listed in KABIZ, the Dutch quality register for healthcare professionals, which means I work to the national care standard for tobacco and nicotine dependence.
The worksheets exist because I kept wanting to hand someone a single page that did not lecture them, and could not find one.
Evidence-informed and developed with reference to current tobacco-dependence and smoking-cessation guidelines, using CBT-informed behavioral tools to support structured cessation conversations.
Every page is built on national standards for tobacco dependence and on published evidence, and checked against the guidance in each. See the seven guidelines. Support tool only. Not medical advice, and not a substitute for the clinical judgment of the practitioner using it. Prescribing decisions, doses and suitability follow your own national guidance and the product information.
Questions
Which stop-smoking medication works best?
Varenicline has the strongest evidence, and combination NRT is close behind. But the medication someone will actually finish beats the one with the better trial results.
My client says patches did not work. What now?
Ask which form, what strength, for how long, and whether they had anything for sudden cravings. Most people have used a single low-dose form for a few days. That is not a fair test of NRT.
What is combination NRT?
A patch for steady background cover, plus a fast-acting form such as gum, lozenge or spray for the moments that break through. High-certainty evidence shows it produces higher long-term quit rates than a single form.
Is cytisine available where I work?
That depends entirely on your country. Licensing, product names, age limits and guideline status differ. Check locally before raising it with a client.
Can varenicline and NRT be used together?
Low-certainty evidence suggests it may improve quit rates compared with varenicline alone, with somewhat more side effects. Whether it is appropriate, and who may prescribe it, follows your own national guidance.
Does medication replace behavioural support?
No. Every guideline pairs the two. Medication lowers the biological pressure; the support is what changes the routines underneath it.
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References
Canadian Task Force on Preventive Health Care. (2025). Tobacco smoking in adults. https://canadiantaskforce.ca/guidelines/published-guidelines/tobacco-smoking-in-adults/
National Institute for Health and Care Excellence. (2025). Tobacco: Preventing uptake, promoting quitting and treating dependence (NICE Guideline NG209). https://www.nice.org.uk/guidance/ng209
Rigotti, N. A., Benowitz, N. L., Prochaska, J. J., Rubinstein, M., Clarke, A., Blumenstein, B., Cain, D. F., & Jacobs, C. (2025). Cytisinicline for smoking cessation: The ORCA phase 3 replication randomized clinical trial. JAMA Internal Medicine, 185(6), 648–655. https://doi.org/10.1001/jamainternmed.2025.0628
Theodoulou, A., Chepkin, S. C., Ye, W., Fanshawe, T. R., Bullen, C., Hartmann-Boyce, J., Livingstone-Banks, J., Hajizadeh, A., & Lindson, N. (2023). Different doses, durations and modes of delivery of nicotine replacement therapy for smoking cessation. Cochrane Database of Systematic Reviews, 2023(6), Article CD013308. https://doi.org/10.1002/14651858.CD013308.pub2
Zhou, X., Huang, Z., Song, Q., Xia, X., Cheng, A., Liu, Z., Shi, S., Gao, Y., Xiao, D., & Wang, C. (2026). Efficacy of combined varenicline and nicotine replacement therapy compared with varenicline or nicotine replacement therapy alone for smoking cessation: A systematic review and meta-analysis. Addiction, 121(3), 499–509. https://doi.org/10.1111/add.70235
World Health Organization. (2024). WHO clinical treatment guideline for tobacco cessation in adults. https://www.ncbi.nlm.nih.gov/books/NBK604665/
