9: Fundamentals of Tobacco Cessation and Managing Risky Alcohol Use

Question 1

Which behavior is the single largest preventable cause of morbidity and mortality in the US?

A) Alcohol use

B) Unprotected sexual intercourse

C) Tobacco use

D) IV drug use

Answer 1

C.
Tobacco use is the leading cause of preventable death in the United States. Physical inactivity is the fourth leading risk factor for global mortality.

Question 2

Smoking leads to or worsens which of the following?

A) Erectile dysfunction

B) Diabetes mellitus

C) Infertility

D) All of the above

Answer 2

D. All of the above.
Smoking worsens or leads to erectile dysfunction, diabetes mellitus and infertility.

Question 3

Which is NOT true about smoking cessation?

A) It leads to a 50% reduction in the risk of heart disease after a year of smoking cessation

B) Quitting at age 30 leads to the same gain in life expectancy as quitting at age 60

C) It leads to a reduction in risk of premature death

D) More than two-thirds of current smokers want to quit completely

Answer 3

B.
Quitting at age 30 adds 10 years of life expectancy versus quitting at age 60, which adds three years of life expectancy.

Question 4

Which treatment for smoking cessation is most effective?

A) Counseling

B) Medication

C) Hypnosis

D) A and B

Answer 4

D. A and B.
The combination of counseling and medication is more effective than either alone, and hypnosis is less effective than either counseling or medication.

Question 5

Each of the following is a first-line medication for smoking cessation approved by the FDA, EXCEPT:

A) Varenicline (Chantix)

B) Bupropion SR (Zyban)

C) Nicotine patches

D) Clonidine

E) Nicotine replacement nasal spray

Answer 5

D.
Clonidine is currently a second-line medication for tobacco cessation as an off-label use. It should be prescribed on a case-by-case basis when the first-line medications are contraindicated or have not been effective.

Question 6

Which statement is true about smoking cessation for the following special populations?

A) First-line for bipolar patients is bupropion.

B) Counseling is the best option for smoking cessation in pregnant smokers

C) Nicotine replacement therapy is not an option for adolescents.

D) Patients with cardiovascular disease are at higher risk of acute coronary syndrome if using nicotine replacement therapy (NRT)

Answer 6

B.
Counseling is the best option for pregnant smokers, as there could be a potential risk of birth defects with NRT. Bipolar patients should not use bupropion but can use the patch. NRT is safe for adolescents. There is no association between nicotine patch use and acute coronary syndrome.

Question 7

Which of the following is NOT a component of the 5 A’s model for smoking cessation?

A) Assist

B) Assess

C) Arrange

D) Accept

Answer 7

D. Accept
The 5 A’s model for tobacco cessation helps to facilitate behavior change. It is comprised of: Ask, Advise, Assess, Assist, Arrange.

The 5 A’s of behavior change counseling are Assess, Advise, Agree, Assist, Arrange.

Question 8

“At-risk drinking” is defined as:

A) Drinking to avoid alcohol withdrawal symptoms

B) Drinking that increases the risk of future problems, but with no current symptoms

C) Getting a DUI

D) Alcohol dependence

Answer 8

B.
At-risk drinking is drinking that increases the risk for future problems, but with no current symptoms; binge drinking ≥ 1 time a month; or exceeding the low risk drinking guidelines at any time.
Getting a DUI would be considered a sign of alcohol use disorder as it is continued use despite internal consequences.
Drinking to avoid withdrawal symptoms is not part of the definition of at-risk drinking or of alcohol use disorder.
“Alcohol abuse and dependence” was the DSM4 terminology for alcohol use disorder.

Question 9

The following patient would be characterized as having moderate alcohol use disorder:

A) A woman who has 1-2 drinks, 5 nights per week over a 12 month period.

B) A male who has no more than 4 drinks on any single day and no more than 14 drinks per week over a 12 month period.

C) A male who does not like to go to a party if there is not going to be alcohol there, has developed tolerance to alcohol use, wakes up craving vodka, and has experienced alcohol withdrawal over a 12 month period.

D) A woman who has lost custody of her children because of her drinking, does not like to go to a party if there is not going to be alcohol there, has developed tolerance to alcohol use, wakes up craving vodka, has experienced alcohol withdrawal, drives drunk and has tried to quit 5 times without success, all over a 12-month period.

Answer 9

C.
A male who does not like to go to a party if there is not going to be alcohol there, has developed tolerance to alcohol use, wakes up craving vodka, and has experienced alcohol withdrawal over a 12 month period.

Alcohol abuse disorder is diagnosed by the presence of at least two out of 11 possible signs or symptoms of the DSM5 alcohol use disorder criteria during a 12-month period.

Moderate alcohol use disorder is categorized by the presence of four to five signs or symptoms that occur over a 12-month period.

Question 10

The following are anti-relapse medications for alcohol use disorder except:

A) Naltrexone

B) Acamprosate

C) Gabapentin

D) Nortriptyline

Answer 10

D.
Nortriptyline is not an anti-relapse medication.
Anti-relapse medications include naltrexone, acamprosate, disulfiram, gabapentin and topiramate.

Question 11

How long does a smoker have to abstain to cut their risk of lung cancer in half?

Answer 11

10 years

Most of the benefit gained in first 5 years (40%)

Question 12

What are the steps in the 5A model for tobacco cessation?

Answer 12

Ask (screen for use)
Advise (of risks/consequences)
Assess (is patient ready?)
Assist (includes pharmacotherapy, counseling)
Arrange (schedule f/u within a week of quit date and 1 month after)

Question 14

For which 4 populations is there insufficient evidence for use of pharmacotherapy in tobacco cessation?

Answer 14

PALS don’t use patches

pregnant women
adolescents
light smokers (<10 per day)
smokeless tobacco users

Question 15

What are the 2 questions in the Fagerstrom Test for Nicotine Dependence that have ranges?

Answer 15

1. How soon until first cigarette (in minutes)?
   <5 (3 pts) >60 (0 points)
2. How many cigarettes a day?
   10 or less (0 points) to 31 or more (3 points)

Question 16

The Fagerstrom rates nicotine dependence from 0-10

What are the cut points in the scale?

Answer 16

5 levels
2-4-5-7-10 (upper limits)

Question 17

What is the most effective monotherapy for tobacco cessation?

Answer 17

Varenicline

nicotinic receptor partial agonist, renally cleared

Cautions: psych or seizure hx, EtOH use, CVD. no other specific contraindications

Question 18

What are the pharmacotherapies available for treatment of alcohol use disorder?

3 FDA, 2 off-label

Answer 18

FDA: Naltrexone, Acamprosate, Disulfiram (= placebo)

off-label: gabapentin increases abstinence rates, topiramate may reduce % days of heavy drinking

Question 19

Regarding Cigarette smoking in the US; select all options that are true.

A - Today’s smokers smoke fewer cigarettes, but have a greater risk of lung cancer. This is due to increased levels of carcinogens in cigarettes and changes to cigarette filters, allowing more vigorous inhalation, permitting carcinogens to penetrate deeper into lung tissue.
B - Tobacco products kill 1 in 3 of those people who use them.
C - Cigarette smoking causes 87% of lung cancer deaths (of which lung adenocarcinoma is the most common), 32% of coronary heart disease deaths, and 70% of all deaths from COPD.
D - Cigarette smoking may worsen erectile dysfunction, risk of bone fractures, DM, Rheumatoid Arthritis, reduced quality of life, Age related macular degeneration (6.6x the risk of neovascular AMD), reduced quality of life and poorer wound healing.
E - Most (just over 2/3rds) of cigarette smokers want to quit, however only 5% will be able to quit without assistance, “cold-turkey” is the least effective method and the most potent quit method is dual-therapy of counselling and medication.

Answer 19

Answer A, D, E are correct.

A – True p 289
B – False. Tobacco products kill 1 in 2 of those people who use them! P289
C – False.
- Cigarette smoking causes:
– 87% of lung cancer deaths (of which lung adenocarcinoma is the most common) = True,
– 32% of coronary heart disease deaths = True
– 70% of all deaths from COPD = False, it’s actually 80%, p289.
D – True. Cigarette smoking may worsen all of the mentioned conditions pg. 290.
Please regarding AMD risk is from Rotterdam Study doi:10.1001/archopht.1996.01100140393005
E –True p291

Question 20

The Five A’s in tobacco cessation, select all that are true.

A – Assess, Advise, Agree, Assist, Arrange
B – Ask, Advise, Assist, Agree, Arrange, or the shortened version if you have a busy clinic, is : Ask, Advise, Refer
C – Are the same in behaviour change as they are in tobacco cessation
D – Advise involves telling the patient that they will die if they continue smoking
E – Ask, Advise, Assess, Assist, Arrange

Answer 20

Answer - E.

A – False p295
B – False p295
C – False p295-296
D – False p 296 advise the patient to quit in a clear, strong and personalised manner e.g. continuing smoking will worsen your asthma
E – True p295

Question 21

Which of the following statements is correct?

a. The AUDIT-C should be done on every patient annually.
b. The AUDIT-C is an evidenced based diagnostic tool.
c. The AUDIT-C comprises 3 questions.
d. The higher the score for the AUDIT-C plus AUDIT questionnaires the higher the specificity for Alcohol Use Disorder.

Answer 21

Answer: C

Rationale:
a. The AUDIT-C should be done on heavy drinkers/those you suspect of heavy drinking at every visit (BR video)
b. The AUDIT-C is an evidenced based screening tool
c. Correct answer
d. The higher the score the higher the sensitivity that the patient has AUD (p. 303)

Question 22

According to the USA guidelines on Alcohol, which of the following is true?

a. For women, a binge equates to 6 drinks in 2 hours.
b. There is no safe amount of alcohol for those diagnosed with colon cancer.
c. Excess alcohol is a risk factor for hypertension.
d. No alcohol is recommended for those < 18 years of age.

Answer 22

Answer: C

Rationale:
a. Women - binge drinking is 4 per 2 hours, men is 5 per 2 hours (p. 301)
b. No safe amount for those with breast or liver cancer
c. Correct
d. In the USA, no alcohol recommended for those < 21!

Question 23

Which of the statements about a landmark study of British physicians is true?

a. Smokers die approximately 15 years younger than non- smokers.
b. Quitting smoking at 30 led to a 10-year increase in life expectancy.
c. Quitting smoking at 60 led to a 5-year increase in life expectancy.
d. The study was conducted over a 30-year time span.

Answer 23

Answer: B

Rationale:
a. Smokers died 10 years younger https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5298160/
b. Correct
c. Quitting at 60 lead to a 3-year increase (p. 290)
d. Study was conducted over a 50- year time span

Question 24

Regarding tobacco use which of the following statement is true?

a. Chewing and smoking tobacco poses the same risk profile.
b. 10 years after stopping smoking, CV disease is reduced by 50%.
c. Smoking adversely affect all phases of the atherothrombotic disease process.
d. After high cholesterol, tobacco use is the second largest cause of preventable death.

Answer 24

Answer: C

Rationale:
a. Smoking is more damaging than chewing
b. At 10 years the risk of lung cancer is reduced by 50% (p. 290)
c. Correct
d. Tobacco use is the number one cause of preventable death (p. 289)

Question 25

Which of the following refer to:
(a) Heavy alcohol use.
(b) At risk drinking.
(c) Alcohol Use Disorder.

1. Impaired control over use.
2. Binge drinking on more than 5 days in the past month.
3. Exceeds the drinking guidelines (set by National Institutes of Health) for any day or week.
4. Cravings or preoccupations.

Answer 25

Answers:
1. c
2. a
3. b
4. c

p. 301

Question 26

Smoking related death in the US – which is correct?

a) Tobacco products kills 1 of every 2 people who use them.
b) 1 in 7 deaths per year.
c) 36% of CHD deaths.
d) 80% deaths from COPD.
e) A and D
f) None of the above.

Answer 26

A & D are correct

1 in 5 deaths
32% of CHD deaths
(p.289)

Question 27

What scenario fits the definition of At risk drinking:

a. 14 drinks in a week.
b. 8 cans of beer within 2 hours after footy game win, not otherwise.
c. 2 glasses of 12% red wine with dinner every day. On Friday night at the bar usually vodka shots with friends.
d. 1.5 oz vodka/week.

Answer 27

Answer c.

At risk drinking p301

Option b binge drinking.

Question 28

Alcohol misuse is associated with - choose the incorrect answer

1. 20% of all cancers
2. Stroke
3. High BP
4. 20% of unintentional injuries
5. 7% of all deaths

Answer 28

A.

p300

Question 29

Which medication/s are second-line medications for tobacco cessation (off-label use)?

a) Varenicline
b) Clonidine
c) Chantix
d) Naltrexone
e) Nortriptyline

Options:
A) c & d
B) a & b
C) c & e
D) b & e
E) b, d and e

Answer 29

Correct answer: D

Clonidine and Nortriptyline are second-line medications.

(p.293)

Question 30

To meet the criteria of Alcohol Use Disorder – severe level how many signs and symptoms does a person need to have?

a) 4 – 5 over 6 months
b) > 6 over 6 months
c) 8+ over 12 months
d) 6+ over 12 months
e) 9+ over 12 months

Answer 30

Answer d.

(p. 302)

Question 31

Which medications for Alcohol Use Disorder is considered first-line anti-relapse medications?

a) Naltrexone & Gabapentin
b) Disulfiram & Topiramate
c) Acamprosate & Naltrexone
d) Acamprosate & Disulfiram
e) Gabapentin & Topiramate

Answer 31

Answer C

pg 305-306

Question 32

The most common form of chemical dependence in the US:

a. Tobacco
b. Heroin
c. Alcohol
d. Nicotine

Answer 32

Answer d

(being the key drug in tobacco, pg 290)

Question 33

Number of cancer deaths which can be prevented if no-one used tobacco products:

a. 1:3
b. 1:5
c. 1:10
d. 1:15

Answer 33

a. 1:3

Question 34

Which two statements are correct regarding tobacco use:

a. Acupuncture is an effective treatment for tobacco cessation.
b. Brief phone counselling sessions are ineffective in tobacco cessation-at least 4 in person sessions are needed.
c. Tobacco products kill 1/3 of people who use them F p 289 (it is 1 in 2 people).
d. Tobacco dependence treatments are very cost effective compared to interventions for other disorders.
e. Adults who buy e-cigarettes have a higher rate of quitting.
f. 1 in 5 deaths in the US is smoking related.
g. NRT seems to have a higher risk of birth defects than does pregnant women continuing to smoke.
h. When using nicotine patches, patients with acute CVD should use caution.

Answer 34

ANSWER d and f

a. F p 294
b. F p 291 4 in person sessions seem to be especially effective but minimal interventions (<3mins) still increase abstinence rates
c. Tobacco products kill 1/3 of people who use them
d. T
e. P 295 F (they tend to continue to smoke and use the e cigarettes)
f. T p 289
g. F p 294
h. F p 294 (No assoc between patches and acute CV events but caution recommended for NRT)

Question 35

Which of the following is incorrect:

A) 1L spirit is 24 drinks
B) 1 standard drink - 5oz (142g) table wine
C) 1 standard drink - 12 oz (290g) beer
D) 750ml wine – 5 drinks

Answer 35

Answer B.

Standard beer weight is 340g

Question 36

Which of the following statements is true? (multiple answers)

1) Smoking cessation reduces risk of MI by 50% after 1 year.
2) It takes 15 years to reduce lung cancer risk by 50%.
3) Someone who quits smoking at age 60 can expect to live 3 years longer.
4) Of people who quit smoking, 50% start again within a month.
5) 5% of people who want to quit are able to do so on their own.

Answer 36

Answer- 3, 5

Pg 290
1 is an immediate effect
2 takes 10 years
4 is within 2 weeks