9. Tobacco Alcohol

Question 1

5As tobacco cessation

Vs 5As of behavior change?

Answer 1

Ask
Advise
Assess
Assist
Arrange 

Behavior change:
Assess
Advice
Agree
Assist
Arrange
~~~

NOTE different sequence of assess/advice for smoking and behavior change

Question 2

Timeline of smoking cessation benefits

Answer 2

Inmediate: reduces risk MI by 50% vs continuing to smoke

1year: risk of heart disease is 50% of a non smoker(??)

2-5years: stroke risk similar to non smoker

10years: lung cancer risk reduced by 50%

Question 3

Quitting cold turkey 
Time to relapse 
What % resume smoking in 
- 14 days? 
- 30 days?

Is this effective long term method?

How does this compare to evidence based programs?

Answer 3

Quitting cold turkey least effective long term treatment

14d - 50% resume smoking
30d - 75% resume smoking

Physicians using evidence based programs can double quitting success rates.
40-50% tobacco free after 3 months

Question 4

Evidence based treatments for smoking cessation

Answer 4

Counseling

• brief clinical interventions
• individual group or telephone counseling
• behavioral therapies
• intensive treatments with a high amount of person-to-person contact
• program treatments using mobile phones

Medication

• OTC/prescription NRT
• prescription non-nicotine medications

Question 5

Motivational interviewing principles for smoking cessation

Answer 5

Express empathy
Develop discrepancy
Roll with resistance
Support self sufficiency

Question 6

5 Rs of motivational interviewing for smoking cessation

Answer 6

Relevance
Risks of smoking
Rewards of quitting 
Roadblocks to quitting 
Repetition

Question 7

Alcohol - anti replaces medications (ARMs)

Answer 7

Naltrexone

• block my receptor
• reduce risk of heavy drinking by83%, reduced drinking days by 4% compared with placebo

Acamprosate

• modulates glutamate neurotransmission
• reduce rate of drinking & increased abstinence by 11 days compared with placebo but not found to have effect on heavy drinking

Second line
Disulfuram (aversion agent, inhibits ADH. High rates noncompliance, not more effective th am placebo)

Gabapentin (possible abuse potential)

Topiramate decreased percentage heavy drinking days vs placebo

Question 8

Smoking cessation pharmacotherapy

Answer 8

NRT (patch, gum, lozenge, inhaler, nasal spray)

Varenicline (Chantix)
- most effective monotherapy

Bupropion SR (Zyban)

Combinations:
Varenicline with bupropion most effective treatment
May use combo of any of above