LMBR9: TOBACCO & ALCOHOL MCQs 1 Flashcards
By Michelle Olson
The single largest preventable cause of morbidity and mortality in the US is (BR289)
a) Obesity
b) Tobacco
c) Alcohol
d) Diabetes
B Tobacco
However in 2017 Cleveland Clinic & NY School of Medicine said that obesity has become #1 COD & disease. BR 289
Tobacco use (BR289)
a. Cost is $300 billion annually
b. Direct medical cost is $130 billion
c. Lost productivity is $150 billion
d. Causes 10 years of life loss
e. All of the above
E All of the above
Todays smokers smoke fewer cigarettes, but have a greater risk of lung cancer because
a. Filters allow less vigorous inhalation
b. Changes in chemicals and composition increase adenocarcinoma
c. Environmental changes
d. The chemicals have decreased in the manufacturing process
e. None of the above
BR 289
Answer is B - changes in cigarette design and composition have led to an increased risk of adenocarcinoma.
- ventilated filters are now used which allow more vigorous inhalation => draw cancer-causing chemicals deeper into lung tissue.
Smoking related deaths(BR289)
a. 480,000 deaths per year in the US (aprox 1 of 5 deaths)
b. Tobacco kills 1 of every 3 people who use cigarettes
c. Smoking causes 80% COPD deaths
d. Smoking causes 100% lung cancer deaths
e. Answers A and C are correct
Answer E
Tobacco products kill 1 in 2 people who use them.
Smoking causes
a) 480 K (1 in 5) deaths in the USA
b) 87% ol lung CA deaths
c) 32% of CAD deaths
Smoking related deaths
1) What proportion of smokers wil be killed by smoking ?
2) What proportion of the following causes of death is due to smoking:
a) Lung cancer
b) Coronary heart disease
c) COPD
3) Approx how many different cancers are related to tobacco use ?
BR289
1) Tobacco kills 1 in 2 people who smoke
2) Smoking causes 87% of lung CA deaths & 32% of CAD deaths & 80% of COPD deaths
3) 40+ cancers due to tobacco use - in all parts of the body
Smoking leads to or worsens
a. Diabetes
b. Rheumatoid arthritis
c. Poor/Delayed wound healing
d. Macular degeneration
e. Erectile dysfunction
f. All of the above
BR 290
Answer F
Also:
Cleft lip/palate
Risk of bone fractures
Increased failure rate for treatment of ALL cancers.
What are adverse health outcomes of smoking related to fertility & pregancy ?
BR 290
Smoking leads to or worsens:
1) Ectopic pregnancy
2) Preterm delivery
3) Still birth
4) Low birth weight
Mn: SPEL
Nicotine(BR290)
a. Second most common cause of dependence in the US
b. Is the key ingredient in tobacco products
c. Is usually able to be treated quickly, easily, and on the first attempt
d. Is not as addictive as heroin, cocaine, or alcohol
BR 290
Answer B
- nicotine is the #1 form of chemical dependence in the US
Health benefits of smoking cessation
a. Risk of heart disease is 50% less for one who quits then one who continues to smoke
b. Increases the risk of premature death and increases the rate of heart attack stroke and lethal cancers
c. After 1 year the risk of stroke is that of a non smoker
d. Quitting at 30 years old gains 5 year life expectancy
e. There are less benefits the younger you quit
(BR290)
Answer A
- takes 2-5 yrs for risk of stroke to = non-smoker
Health benefits of smoking cessation
1) After _ yrs the risk of lung cancer is reduced by _%
2) How many years of life are gained if one quits at:
a) Age 30
b) Age 60
(BR290)
1) After 10 yrs, risk of CA lung decreased by 50%
2) Yrs life gained if quit at _
30 => 10 YOL gained
60 => 3 YOL gained
Tobacco cessation
a. Smokers can and do quit
b. There are more former smokers in the world than current smokers
c. Most tobacco users want to quit
d. Only 5% of tobacco users who want to quit will be able to without assistance
e. All of the above
BR 290
Answer E
- 68% (2/3) of smokers want to quit.
Success in quitting smoking
1) If a person quits ‘cold turkey’, what is the risk of them resuming smoking ?
2) What is the net effect of MDs using evidence-based programs
3) In pts in MD directed Rx programs, at 3 mos, what proportion are tobacco free ?
BR 291
1) If quit ‘cold turkey’, resumption rates are:
- 50% @ 14 days
- 75% at 30 days
2) Net effect of MD program is a doubling of quitting success rates
3) In MD programs, at 3 mos, ~ 50% (40-50%) are tobacco free
Methods to quit smoking(BR291)
a. Counseling is effective evidence based treatment
b. Medication that has nicotine works best
c. Relapses are not normal in tobacco cessation
d. Counseling and medication is more potent than either alone
e. A and D are both true
Answer E
- non-nicotine meds also work
- other effective interventions:
1) Brief clinical interventions
2) Individual, group, or telephone counselling
3) Behavioral therapies
4) Program Rx using mobile phones
US Public Health Service Clinical Practice Guidelines(BR291)
a. Clinicians should assess the patients once a year and document
b. Tobacco use treatments are not effective across a broad range of populations
c. Brief tobacco dependence treatment is not effective and less than 3 minute interventions do not work
d. individual , group and telephone counseling is effective and the more intense the more effective
Answer D
Tobacco dependence treatments are clinically effective and very cost effective compared to interventions for other disorders - all of the following are true except
a. If a tobacco user is not ready to quit, it is not useful to use motivational interviewing until they are ready
b. Telephone quitline is effective
c. Combination of counseling and medication is more effective than either alone
d. Medication should be encouraged by clinicians unless the medication is contraindicated in that population(pregnant women, adolescents, light smokers, smokeless tobacco users)
e. There are 7 FDA approved medications, 5 nicotine replacement therapies and 2 non-nicotine replacement
(BR292)
Answer A
- if not ready to quit, use motivational interviewing to increase future quit attempts.
In terms of counselling for tobaco cessation:
1) Is there a ‘dose-response’ relationship ?
2) What are features of an increased dose ?
3) Name 2 features of the most effective counselling
BR291
In terms of counselling for tobaco cessation:
1 & 2) There is a ‘dose-response’ relationship:
a) More intense interventions more effective
b) Person-to-person (esp if > 4 sessions) more effective
3) Most effective counsellings includes:
a) PRACTICAL counselling which includes problem solving & skills training
b) Social support must be delivered as part of treatment.
What are some populations in which medications for smoking cessation may be contraindicated ?
BR292
Populations in which medications for smoking cessation may be contraindicated:
1) Pregnancy
2) Smokeless tobacco users
3) Light smokers
4) Adolescents
What are the mechanisms of the following drugs:
a) Nicotine replacement therapies (name 4 types & which require a prescription) - where active, physiological result
b) Varenicline (Chantix)
c) Bupropion SR (Zyban)
BR292-3
Mechanism:
a) Nicotine replacment Rx:
- Patch, gum, lozenge, Rx (inhaler, nasal spray)
- direct stimulation of nicotinic receptors in the ventral tegmental area of the brain which leads to dopamine release
b) Varenicline - nicotinic receptor partial agonist. Prevent withdrawal while blocking nicotine from attaching to the receptor (thereby stopping nicotine highs).
c) Bupropion SR - inhibits NE & DA reuptake so more is available to attach to the corresponding receptors and stimulate the postsynaptic neuron.
Mn: ‘Bupropion DANE’
In terms of drugs used for smoking cessation
1) What is the most effective monotherapy
2) What is the ‘most effective treatment’
BR292-3
In terms of drugs used for smoking cessation
1) Varenicline (Chantix) is the most effective monotherapy (51% NS @ 3mos, 35% @ 6mos)
2) Combination of varenicline + bupropion SR (71% tobacco free @ 3/12 program end, 58% @ 6 mos)
In terms of drugs used for smoking cessation
List 2 second line medications and their mechanism of action
BR293
Two second line agents
1) Clonidine - a central alpha2 adrenergic agonist resulting in reduced sympathetic outflow from the CNS (grt decreased arterial BP)
2) Nortriptyline - inhibits reuptake of serotonin & NE by presynaptic neuronal membrane => inc [5HT] and [NE] in the synapse.
Nicotine replacement therapies mechanism of action work by direct stimulation in the ventral tegmental area of the brain, which leads to dopamine release which of the following
is true(BR292)
a. Drugs of abuse like nicotine work in the serotonin pathway
b. Nicotine patch alone is 20% effective compared to placebo at 8 weeks
c. Lozenges alone are 40% effective compared to placebo at 8 weeks
d. Bupropion SR (Zyban) is the most effective monotherapy nicotine replacement medication
Answer C (Lozenge 40% NS vs Plc 30% @ 8 wks)
Varenicline(Chantix) is the most effective monotherapy nicotine replacement medication (51% NS @ 3 mos, 35% NS @ 6 mos)
Two non-nicotine medications exist, which of the following is false
a. Varenicline(Chantix) is the most effective monotherapy non-nicotine replacement medication
b. Vareniciline(Chantix) in 12 week trial has 51% tobacco free success compared to placebo 21% and 35% tobacco free 6 months
c. Varenicline(Chantix) mechanism of action partial agonist at nicotinic receptor and prevents withdrawal symptoms
d. Bupropion(Zyban) 20% tobacco free at 8 weeks
e. Bupropion(Zyban) mechanism of action inhibits reuptake norepinephrine and dopamine
BR292-293
Answer D
Initiating smoking cessation is dependent on the clinician familiarity with medications, contraindications, patient preferences, and previous patient experience with the medications.
All of the following are true except
a. Treatment combinations are more effective than monotherapies in individuals without chronic disease or psychiatric illness
b. The combination of varenicline and bupropion SR is the most effective
c. The combination of varenicline, bupropion SR, and nicotine replacement therapies may be even more effective, but only preliminary data is available
d. For those with one or more chronic illness or mental disease a triple medication regime is recommended(bupropion SR, patch, and one nicotine replacement therapy)
e. All of the following are true
(BR293)
Answer E
All of the following are true in considering treatment for tobacco cessation except
a. Light smokers (<10 cigarettes per day) show no benefit from nicotine replacement therapy
b. Most patients with mental illness require medication to be successful often times needing higher doses and longer duration
c. Patch is recommended for bipolar or schizophrenic patients
d. Nicotine replacement packaging recommends caution in cardiovascular disease, but there is no association between nicotine patches and cardiovascular events
e. All of the following are true
BR 293-4
Answer E
- Light smokers (<10 cigarettes per day) show no benefit from nicotine replacement therapy
List risks of smoking in pregnancy for the pregnancy
Is there an increased risk of congenital abnormalities ?
Source: UpToDate
Smoking in pregnancy:
1) Spontaneous pregnancy loss
2) Placental abruption
3) Preterm premature rupture of membranes (PPROM)
4) Placenta previa
5) Preterm labor & delivery
6) Ectopic pregnancy
7) Miscarriage
Fetal complications
1) Low birth weight
2) Stillbirth / neonatal death
3) Cleft lip & palate (overall congenital abnormalities similar)
Which of the following is false regarding smokers
a. Counseling is best for pregnant smokers
b. Over the counter nicotine replacement such as patches, lozenges, or gum are harmful in pregnancy and should always be avoided
c. Smoking in pregnancy increases risk of stillbirth
d. Nicotine replacement is safe in adolescents
e. Long term therapy has no known health risks
BR 294
Answer B
In pregnancy: “OTC nicotine replacement (patches, lozenge, gum) benfits > risks. No harm is expected, but this is based on limited studies”.
How many years of life does a smoker lose ?
BR 289
Smoker loses ~ 10 yrs of life
The following modalities for smoking cessation are not evidence based
a. Acupuncture
b. Hypnosis
c. Physiological feedback
d. Electronic nicotine delivery system
e. A, B, C, D are not evidence based treatments for smoking cessation
BR 294
Answer E
Which is true about electronic nicotine delivery systems(e-cigarettes, e-hookahs)
a. They are made of 2 parts a chamber that holds liquid and a heating device
b. They are FDA regulated and approved for smoking cessation treatment
c. Nicotine liquid is not poisonous to children
d. Aerosol has more harmful chemicals than tobacco smoke
e. More youths are using e-cigarettes than adults, but most adults that purchase e-cigarettes to quit end up using this and continuing to smoke
BR 294-5
Answer E
Electronic devices have 3 parts (battery is third part)
Important benefits of counseling in smoking cessation include
a. Coping skills are not important
b. Recognizing situations where they may be vulnerable to smoke again is not beneficial
c. Provide basic information about smoking and successful quitting
d. Engaging patients in discussions about the quitting process is not necessary
BR 295
Answer C
What is recommended nicotine cessation therapy in these patients:
a) Bipolar
b) Schizophrenic
c) Cardiovascular disease
d) Pregnant
a) Bipolar - Patch
b) Schizophrenic - Patch
c) No assoc of patch w CV events (even if still smoking) but be cautious if acute CV disase.
d) Counselling
According to approval, how long can these treatments be used:
1) Bupropion SR
2) Varenicline
BR 294
Approval duration
1) Bupropion SR - 6 mos
2) Varenicline - 6 mos (12 wks, may repeat x 1)
