Section 9: Smoking and alcohol 8%

Question 1

T/F:
A) tobacco is the single largest preventable cause of morbidity and mortality in the US
B) $ 130 billion annually in direct medical costs
C) appx 16mil Americans suffer from dis caused by smoking
D) comp to people who never smoked smokers suffer more health probs and disability and lose appx 10 y of life

Answer 1

A) true; acc to CDC, however preliminary research from Cleavelend Clinic and New York School of MEdicine presented OBESITY as the leading preventable cause of disease and death
B) true
C) true
D0 True

Question 2

T/F:
A) today’s smokers smoke more cigarrettes than those in the past as they are more available
B) appx 1 in 50 deaths in the US is related to smoking
C) 1 of every 12 people who smoke will be killed by tobacco products
D) smoking is as attributed: 87% lung ca deaths, 32% coronary heart dise. deaths, 80% all deaths from COPD

Answer 2

A) FALSE: smoke fewer cigarrettes but have greater risk of lung cancer due to changes in design and composition (70 known carcinogens in cigarette smoke)
B) FALSE: appx 1 in 5 deaths in the US is related to smoking (480000deaths/ year)
C) FALSE: 1 of every 2 people who smoke will be killed by tobacco products
D) true

Question 3

T/F:
A) smoking is mostly assoc w/ lung cancer and plays small part in cancers of other body organs
B) smoking is associated with many other conditions , including inflammatory / autoimmune, reproductive function, bone halth, poor healing and poorer response to immunotherapy and chemotherapy, etc.
C) health benefits of quitting smoking include: reduced risk of cancer and other smoking assoc diseases, incl. CVD, COPD, premature death

Answer 3

A) FALSE: 40+ cancers have a known assoc w/ smoking
B) true
C) true

Question 4

T/F:
A) there are no immediate but many delayed benefits of quitting smoking
B) at 2-3 years the risk of stroke is appx equal to that of non smoker
C) at 10 years the risk of lung ca is reduced by 50%
D) quitting smoking at any age improves life expectancy

Answer 4

A) FALSE: quitting smoking leads to immediate reduction in risk of heart attack by 50% (com to someone who continues smoking)
B) true
C) true
D) true: quitting at 30 yo gains 10 y of life, quitting at 60. you gains 3 y of life

Question 5

T/F:
A) today, there is more former smokers than current smokers and most tobacco users WANT to quit
B) only 5% of those who want to quit will be able to do so without assistance because nicotine is as addictive as heroin, cocaine or alcohol
C) quitting cold turkey: half of people will resume smoking within 2 weeks; 3/4 will resume within 1 month
D) physicians using evidence based programs can triple success rates
E) slips and relapses are normal and considered part of change process
C) counselling and medication work better together than either one of them alone

Answer 5

A) TRUE, 68% current smokers want to quit
B) TRUE
C) TRUE
D) FALSE: double ; 40-50% of pat on quitting programs will be tobacco free at “quit date”
E) true
F) true

Question 6

10 key recommendations on tobacco cessation from the US Public HEalth Service clinical practice guideline (list at least 5)

Answer 6

1. clinicians need to recognise that tobacco dependence is a CHRONIC DISEASE and should be TREATED and appropriately FOLLOWED UP
2. clinicians and health care workers should CONSISTENTLY ASSESS and DOCUMENT tobacco use
3. Treatments are EFFECTIVE across ALL PPN: clinicians should encourage EVERYONE WILLING TO STOP to use effective treatments
4. BRIEF TOBACCO DEPENDENCE TREATMENT IS EFFECTIVE: mininal interventions (<3min) can still be effective
5. Individ/ group/ telephone cousnelling is effective: there is a DOSE RESPONSE RELATIONSHIP the more intervention the more effect; person to person, esp > 4 sessions most effective and should include practical problem solving and skills training, social support
6. numerous effective meds exist, certain combinations are more effective
7. a combination of counselling counselling and medication work better together than either one of them alone; interventions offered inmultiple formats are more effective; apps, print outs, e-interventions can be added
8. telephone quit line is effective
9. if user not ready to quit, use MI skills to increase future attempts
10. treatments are clinically effective and very cost effective comp to interventions for many other disorders

Question 7

T/F: tobacco cessation pharmacotherapy
A) should be offered to everyone who wants to quit
B) certain combinations are more effective than either one of them alone
C) first line medications include all EXCEPT:
1. NRT
2. verenecline (Chantix)
3. Buporoprion SR (Zyban)
4. Clonidine
5. Nortriptyline

Answer 7

A) FALSE: not if contraindicated or pregnant, smokeless tobacco users, light smokers, adolescents
B) TRUE
C) 4 and 5 (Clonidine and nortriptyline)
NB:
- varenecline = most effective monotherapy (51% at 12weeks vs 21% placebo), 35% at 6months (17% placebo) , partional nicot rec agonist
- zyban (bupropion) ; 40% vs 30% plac at 8 weeks, inhibits reuptake of norepineph and dopamine
- Nortrip and Clonidine = second line - use on case by case basis

Question 8

T/F:
A) NRT works by simulating effects of smoking and taking away the cravings
B) all of the formulations of NRT in the US are available OTC
C) NRT patches and lozenges are more effective than placebo even when used alone
D) combination of varenecline and bupropion is the most effective treatment
E) combination of NRT and non-nicotine medication can be safely used and is known to be more effective than either one alone
F) those with one or more chronic disease(s) or mental illness a tripple medication regime is recommended (buproprion SR + patch + another NRT)

Answer 8

A) TRUE: NRT works by stimulating dopamine release in ventral tegmental area
B) FALSE: patch, gum, lozenge (all OTC), inhaler or nasal spray (Rx only)
C) TRUE: 45% quitters are tobacco free at 8 weeks when using NRT patch alone, 40% of those using lozenges (compared to placebo; 30%)
D) TRUE: 71% quit at 12 weeks, 58% Tobacco free at 6 months!
E) TRUE:
- zyban + patch + lozenge = 54% at 8 weeks
- zyban + lozenge = 50% at 8 weeks
recent studies for varenacline + nrt +/- zyban = ok safety and can be used
F) TRUE: 62% vs 37 with patch alone at 8 weeks, 35% at 6 months vs 19% / patch alone

Question 9

factors to consider when prescribing:

A)
B)

Answer 9

1. clinicians familiarity w/ meds
2. contraindications
3. pat preference
4. pat prev experience
5. pat characteristics (h/o depression, suiciede attemps, wt gain concerns, recent MI, etc.)
6. frequency of use and level of dependence

Question 10

T/F:
A) average wt gain whn quitting smoking is 10 kg
B) there is no gender preference w/ regards to wt gain when quitting smoking;
C) bupropion and NRT may delay but not prevent wt gain

Answer 10

A)false: average wt gain whn quitting smoking is < 10lbs (4.5kg)
B) FALSE: wt gain after quitting smoking is more prevalent in women
C) TRUE

Question 11

T/F:
A) light smokers (<10cig/day) need the lowest dose of NRT (7mg/24hrs)
C) most pat w/ mental illness require medication when quitting , they may need higher doses, longer duration of treatment and a combination of meds
D) bipolar patients should not be prescribed bupriopion, patch is the recommended treatment
E) schizophrenia: patch is the recommended treatment

Answer 11

A) FALSE: light smokers (<10cig/day) show no benefit from NRT
B) true
C) true
D) true

Question 12

T/F:
A) it is not recommended for pat w/ cardiovasc dis to use NRT as there is increased risk of MI
B) NRT and counselling is the recommended treatment, all forms of NRT are safe in pregnancy
C) continuing smoking in pregnancy increases risk of premature or stillbirth & IUGR; and likely has a higher risk of harm than risk from NRT
D) NRT is thought to be safe for adolescents but there is very little research on adolescents hence generally not recommended

Answer 12

A) FALSE: no assoc betw patch and MI, even if cont smoking on it, lathough packaging recommends “caution”
B) FALSE: counselling good, patches, loxenges, gum are ok and benefits outweigh the harms, spray or inhaler are NOT SAFE and assoc w/ birth defects (Cat D), Zyban and Chamtix cat C
C) true
D) true

Question 13

T/F:
long term pharmacotherapy for quitting:
A) may be helpful for users w/ persistent withdrawal sympt
B) long term NRT is not recommended
C) Zyban is approved for up to 6 months
D) Campix is recomm for 12 weeks, then may be repeated for 12 more (6 months total)

Answer 13

A) true
B) false; no known health risks and may be helpful for persistent withdrawal symptoms
C) true
D) true

Question 14

A) accupuncture and hypnoses have shown demonstrable effectivenes in smoking cessation in RCT’s
B) electronic nicotine delivery systems are not FDA approved for tobacco cessation treatments and their safety is uncertain
C)

Answer 14

A) false: no evidence to support

B) true

Question 15

what constitutes effective counselling for smoking?

Answer 15

1. practical counselling, focused on problem solving and skills training
   - recognise vulnerable situations/ environments
   - develop coping skills
   - provide basic information about smoking and successful quitting
   - provide support and encouragement, communicate care and concern
   - engage pat in quitting process

Question 16

5A’s for SMOKING CESSATION

Answer 16

ASK: identify and document tob use for EVERY pat
ADVISE: use clear, strong, personalised manner
ASSESS: is the user ready and willing to quit?
ASSIST: counselling and/or pharmacotherapy for those who are ready
ARRANGE : schedule follow up and accountability, preferentially one week prior to quit date and 3 days after quit day

Question 17

5A’s for BEhaviour change (excl. smoking cessation)

Answer 17

ASSES: 
ADVISE
AGREE
ASSIST
ARRANGE

Question 18

3A’s: Alternative model for time constrains:

Answer 18

ASK
ADVICE
REFER- conect with beh support

Question 19

what is the ideal quit day for smoking cessation?

Answer 19

preferably within 2 weeks after the decision to quit

Question 20

what are the ideal follow up times?

Answer 20

1. preferably a week prior the set quit day and 3 days after the set quit day
2. within first monthafter quit day
3. additional f/u as needed

Question 21

what to discuss during follow up appointment after quitting smoking

Answer 21

1. problems encoutered
2. anticipated challenges
3. assess medication use/ problems
4. discuss quit lie support/ other support
5. address tobacco use at each following visit
   congratulate if successful on quit attempt

Question 22

MI principles

Answer 22

Express EMpathy
Develop discrepancy
Roll with resistance
Support self-efficacy

Question 23

How can you express empathy?

Answer 23

1. open ended questions
2. reflective listening (gain shared understanding)
3. normalise feelings and concerns
4. support autonomy and right to choose or reject change

Question 24

How can you nudge develop discrepancy between what is and what is desired/ values?

Answer 24

1. highlight discrepancy betw pat goals/ values/ priorities and present behaviour
2. reinforce and support change talk
3. build and deepen commitment to change

Question 25

How do you Roll with resistance?

Answer 25

BAck off and use reflection when patient expresses resistance
express empathy
ask permission to provide information

Question 26

How can you support self efficacy?

Answer 26

help the patient identify and build on past success

offer options for achievable small steps toward change

Question 27

5R’s of MI

Answer 27

RELEVANCE
RISK
REWARDS
READBLOCKS
REPETITION

Question 28

T/F:
A) almost 1/3 adult US ppn has meets DSM-V criteria for some degree of alcohol use disorder
B) 2.5 million years of life lost per year among us adults

Answer 28

A) TRUE: 26% of adults in US are at-risk drinkers or have mild alcohol use do, 3% moderate, 1% severe
B) TRUE

Question 29

heavy drinking increases risk for all except: 
A)  all-cause mortality 
B) hypertension
C) stroke
D) unintentional injuries
E) intentional injuries, incl. suicide
F) cancers 
G) bipolar do
H) ischaemic heart disease

Answer 29

A) true: 7% all adult deaths in US assoc w/ alcohol use
B) true
C) true
D) true (20% all adult assoc w/ alc use)
E) true
F) true (10% all adult assoc w/ alc use)
G) false
H) not stated in manual => false for this purposes

Question 30

T/F
With regards to alcohol misuse, choose populations known to have higher risk:
A) US regions w/ higher prevalence of alcohol misuse : Northeast, upper Midwest, Alaska, Hawaii
B) 35-50 yo
C) higher prevalence in low SES households
D) Whites > Blacks/ Asians
E) Men = women
F) psychiatric and trauma patients
G) positive family history

Answer 30

A) TRUE: regions w/ higher prevalence: Northeast, upper Midwest, Alaska, Hawaii- binge drinking (South west least likely) 
B)  FALSE: 18-34 yo
C) FALSE: prevalence increases w/ income
D) TRUE
E) Men 23% > Women 11%
F, G) both true

Question 31

T/F:
A) it has become in-beded in practice to routinely ask about alcohol use
B) alcohol misuse should be treated as a chronic disease
C) anti-relapse medications + medicl management are as effective as addiction counselling for mild to moderate alcohol use do
D) there is grade B evidence, supporting identification and brief advice by health care provider as an effective way to reduce drinking and its associated risks

Answer 31

A) false: only 10% ask
B) TRUE
C) TRUE
D) TRUE

Question 32

T/F: 
standard alcoholic drink in the US is: 
A) 12 oz regular beer 
B) 6 oz wine 
C) 1 oz os 80-proof spirit

Answer 32

A) true
B) 5 oz wine
C) 1.5 oz (shot) of 80-proof spirits

Question 33

T/F:
750 wine bottle = 5 drinks
750 spirit bottle = 18 drinks
1L spirits = 24 drinks

Answer 33

all true

Question 34

LOW RISK DRINKING GUIDELINES by NATIONAL INSTITUTE OF HEALTH (NIH)

Answer 34

men: no more than 4 / day, no more than 14 in 7 days
women: no more than 3/day, no more than 7 in 7 days

Question 35

definition of binge drinking:
BAL = ……….
… drinks in …hours (men and women)

Answer 35

BAL 0.08mg/L

5 drinks in 2 hours (men), 4 drinks in 2 hours (wom)

Question 36

T/F:
A) heavy alcohol use = exceeding recommended levels on daily basis
B) at-risk drinking;
- exceeds recommended levels for any day or week
- binge drinking at least once a month
- drinking that increases the risk of future problems even in absence current symptoms

Answer 36

A) FALSE: binge drinking more than 5 days in the past month

B) TRUE

Question 37

When is it recommended to screen for alcohol use:

Answer 37

ALL PATIENTS SHOULD BE ASKED ABOUT DRINKING

• annual prevention / physical examination
• high risk groups : younger people, high risk regions, trauma/ stds, family history, psychiatric hx, pregnant or planning to be, - heavy smokers, clinical suspicion

Question 38

SCREENING FOR ALCOHOL USE:

Answer 38

ALL PATIENTS SHOULD BE ASKED ABOUT DRINKING
How many times in the past year have you had 4 or more drinks (women), 5 or more (men) in a day? : document if this is positive (number of drinking days/ week, number of drinks)
GIVE BRIEF ADVICE
COMPLETE ADDITIONAL WRITTEN AUDIT (10 q)

Question 39

T/F: AUDIT
A) screens for 6+ drinks but NIH states 5+ drinks
B) written screen recommended to be done if patient screened positive for drinking above NIH low risk drinking guidelines (one question screen)
C) 6 self-reported items, scored 0-5
D) is not done often enough as it provides additional burden on already stretched health care professionals, as is time consuming
E) scores help guide therapy but don’t correlate well with likelihood of AUD and its severity
F) is not a validated tool but is helpful in clinical practice

Answer 39

A) true
B) true
C) FALSE 10 self reported items, 0-4
D) FALSE: recommended, provides meaningful information and low burden to pat and staff
E) false; scores correlate with severity and likelihood of AUD, higer scores = best sensitivity
F) false: is validated and part of vital signs

Question 40

AUDIT

Answer 40

1. How often alc.
2. How many drinks
3. how often 6 or more
4. last year: how often not able to stop
5. last year: how often needed a drink mane
6. last year: how often failed to do what expected
7. last year: how often guilt/ remorse
8. last year: how often unable to remeber
9. EVER injured self/ other because of drink
10. others expressed concern about your drinking

Question 41

AUDIT score

Answer 41

5-10 at risk drinker (20% will have alcohol use do)
11-15: more at risk (40% 20% will have alcohol use do)
16+ high probability of mod AUD 90%

Question 42

AUDIT-C (CONSUMPTION)
A) is a short version of AUDIT questionnaire and has been validated
B) questions are rated the same as for full AUDIT (0-4)
more than 4 is a positive screen and indicates hazardous or harmful drinking

Answer 42

A) false: not validated
B) true
C) false: >5 = positive (hazardous or at risk drinking) ; requires further assessment

Question 43

AUDIT C (consumption)

Answer 43

1. how often do you have a drink containing alcohol?
2. How many drinks containing alcohol do you have on a typical day when you are drinking?
3. How often do you have more than 6 drinks on one occs.?

Question 44

T/F:
at risk drinkers w/ mild alcohol use do
A) exceeds 6 drinks per occasion at least once a month
B) 0 symptoms of AUD
C) recommended action: brief advice to reduce, no medication, follow up
D) use MI techniques to motivate change

Answer 44

A) false: 5+
B) false: 0-3 symptoms of AUD
C) brief advice to reduce + naltrexone 25-50mg po prn at time of drinking + follow up booster session
D) true

Question 45

T/F:
MIld to moderate AUD
A) experience symptoms of impaired control
B) usually occurs as an isolated episode, (can last for 3-4 years) , then resolves; few receive treatment, similar to functional depression
C) management: 1ry care setting, behavioural health + anti-relapse meds

Answer 45

A) TRUE: going over limits, desire to cut down, use despite internal conseq., tolerance
B) TRUE
C) TRUE
D) TRUE: ARM (antirelapse medications) as effective as addiction counselling, similar effect size as SSRI in depression appx NNR 4

Question 46

what resource is recommeded to use in the US for at risk drinking?

Answer 46

“Rethinking Drinking” rethinkingdrinking.niaaa.nih.gov

Question 47

T/F: severe recurrent alcohol use do:
A) RF’s include: ACEs, fa history, early onset (teens)other subst use or psych do
B) treatment: addiction counselling +/- ARMs + medical management for withdrawal sympt+ recruit support + refer to specialist + follow up
C) ARMs are not effective in this group of patients due to severity of the problem and its “endogenous” nature

Answer 47

A) true
B) true;
C) FALSE: ARMs comparable to AA and counselling, at lest as good as SSRIs for depression, improve proportion of patients who enter long term recovery

Question 48

tracking outcomes of AUD treatment:
A) GGT helpful to track if initially elevated
B) check at every visit whether drinking or not and document

Answer 48

A) true

B) FALSE: collect quantitative measures; how often, how much +/- AUDIT/ AUDIT C

Question 49

ARMS (nti-relpase medications)
A) first line: Naltrexone, acamprosate, disulfiram
B) naltrexone works by blocking opioid receptor and significantly reduces drinking com to placebo, as well as reduces the number of drinking days
C) acamprosate is as effective as naltrexone but is much more expensive hence used less often

Answer 49

A) false: 1st line Naltrexone, Acamprosate, 2nd line: disulfiram, gabapentin, topiramate
B) true: 83% reduction of heavy drinking comp to placebo; reduced drinking days 4%
C) false: RR (vs placebo) 0.86, NNT=9, increased abstinence duration by 11 days but NOT EFFETIVE on heavy drinking