Tobacco Cessation and Risky Alcohol Use Flashcards
What is the single largest preventable cause of morbidity and mortality in the US?
Tobacco use
Approximate annual cost to the US in terms of direct medical costs and lost productivity due to tobacco use?
~$300 billion
How many years of life are lost in smokers compared with those who have never smoked on average?
10 years of life lost
Why are today’s smokers more at risk of lung cancer despite generally smoking fewer cigarettes daily?
1) ventilated filters allow more vigorous (deeper) inhalation of smoke / chemicals
2) ~70 chemicals in cigarette smoke known to be carcinogenic (increased through manufacturing changes)
Of 5 deaths in the US each year how many may be attributed to smoking?
1 in 5
Of those who use tobacco products how many will be killed by it?
1 in 2
Of all lung cancers in the US how many are caused by smoking?
87% of all lung cancers
What % of CHD is attributable to smoking?
32% of CHD
What % of COPD is attributable to smoking?
80% of COPD cases
What % of cancer deaths would be avoided if NO ONE smoked/used tobacco products?
33.3% (one third cancer deaths would be avoided)
List as many conditions as you can which may be worsened or caused by smoking (at least 14)
there are many more not listed…
Diabetes RA Impaired Immune system function (tar/chemicals) Infertility Poor wound healing TB Ectopics / preterm delivery / still birth / low birth weight Cleft lip / palate Eretile dysfunction Age-related macular degeneration Failure rate of cancer treatment Bone #s Muscular aches / pains reduced QoL
The risk of MI halves how quickly after quitting smoking?
Immediately
The risk of CHD reduces by 50% how quickly after quitting smoking?
1 year after quitting (CHD)
Stroke risk is equivalent to non-smokers how long after quitting smoking?
2-5yrs (stroke, non-smokers)
How long after stopping smoking does the risk of lung cancer reduce by 50%?
10 yrs (lung cancer 50%)
of the 68% of Americans who wish to quit smoking completely what % will be able to do so without assistance?
5%
Quitting smoking ‘cold-turkey’ will lead to what % of people resuming smoking within 14 days?
50% (75% within 30 days - least effective method!)
What is the the most efficacious approach to treatment for helping someone to stop smoking?
Combination counselling and medication
both independently evidence-based methods
For individual / group / phone smoking cessation counselling there is a dose-response relationship. How many sessions of person-to-person tx are considered to be especially effective?
> 4 sessions
For most effective smoking cessation counselling what 2 features have been found to be most effective?
Practical counselling - prob solving / skills training
Social support provision
Smoking cessation is most effectively achieved with use of multi-format assistance / tx. Besides medication and counselling what other formats can be effective?
Tailored materials - web-based or print
Telephone Helplines
Motivational interviewing
The US department of Health and Human Services recommends encouragement of medication in smoking cessation in all except which groups (where evidence is insufficient)? (4)
Pregnant women
Smokeless tobacco users
Adolescents
Light smokers (<10/day)
List the 7 FDA approved 1st line medications for smoking cessation (5 NRTs and 2 drugs)
5 x NRTs:
Nicotine patch, gum, lozenge, inhaler, nasal spray
2 x medications:
Varenicline (Chantix)
Bupropion SR (Zyban)
Which is the most effective drug mono-therapy for smoking cessation?
Varenicline
Compared to the 21% with placebo how many are tobacco-free after a 12-week programme of Varenicline?
51% tobacco-free at end of 12-week programme
What is the mechanism of action of Varenicline?
Varenicline = partial nicotinic receptor agonist
Thereby causing some of the effect of nicotine preventing withdrawal but blocking nicotine attachment avoiding nicotine highs!)
How do nicotine replacement therapies (NRTs) work?
Directly stimulates nicotinic receptors in the ventral tegmental area of the brain -> leads to dopamine release
At the end of an 8-week programme 40% of smokers are tobacco-free with use of Bupropion SR. how does this compare to placebo over 8-weeks?
8-weeks with placebo = 30% tobacco free
What is the mechanism of action of Bupropion SR?
Noradrenaline and dopamine reuptake inhibitor
more available to attach to receptors and stimulate post-synaptic neuron
In terms of medication what is the most effective treatment for smoking cessation in those without chronic disease / psychiatric illness?
% tobacco free after 12-wks and 6 months?
Combination of Varenicline and Bupropion SR
71% tobacco free at end of 12-week programme; 58% after 6months
Approx what % of people are tobacco free after 8weeks of combination of Bupropion SR and nicotine lozenge +/- patch?
50%
54% with all 3
Combination of Varenicline, Bupropion SR and NRTs are more effective than varenicline and bupropion alone
True or False?
Preliminary data suggests MAY be more effective
Cannot claim to definitively be true
For those with chronic disease or mental illness what combination of medical smoking cessation therapies have been found to be most effective?
Triple therapy
Bupropion SR, patch and one other NRT e.g. lozenge
List the two 2nd line drug therapies for smoking cessation
1) Clonidine (HTN, migraine prevention, menopause flushing)
2) Nortriptyline (off-licence in UK)
Weight gain is more associated with Varenicline than Bupropion SR - True or False?
True (~4.5kg)
Bupropion may delay but not prevent weight gain - more common in women
What form of smoking cessation treatment is most recommended in those with Bipolar or Schizohrenia?
Nicotine Patch
In general terms smoking cessation therapies may need to be adjusted in which ways for those with mental illness ?
Most require medication
Longer duration
Combi medications
True or False?
Nicotine patches have been associated with acute cardiovascular events
False - no association demonstrated
though NRT packaging recommends caution in those with acute CVD
What form of smoking cessation therapy is best in pregnant women?
Counselling
What category do Varenicline & Bupropion SR and NRTs fall into with regards to pregnancy and risk of foetal abnormalities?
Varenicline & Bupropion SR - Category C
NRTs - Category D
(Cat C = effects demonstrated in animal studies, no adequate evidence in human studies
Cat D = +ve evidence in human studies of foetal risk but potential benefits may outweigh the risks - i.e. continuation of smoking likely more risk of harm to foetus than the above therapies)
Are there known risks associated with longterm NRTs?
No known health risks
For how long is treatment with Bupropion SR approved?
6 months
What are the treatment length recommendations for Varenicline?
12-weeks
May be repeated for 12 more weeks in relapse
(max 6 months total)
List 6 forms of treatment for smoking cessation that have not demonstrated effectiveness in trials
2 x no evidence
4 x insufficient evidence
No evidence:
1) Acupuncture
2) Hypnosis
Insufficient evidence:
3) physiological feedback (e.g. meditation)
4) restricted environmental stimulation therapy (minimal sensory input)
5) use of incentives
6) cutting down slowly
E-cigarettes for smoking cessation - FDA approved?
No
Nicotine liquid in e-cigarettes can lead to poisoning via what routes?
Ingestion or skin-absorption
Aerosolised nicotine liquid from e-cigs is less harmful than tobacco smoke but still contains what substances which can be carcinogenic (as well as other carcinogenic chemicals)?
Heavy metals: lead, nickel, tin
Which group are more likely to use e-cigarettes?
Adolescents > Adults
Nicotine can be harmful to which major organ in adolescent development?
The brain
There is good evidence that e-cigarettes help adults to quit smoking - true or false?
False
Shows they usually continue to use both e-cigs and cigarettes
What are the 5As of smoking cessation?
1) Ask (identify tobacco use)
2) Advise (clear, strong, personalised)
3) Assess (readiness to quit)
4) Assist (counselling / pharmacotherapy if ready)
5 Arrange (f/u ideally 1wk prior to quit date and 3/7 after)
(See page 295-6 for more detail)
How do the 5As of smoking cessation differ to the 5As of behaviour change?
Smoking vs Behaviour Change 5As: 1) Ask vs Assess 2) Advise vs Advise 3) Assess vs Agree 4) Assist vs Assist 5) Arrange vs Arrange (1 and 3 differ only!)
What are the 4 principles of motivational interviewing?
Express empathy (reflective, normalise feelings, auton.)
Develop discrepancy (between goals and behaviour)
Roll with resistance (back off and reflect if resist)
Support self-efficacy (identify successes, small steps)
(See pages 297-8 for more detail)
What are the 5 Rs of motivational interviewing?
Relevance (ask pt to identify -ve consequences)
Risks (try to personalise)
Rewards (identify potential benefits)
Roadblocks (identify barriers)
Repetition (often takes several attempts)
what % of the US population are considered ‘at-risk drinkers’ or to have mild alcohol use disorder (AUD)?
26%
Excessive alcohol use can lead to 10% of all ___, 20% of all ___ injuries and __% of all deaths (inc RTAs, cancer, suicide)
Excessive alcohol use can lead to 10% of all CANCERS, 20% of all INTENTIONAL injuries and 7% of all deaths (inc RTAs, cancer, suicide)
What 2 cardiovascular related risks are particularly associated with heavy alcohol use along with accidental injuries and cancer.
HTN
Stroke
To what substance has health benefit from moderate alcohol consumption been attributed?
Properties of red grapes
therefore similar benefit to simply eating grapes!
In which 8 groups have higher levels of alcohol consumption been recognised?
a) Age: 18-34 (28%)
b) Wealthier (prevalence increases with income)
c) Whites > Black or Asians
d) Men (23%) > Women (11%)
e) Smokers
f) those with psychiatric disorders
g) Trauma patients
h) +ve FHx
What % of the time do those with AUD receive appropriate assessments?
10% of the time!
AUDIT OPPORTUNITY!
According to the National Institutes of Health what are the low risk drinking guidelines for men?
MEN
No more than 4 drinks on any day
No more than 14 drinks in any 7 days
According to the National Institutes of Health what are the low risk drinking guidelines for women?
WOMEN
No more than 3 drink on any day
No more than 7 drinks in any 7 days
As of April 2018 what are the UK safe drinking guidelines for both men and women?
No more than 14 units / week
spread over 3+ days
In terms of both blood alcohol level and time in which consumed what is considered “binge drinking”?
Men: 5 drinks in 2 hours
Women: 4 drinks in 2 hours
Blood alcohol level: 0.08mg/L
How many “binge” drinking sessions / month are deemed ‘Heavy Drinking’?
> 5 days a month of binge drinking = heavy alcohol use
What 3 drinking behaviours would be defined ‘at-risk drinking’?
‘At Risk Drinking’:-
1) exceeding daily / weekly recommendations
2) binge drinking at least once / month
3) drinking that increases the risk of future problems, even though there are no current symptoms
What DSM5 term is now used to describe what was once “alcohol abuse and dependence”?
Alcohol use disorder (AUD)
NB alcoholic/alcoholism = imprecise & stigmatising
List the 7 most common symptoms / consequences associated with AUD
Consequences / symptoms associated with AUD:
1) Significant distress or impairment
2) Impaired control over use
3) Cravings and pre-occupation
4) Persistent desire to quit or cut down (unsuccessful)
5) Use despite internal consequences (hangover, nausea, heartburn, depression, other health problems)
6) 10% develop serious external consequences (job loss, legal issues, role-failure)
7) Most severe 10% - rehab, jail, hospitalised
What are the 11 DSM5 diagnostic criteria for AUD?
focusing on past 12 month period
1) Had times drank more or for longer than intended
2) >once wanted to cut down / quit but couldn’t
3) Significant time spent on activities to obtain alcohol / recover from its effects
4) A lot of time spent drinking or getting over after effects
5) Drinking (or being sick from) prevented you from taking care of yourself / family / job / school problems
6) Continued to drink despite it causing issues with friends or family
7) Stopped or reduced activities used to get enjoyment from to drink
8) >once involved in situations while / after drinking that could have increased your chances of getting hurt
9) Cont to drink in-spite of it causing depression / anxiety or other health problem
10) Had to drink much more to get same effect used to
11) Withdrawal symptoms
What DSM-5 scores are associated with mild, moderate and severe AUD?
2-3 = mild 4-5 = moderate 6+ = severe AUD
Current 12-month prevalence of mild AUD in US Men and women?
Mild AUD prevalence
Men: 10%
Women: 5%
How regularly should a prevention screening / examination take place for AUD?
Annually
particularly in higher risk groups - young, trauma / STDs, FHx, pregnancy, Heavy smokers, if clinical suspicion
To all pts who answer ‘once or more’ to the Q “How many days in the past yr have you had >4 (women) >5 (men) drinks in a day” what 2 further Qs should be documented?
1) number of days drinking per week
2) number of drinks per day
(give brief advice re guidelines and to reduce and assess further with written screening))
What questionnaire can be used as a written screening for AUD?
AUDIT
10 self-reported items rated 0-4 (never - high number of occurrences)
What AUDIT scores are associated with:
- ‘at risk drinking’
- more ‘at-risk’
- high probability of moderate AUD?
At risk: 5-10
More at risk: 11-15
High probability of moderate AUD: 16+
(high scores = higher sensitivity)
NB: AUDIT screens for 6+ drinks / day, NIH advises 5+ is risky
What is AUDIT-C as opposed to the AUDIT screening?
3 Qs as opposed to 10 (still 0-4 scoring for each)
Looks at consumption alone rather than feelings / consequences of
1) how often do you have an alcoholic drink
2) how many on a typical drinking day
3) how often do you have 6+ drinks on one day
What score is considered a +ve screening and may indicate hazardous or harmful drinking on AUDIT-C?
> 5
though US website says >/=3 women and >/=4 men
Risk reduction and management for mild-moderate AUD can be achieved in what settings and with what tx?
Primary care setting
Behavioural interventions
(Resource provision)
CONSIDER anti-relapse medication (as effective as addiction counselling, similar efficacy to SSRIs in depression)
Risk factors for severe AUD? (6)
FHx Early childhood neglect Behavioural problems as a child Early onset (teens) Chronic or recurrent course Other substance abuse / psychiatric disorder
What treatment options are available for severe AUD? (7)
- Counselling
- Consideration of anti-relapse medications
- Medical mx for withdrawal symptoms
- Recruit support from family / friends
- Relate medical disorders to alcohol if applicable
- Encourage attempts to stop / reduce
- Refer to addiction specialist - esp if life impairment but lifestyle changes / initial interventions ineffective
Anti-relapse medications in AUD are comparable in efficacy to SSRIs in depression. What is the NNT?
4 (to avoid relapse within 2 yrs)
What LFT is most worth monitoring if deranged in suspected AUD?
GGT
What are the two 1st line anti-relapse medications for AUD?
1) Naltrexone 50mg PO OD-BD
BNF: 25mg OD then inc to 50mg OD (max wkly 350mg)
2) Acamprosate
<60kg 666mg OM + 333mg BD
>60kg 666mg TDS
How does Naltrexone work in AUD?
Blocks Mu-Opioid receptor
Compared to placebo how effective is Naltrexone at reducing risk and rate of heavy drinking?
Reduced risk of heavy drinking compared to placebo 83%
Reduced number of days drinking by 4%
How does Acamposate work in AUD?
Effects compared with Naltrexone and on heavy drinking?
Acamposate:
Modulates glutamate neurotransmission
Less effective than Naltrexone - reduces drinking rate by ~14%, increased abstinent days by 11
No effect on heavy drinking
What three 2nd line drugs can be used in AUD treatment?
1) Disulfiram 250mg OD PO
2) Gabapentin 300-600mg BD-TDS
3) Topiramate 100-150mg BD PO (off-label but reduced % heavy drinking days vs placebo over 14 weeks)
How does Disulfiram work?
inhibits aldehyde dehydrogenase - leading to build up of alcohol metabolite acetaldehyde
What unpleasant side effects can result from Disulfiram?
nausea, vomiting, headache, sweating
Benefit and risk in gababpentin?
Higher abstinent rates particularly with 900mg and 1800mg / day
Risk of abuse
Briefly outline the definitions of Cat A, B, C, D and X regarding safe use of medication in pregnancy
A - Adequate and well controlled studies failed to show risk to foetus in 1st trimester in humans (no evidence in subsequent trimesters either)
B - Adequate and well controlled studies failed to demonstrate foetal harm in animals, no adequate well-being-controlled studies in humans
C - Adverse foetal reaction in animals, no adequate studies in humans but benefit MAY outweigh risk
D - +ve evidence human foetal risk but benefit MAY outweigh risk
X - Clearly demonstrated adverse effect on human foetus, RISK clearly OUTWEIGHS benefit - DO NOT USE
