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Lifestyle Medicine > Tobacco Cessation and Risky Alcohol Use > Flashcards

Tobacco Cessation and Risky Alcohol Use Flashcards

1
Q

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

A

Tobacco use

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2
Q

Approximate annual cost to the US in terms of direct medical costs and lost productivity due to tobacco use?

A

~$300 billion

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3
Q

How many years of life are lost in smokers compared with those who have never smoked on average?

A

10 years of life lost

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4
Q

Why are today’s smokers more at risk of lung cancer despite generally smoking fewer cigarettes daily?

A

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)

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5
Q

Of 5 deaths in the US each year how many may be attributed to smoking?

A

1 in 5

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6
Q

Of those who use tobacco products how many will be killed by it?

A

1 in 2

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7
Q

Of all lung cancers in the US how many are caused by smoking?

A

87% of all lung cancers

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8
Q

What % of CHD is attributable to smoking?

A

32% of CHD

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9
Q

What % of COPD is attributable to smoking?

A

80% of COPD cases

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10
Q

What % of cancer deaths would be avoided if NO ONE smoked/used tobacco products?

A

33.3% (one third cancer deaths would be avoided)

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11
Q

List as many conditions as you can which may be worsened or caused by smoking (at least 14)

there are many more not listed…

A 
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
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12
Q

The risk of MI halves how quickly after quitting smoking?

A

Immediately

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13
Q

The risk of CHD reduces by 50% how quickly after quitting smoking?

A

1 year after quitting (CHD)

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14
Q

Stroke risk is equivalent to non-smokers how long after quitting smoking?

A

2-5yrs (stroke, non-smokers)

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15
Q

How long after stopping smoking does the risk of lung cancer reduce by 50%?

A

10 yrs (lung cancer 50%)

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16
Q

of the 68% of Americans who wish to quit smoking completely what % will be able to do so without assistance?

A

5%

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17
Q

Quitting smoking ‘cold-turkey’ will lead to what % of people resuming smoking within 14 days?

A

50% (75% within 30 days - least effective method!)

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18
Q

What is the the most efficacious approach to treatment for helping someone to stop smoking?

A

Combination counselling and medication

both independently evidence-based methods

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19
Q

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?

A

> 4 sessions

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20
Q

For most effective smoking cessation counselling what 2 features have been found to be most effective?

A

Practical counselling - prob solving / skills training

Social support provision

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21
Q

Smoking cessation is most effectively achieved with use of multi-format assistance / tx. Besides medication and counselling what other formats can be effective?

A

Tailored materials - web-based or print
Telephone Helplines
Motivational interviewing

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22
Q

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)

A

Pregnant women
Smokeless tobacco users
Adolescents
Light smokers (<10/day)

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23
Q

List the 7 FDA approved 1st line medications for smoking cessation (5 NRTs and 2 drugs)

A

5 x NRTs:
Nicotine patch, gum, lozenge, inhaler, nasal spray

2 x medications:
Varenicline (Chantix)
Bupropion SR (Zyban)

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24
Q

Which is the most effective drug mono-therapy for smoking cessation?

A

Varenicline

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25
Q

Compared to the 21% with placebo how many are tobacco-free after a 12-week programme of Varenicline?

A

51% tobacco-free at end of 12-week programme

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26
Q

What is the mechanism of action of Varenicline?

A

Varenicline = partial nicotinic receptor agonist

Thereby causing some of the effect of nicotine preventing withdrawal but blocking nicotine attachment avoiding nicotine highs!)

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27
Q

How do nicotine replacement therapies (NRTs) work?

A

Directly stimulates nicotinic receptors in the ventral tegmental area of the brain -> leads to dopamine release

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28
Q

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?

A

8-weeks with placebo = 30% tobacco free

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29
Q

What is the mechanism of action of Bupropion SR?

A

Noradrenaline and dopamine reuptake inhibitor

more available to attach to receptors and stimulate post-synaptic neuron

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30
Q

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?

A

Combination of Varenicline and Bupropion SR

71% tobacco free at end of 12-week programme; 58% after 6months

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31
Q

Approx what % of people are tobacco free after 8weeks of combination of Bupropion SR and nicotine lozenge +/- patch?

A

50%

54% with all 3

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32
Q

Combination of Varenicline, Bupropion SR and NRTs are more effective than varenicline and bupropion alone

True or False?

A

Preliminary data suggests MAY be more effective

Cannot claim to definitively be true

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33
Q

For those with chronic disease or mental illness what combination of medical smoking cessation therapies have been found to be most effective?

A

Triple therapy

Bupropion SR, patch and one other NRT e.g. lozenge

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34
Q

List the two 2nd line drug therapies for smoking cessation

A

1) Clonidine (HTN, migraine prevention, menopause flushing)

2) Nortriptyline (off-licence in UK)

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35
Q

Weight gain is more associated with Varenicline than Bupropion SR - True or False?

A

True (~4.5kg)

Bupropion may delay but not prevent weight gain - more common in women

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36
Q

What form of smoking cessation treatment is most recommended in those with Bipolar or Schizohrenia?

A

Nicotine Patch

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37
Q

In general terms smoking cessation therapies may need to be adjusted in which ways for those with mental illness ?

A

Most require medication
Longer duration
Combi medications

38
Q

True or False?

Nicotine patches have been associated with acute cardiovascular events

A

False - no association demonstrated

though NRT packaging recommends caution in those with acute CVD

39
Q

What form of smoking cessation therapy is best in pregnant women?

A

Counselling

40
Q

What category do Varenicline & Bupropion SR and NRTs fall into with regards to pregnancy and risk of foetal abnormalities?

A

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)

41
Q

Are there known risks associated with longterm NRTs?

A

No known health risks

42
Q

For how long is treatment with Bupropion SR approved?

A

6 months

43
Q

What are the treatment length recommendations for Varenicline?

A

12-weeks
May be repeated for 12 more weeks in relapse
(max 6 months total)

44
Q

List 6 forms of treatment for smoking cessation that have not demonstrated effectiveness in trials

2 x no evidence
4 x insufficient evidence

A

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

45
Q

E-cigarettes for smoking cessation - FDA approved?

A

No

46
Q

Nicotine liquid in e-cigarettes can lead to poisoning via what routes?

A

Ingestion or skin-absorption

47
Q

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)?

A

Heavy metals: lead, nickel, tin

48
Q

Which group are more likely to use e-cigarettes?

A

Adolescents > Adults

49
Q

Nicotine can be harmful to which major organ in adolescent development?

A

The brain

50
Q

There is good evidence that e-cigarettes help adults to quit smoking - true or false?

A

False

Shows they usually continue to use both e-cigs and cigarettes

51
Q

What are the 5As of smoking cessation?

A

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)

52
Q

How do the 5As of smoking cessation differ to the 5As of behaviour change?

A 
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!)
53
Q

What are the 4 principles of motivational interviewing?

A

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)

54
Q

What are the 5 Rs of motivational interviewing?

A

Relevance (ask pt to identify -ve consequences)
Risks (try to personalise)
Rewards (identify potential benefits)
Roadblocks (identify barriers)
Repetition (often takes several attempts)

55
Q

what % of the US population are considered ‘at-risk drinkers’ or to have mild alcohol use disorder (AUD)?

A

26%

56
Q

Excessive alcohol use can lead to 10% of all ___, 20% of all ___ injuries and __% of all deaths (inc RTAs, cancer, suicide)

A

Excessive alcohol use can lead to 10% of all CANCERS, 20% of all INTENTIONAL injuries and 7% of all deaths (inc RTAs, cancer, suicide)

57
Q

What 2 cardiovascular related risks are particularly associated with heavy alcohol use along with accidental injuries and cancer.

A

HTN

Stroke

58
Q

To what substance has health benefit from moderate alcohol consumption been attributed?

A

Properties of red grapes

therefore similar benefit to simply eating grapes!

59
Q

In which 8 groups have higher levels of alcohol consumption been recognised?

A

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

60
Q

What % of the time do those with AUD receive appropriate assessments?

A

10% of the time!

AUDIT OPPORTUNITY!

61
Q

According to the National Institutes of Health what are the low risk drinking guidelines for men?

A

MEN

No more than 4 drinks on any day
No more than 14 drinks in any 7 days

62
Q

According to the National Institutes of Health what are the low risk drinking guidelines for women?

A

WOMEN

No more than 3 drink on any day
No more than 7 drinks in any 7 days

63
Q

As of April 2018 what are the UK safe drinking guidelines for both men and women?

A

No more than 14 units / week

spread over 3+ days

64
Q

In terms of both blood alcohol level and time in which consumed what is considered “binge drinking”?

A

Men: 5 drinks in 2 hours
Women: 4 drinks in 2 hours
Blood alcohol level: 0.08mg/L

65
Q

How many “binge” drinking sessions / month are deemed ‘Heavy Drinking’?

A

> 5 days a month of binge drinking = heavy alcohol use

66
Q

What 3 drinking behaviours would be defined ‘at-risk drinking’?

A

‘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

67
Q

What DSM5 term is now used to describe what was once “alcohol abuse and dependence”?

A

Alcohol use disorder (AUD)

NB alcoholic/alcoholism = imprecise & stigmatising

68
Q

List the 7 most common symptoms / consequences associated with AUD

A

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

69
Q

What are the 11 DSM5 diagnostic criteria for AUD?

focusing on past 12 month period

A

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

70
Q

What DSM-5 scores are associated with mild, moderate and severe AUD?

A 
2-3 = mild
4-5 = moderate
6+ = severe AUD
71
Q

Current 12-month prevalence of mild AUD in US Men and women?

A

Mild AUD prevalence
Men: 10%
Women: 5%

72
Q

How regularly should a prevention screening / examination take place for AUD?

A

Annually

particularly in higher risk groups - young, trauma / STDs, FHx, pregnancy, Heavy smokers, if clinical suspicion

73
Q

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?

A

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))

74
Q

What questionnaire can be used as a written screening for AUD?

A

AUDIT

10 self-reported items rated 0-4 (never - high number of occurrences)

75
Q

What AUDIT scores are associated with:

  • ‘at risk drinking’
  • more ‘at-risk’
  • high probability of moderate AUD?
A

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

76
Q

What is AUDIT-C as opposed to the AUDIT screening?

A

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

77
Q

What score is considered a +ve screening and may indicate hazardous or harmful drinking on AUDIT-C?

A

> 5

though US website says >/=3 women and >/=4 men

78
Q

Risk reduction and management for mild-moderate AUD can be achieved in what settings and with what tx?

A

Primary care setting
Behavioural interventions
(Resource provision)
CONSIDER anti-relapse medication (as effective as addiction counselling, similar efficacy to SSRIs in depression)

79
Q

Risk factors for severe AUD? (6)

A 
FHx
Early childhood neglect 
Behavioural problems as a child
Early onset (teens)
Chronic or recurrent course
Other substance abuse / psychiatric disorder
80
Q

What treatment options are available for severe AUD? (7)

A
  • 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
81
Q

Anti-relapse medications in AUD are comparable in efficacy to SSRIs in depression. What is the NNT?

A

4 (to avoid relapse within 2 yrs)

82
Q

What LFT is most worth monitoring if deranged in suspected AUD?

A

GGT

83
Q

What are the two 1st line anti-relapse medications for AUD?

A

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

84
Q

How does Naltrexone work in AUD?

A

Blocks Mu-Opioid receptor

85
Q

Compared to placebo how effective is Naltrexone at reducing risk and rate of heavy drinking?

A

Reduced risk of heavy drinking compared to placebo 83%

Reduced number of days drinking by 4%

86
Q

How does Acamposate work in AUD?

Effects compared with Naltrexone and on heavy drinking?

A

Acamposate:

Modulates glutamate neurotransmission

Less effective than Naltrexone - reduces drinking rate by ~14%, increased abstinent days by 11

No effect on heavy drinking

87
Q

What three 2nd line drugs can be used in AUD treatment?

A

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)

88
Q

How does Disulfiram work?

A

inhibits aldehyde dehydrogenase - leading to build up of alcohol metabolite acetaldehyde

89
Q

What unpleasant side effects can result from Disulfiram?

A

nausea, vomiting, headache, sweating

90
Q

Benefit and risk in gababpentin?

A

Higher abstinent rates particularly with 900mg and 1800mg / day
Risk of abuse

91
Q

Briefly outline the definitions of Cat A, B, C, D and X regarding safe use of medication in pregnancy

A

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

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