1. Case Study: Michael
Michael is a 24-year-old man. He presents in the clinic with a severe productive cough, shortness of breath, and increased temperature x 3 days. He had 2 previous diagnoses of acute bronchitis. Family history includes his mother, with a recent diagnosis of emphysema, and his father, who died of lung cancer. Both of Michael’s siblings smoke. He is presently dating a smoker. On physical exam his BP is 138/76, pulse 90, respirations 22, and temperature 101.1° F. His lungs have diffuse rhonchi and he has a cough, which is productive of purulent sputum. His smoking history indicates that he has smoked 2 packs of cigarettes per day for 8 years. He has his first cigarette immediately after waking. He tried to quit last year using the patch but was only able to remain abstinent for 2 days. His girlfriend smokes but may be willing to quit smoking with him.
Which ONE of the following statements is true?
Michael’s failure to quit on his first attempt indicates that he will be unlikely to successfully quit in the future
Michael should be treated for his acute illness and smoking cessation should be addressed at a subsequent visit
Michael should be treated for his acute illness. The risk to smokers of acute respiratory infections should be highlighted, and he should be asked if he is willing to quit at this time.
It is inappropriate to continue to discuss Michael’s smoking, as he is already aware of health implications from the media and from his parents’ health history
2. Case Study: Maria
Maria is a 27-year-old woman who presents in the clinic having just learned that she is pregnant. She has no significant medical history and had recently discontinued oral contraceptives. She has been married for 3 years to a nonsmoker. She and her husband are pleased about starting a family. She works as a computer programmer. On physical exam she has a BP of 114/70, pulse 70. Smoking history indicates that she smokes 10-15 cigarettes per day, has smoked for 5 years, and smokes her first cigarette within 30 minutes after waking. She only smokes outside the home and has never tried to quit. Her husband is encouraging her to quit.
You have ASKED Maria about her tobacco use and ADVISED her to quit, stressing the impact of smoking on her pregnancy. Your ASSESSment indicates that she is ready to make a serious quit attempt now. Which of the strategies would NOT be appropriate to ASSIST her in her quit attempt?
Ask Maria how she feels about quitting and listen to her concerns
Set a quit date after which she should not smoke, not even a puff
Discuss with Maria the importance of quitting now for a healthy pregnancy and for the health of her child
Encourage Maria to decrease her cigarettes to 5 or less per day
3. It is important to ARRANGE follow-up contact. Which ONE of the following strategies would be MOST helpful to Maria?
Give her a pamphlet about quitting smoking
Arrange a follow-up visit with the clinic nurse within a week after her quit date
Schedule a follow-up visit in 2 months to check on her quit status
Tell her to call your office if she has any questions
4. Case Study: Joseph
Joseph is a 42-year old male who has visited his dentist complaining of a loose tooth. Examination reveals that Joseph has bone loss consistent with moderate to severe periodontal disease. Further examination reveals that Joseph has numerous mobile teeth and some missing teeth. His health history reveals that he smokes 1.5 packs of cigarettes per day and has a history of hypertension and type 2 diabetes. Joseph and his dentist have previously discussed the link between periodontal disease and his oral systemic health issues. Joseph states he is interested in quitting.
What can Joseph’s dentist do to initially help him determine the best ways to quit smoking?
Provide Joseph with the state quit line number and advise him to contact them for help to support his quit attempt
Review cessation medications options and offer to prescribe medications to support his quit attempt.
Review the oral health benefits of quitting, provide brief counseling, and offer Joseph treatment plan options based on his cessation decision
All of the above
5. Indicate which of the phrases below is MOST ACCURATE to complete the following sentence:
Relapse prevention strategies, such as encouragement, discussions of the benefits of quitting, and assessment of potential challenges to staying quit, should be used with
Heavy smokers who smoke more than 20 cigarettes per day
Tobacco users who have already had several failed quit attempts
Persons using only spit tobacco
Former tobacco users, in particular those who have quit recently
6. Case Study: Tonya
Tonya is a 22-year-old woman who presents at the clinic for a pre-employment physical. She has never been hospitalized and has no current medical problems. Her birth parents are both living and are in apparent good health. She is unmarried with no children. She is concerned about her weight and performs aerobic exercises 3-4 times weekly. She is 5′3″, weighs 120 lb, BP 126/70, pulse 66. Smoking history indicates that she has smoked 20-25 cigarettes per day for 5 years, and smokes her first cigarette 1-2 hours after waking. She tried to stop smoking 1 year ago but relapsed after gaining 7 lb. She states that she feels that being overweight is as bad for her as smoking. Tonya is starting a new job in 2 weeks in a smoke-free office. She would like to stop smoking and has some confidence in her ability to stop.
Which of the following interventions would be most appropriate in assisting Tonya with quitting?
Deny the impact of weight gain
Assist Tonya in establishing a strict diet and exercise regimen
Consider the use of cessation medications that delay weight gain
Refer Tonya for hypnosis because she failed her first quit attempt
7. Case Study: Jackson
Jackson is a 32-year-old man who comes to the clinic with a sore throat x 1 week, and also complains of muscular aches and pains. He has an unremarkable medical history. His mother has adult-onset diabetes and his father has hypertension. He is married with 3 children. Findings on physical exam: temperature 99.9°, BP 146/88, pulse 80, respirations 18. Throat slightly erythematous. Jackson smokes 1.5 packs per day and smokes his first cigarette immediately upon rising. He has no previous quit attempts. He is not interested in stopping but is somewhat confident that he could if he tried.
Which of the following statements is NOT true regarding the intensity of providing treatment for Jackson?
Only intensive treatment programs are effective
Even a 3- to 10-minute intervention can be effective
Brief treatment is more effective than no treatment
Intensive treatment is more effective than brief treatment
8. Which of the following approaches would be MOST helpful to motivate Jackson to consider quitting smoking?
Remind Jackson what smoking is going to do his health if he continues smoking
Encourage him to examine his relationship to tobacco
Provide a motivational intervention designed to enhance future quitting
Set a quit date for Jackson
9. Case Study: Sam
Sam is a 71-year old man currently hospitalized with a diagnosis of emphysema. He has been treated for coronary artery disease since age 50 with statins and daily aspirin. Over the past several years, he has experienced mild dyspnea with exercise, which he has attributed to “aging”. He was admitted following complaints of worsening dyspnea and increased cough with yellow sputum production for the last several months. A 100 pack-year smoker, he has tried to quit numerous times in the past and once succeeded in not smoking for a full year. His physical exam demonstrated mild tachypnea and lungs that demonstrate ronchi. He is obviously worried about this hospitalization and suggests to his doctor that maybe his smoking is responsible for his worsening health; but he feels that it is too late for him to try quitting.
Which of the following strategies would be MOST appropriate for Sam?
Provide Sam with quit smoking self-help materials to read while hospitalized
Recommend that Sam call his community quit smoking group after discharge
Provide assistance, encouragement to quit, and cessation medication while hospitalized and arrange for followup before Sam’s discharge
Focus on treating his current medical condition and strongly recommend that Sam try quitting again after his discharge
10. Which one of the following drugs has been found to be safe and effective for the treatment of tobacco dependence and has been approved for that use by the US Food and Drug Administration (FDA)?
Nortriptyline
Nicotine patch
Nicotine sublingual tablet
Clonidine
11. Case Study: Grace
Grace is a 3 year-old whose mother brings her to the pediatric nurse practitioner because of recurrent upper respiratory infections and several episodes of a nonproductive cough in the past month after Grace is in bed. Grace has had no hospitalizations or emergency department visits. She has met developmental milestones and appears happy and healthy. Vital signs are: temperature 98.6 F, respiratory rate 17, heart rate 82, and BP 118/60. Chest sounds are clear. Family history reveals that that both of Grace’s parents smoke, both inside and outside of the house and, occasionally in the car.
Which of the following would be an appropriate strategy at this time?
Refrain from discussing parental smoking since neither of them are your patient
Suggest that the parents smoke only outside the home
Mention that some states are making it illegal to smoke in cars with a child under age 15
Provide information on secondhand smoke exposure and offer the parents help in preparing for a quit attempt
Answers:
Case Study: Michael
Michael is a 24-year-old man. He presents in the clinic with a severe productive cough, shortness of breath, and increased temperature x 3 days. He had 2 previous diagnoses of acute bronchitis. Family history includes his mother, with a recent diagnosis of emphysema, and his father, who died of lung cancer. Both of Michael’s siblings smoke. He is presently dating a smoker. On physical exam his BP is 138/76, pulse 90, respirations 22, and temperature 101.1° F. His lungs have diffuse rhonchi and he has a cough, which is productive of purulent sputum. His smoking history indicates that he has smoked 2 packs of cigarettes per day for 8 years. He has his first cigarette immediately after waking. He tried to quit last year using the patch but was only able to remain abstinent for 2 days. His girlfriend smokes but may be willing to quit smoking with him.
Which ONE of the following statements is true?
Answer: Michael should be treated for his acute illness. The risk to smokers of acute respiratory infections should be highlighted, and he should be asked if he is willing to quit at this time.
Even brief advice to quit by a clinician results in greater quit rates. Smokers cite a clinician’s advice to quit as an important motivator for attempting to stop smoking. Therefore, clinicians should urge all tobacco users to quit. This advice should be clear and strong. For example, “As your physician, I must tell you that the most important thing you can do to improve your health is to stop smoking.”
Case Study: Maria
Maria is a 27-year-old woman who presents in the clinic having just learned that she is pregnant. She has no significant medical history and had recently discontinued oral contraceptives. She has been married for 3 years to a nonsmoker. She and her husband are pleased about starting a family. She works as a computer programmer. On physical exam she has a BP of 114/70, pulse 70. Smoking history indicates that she smokes 10-15 cigarettes per day, has smoked for 5 years, and smokes her first cigarette within 30 minutes after waking. She only smokes outside the home and has never tried to quit. Her husband is encouraging her to quit.
You have ASKED Maria about her tobacco use and ADVISED her to quit, stressing the impact of smoking on her pregnancy. Your ASSESSment indicates that she is ready to make a serious quit attempt now. Which of the strategies would NOT be appropriate to ASSIST her in her quit attempt?
Answer: Encourage Maria to decrease her cigarettes to 5 or less per day
Strategies that clinicians can use in assisting patients to quit smoking include asking how they feel about quitting, setting a quit date with them, and discussing the positive effect that quitting will have on their families.
It is important to ARRANGE follow-up contact. Which ONE of the following strategies would be MOST helpful to Maria?
Answer: Arrange a follow-up visit with the clinic nurse within a week after her quit date
Follow-up contact should begin soon after the quit date, preferably during the first week. A second follow-up contact is recommended within the first month. Schedule further follow-up contacts as indicated.
Case Study: Joseph
Joseph is a 42-year old male who has visited his dentist complaining of a loose tooth. Examination reveals that Joseph has bone loss consistent with moderate to severe periodontal disease. Further examination reveals that Joseph has numerous mobile teeth and some missing teeth. His health history reveals that he smokes 1.5 packs of cigarettes per day and has a history of hypertension and type 2 diabetes. Joseph and his dentist have previously discussed the link between periodontal disease and his oral systemic health issues. Joseph states he is interested in quitting.
What can Joseph’s dentist do to initially help him determine the best ways to quit smoking?
Answer: All of the above
Physicians, dentists, nurses, physician assistants, pharmacists, or other healthcare professionals are uniquely poised to intervene with patients who use tobacco. The Public Health Service Guideline Treating Tobacco Use and Dependence 2008 Update emphasizes the importance of treating all patients who use tobacco at every healthcare clinic. This Guideline is directed toward clinicians, allied health professionals, healthcare insurers, purchasers, and administrators and sets a new standard of care for smoking cessation treatment.
Indicate which of the phrases below is MOST ACCURATE to complete the following sentence:
Relapse prevention strategies, such as encouragement, discussions of the benefits of quitting, and assessment of potential challenges to staying quit, should be used with
Answer: Former tobacco users, in particular those who have quit recently
Clinicians should provide brief, effective relapse prevention treatment to all patients who have recently quit tobacco use. Minimal relapse prevention consists of congratulating success, encouraging continued abstinence, and discussing the benefits of quitting, the problems encountered during quitting, and the anticipated challenges to staying quit (eg, alcohol, weight gain, stress, and other tobacco users in the household).
Case Study: Tonya
Tonya is a 22-year-old woman who presents at the clinic for a pre-employment physical. She has never been hospitalized and has no current medical problems. Her birth parents are both living and are in apparent good health. She is unmarried with no children. She is concerned about her weight and performs aerobic exercises 3-4 times weekly. She is 5′3″, weighs 120 lb, BP 126/70, pulse 66. Smoking history indicates that she has smoked 20-25 cigarettes per day for 5 years, and smokes her first cigarette 1-2 hours after waking. She tried to stop smoking 1 year ago but relapsed after gaining 7 lb. She states that she feels that being overweight is as bad for her as smoking. Tonya is starting a new job in 2 weeks in a smoke-free office. She would like to stop smoking and has some confidence in her ability to stop.
Which of the following interventions would be most appropriate in assisting Tonya with quitting?
Answer: Consider the use of cessation medications that delay weight gain
For former smokers concerned with weight gain, the clinician should maintain the patient on medication known to delay weight gain (eg, bupropion sustained-release (SR) and nicotine replacement therapy, particularly 4 mg nicotine gum and lozenge). The clinician should also recommend starting or increasing physical activity, reassure the patient that some weight gain after quitting is common and is usually self-limiting, emphasize the health benefits of quitting relative to the health risks for modest weight gain, emphasize the importance of a healthy diet and active lifestyle, suggest low-calorie substitutes, and refer the patient to a nutritional counselor or program.
Case Study: Jackson
Jackson is a 32-year-old man who comes to the clinic with a sore throat x 1 week, and also complains of muscular aches and pains. He has an unremarkable medical history. His mother has adult-onset diabetes and his father has hypertension. He is married with 3 children. Findings on physical exam: temperature 99.9°, BP 146/88, pulse 80, respirations 18. Throat slightly erythematous. Jackson smokes 1.5 packs per day and smokes his first cigarette immediately upon rising. He has no previous quit attempts. He is not interested in stopping but is somewhat confident that he could if he tried.
Which of the following statements is NOT true regarding the intensity of providing treatment for Jackson?
Answer: Only intensive treatment programs are effective
The longer the session length, the more overall person-to-person contact, and the greater the number of visits, the more successful the treatment outcome. However, even a minimal intervention, lasting less than 3 minutes, can significantly increase overall tobacco abstinence rates.
Which of the following approaches would be MOST helpful to motivate Jackson to consider quitting smoking?
Answer: Provide a motivational intervention designed to enhance future quitting
Patients unwilling to make a quit attempt during a visit may lack information about the harmful effects of tobacco use and the benefits of quitting, may lack the required financial resources, may have fears or concerns about quitting, or may be demoralized because of previous failed quit attempts. Such patients may respond to brief motivational interventions on the basis of principles of motivational interviewing.
Case Study: Sam
Sam is a 71-year old man currently hospitalized with a diagnosis of emphysema. He has been treated for coronary artery disease since age 50 with statins and daily aspirin. Over the past several years, he has experienced mild dyspnea with exercise, which he has attributed to “aging”. He was admitted following complaints of worsening dyspnea and increased cough with yellow sputum production for the last several months. A 100 pack-year smoker, he has tried to quit numerous times in the past and once succeeded in not smoking for a full year. His physical exam demonstrated mild tachypnea and lungs that demonstrate ronchi. He is obviously worried about this hospitalization and suggests to his doctor that maybe his smoking is responsible for his worsening health; but he feels that it is too late for him to try quitting.
Which of the following strategies would be MOST appropriate for Sam?
Answer: Provide assistance, encouragement to quit, and cessation medication while hospitalized and arrange for followup before Sam’s discharge
It is vital that hospitalized patients attempt to quit using tobacco because tobacco use may interfere with their recovery and overall health. Hospitalized patients may be particularly motivated to make a quit attempt, and clinicians should take advantage of this “teachable moment.”
Which one of the following drugs has been found to be safe and effective for the treatment of tobacco dependence and has been approved for that use by the US Food and Drug Administration (FDA)?
Answer: Nicotine patch
FDA-approved medications for treating tobacco use include bupropion SR, nicotine gum, nicotine inhaler, nicotine lozenge, nicotine nasal spray, the nicotine patch, and varenicline. Nortriptyline, nicotine sublingual tablet, and clonidine are sometimes used for smoking cessation but are not approved by the FDA.
Case Study: Grace
Grace is a 3 year-old whose mother brings her to the pediatric nurse practitioner because of recurrent upper respiratory infections and several episodes of a nonproductive cough in the past month after Grace is in bed. Grace has had no hospitalizations or emergency department visits. She has met developmental milestones and appears happy and healthy. Vital signs are: temperature 98.6 F, respiratory rate 17, heart rate 82, and BP 118/60. Chest sounds are clear. Family history reveals that that both of Grace’s parents smoke, both inside and outside of the house and, occasionally in the car.
Which of the following would be an appropriate strategy at this time?
Answer: Provide information on secondhand smoke exposure and offer the parents help in preparing for a quit attempt
Secondhand smoke is harmful to children. Cessation counseling delivered in pediatric settings has been shown to be effective in increasing abstinence among parents who smoke. Therefore, to protect children from secondhand smoke, clinicians should ask parents about tobacco use and offer them cessation advice and assistance.