NMS Q&A Family Medicine

Smoking Cessation 243Examination Answers1. The answer is C. Nausea is the most common sideeffect of varenicline, and it was reported in 40% of patientsover a one-year study. Although disturbance in attentionspan, anxiety and depression have garnered much attentionthey arise in only 1% to 2% of patients. The metabolismof metformin is not affected by Chantix; therefore,chances of either hypoglycemia or hyperglycemia are nomore likely in this diabetic patient while taking the vareniclinethan would be the case if she were not taking thedrug. Varenicline functions as an acetyl-choline agonist,resulting in decreased urge to smoke during withdrawal.2. The answer is B. Mesothelioma does not becomesymptomatic until at least 15 years after the original exposureto asbestos. Each of the other choices could be causesof symptoms and each of which in turn is accelerated inprogression if not precipitated outright by smoking, particularlyat the duration and intensity of smoking exhibitedby the patient depicted.3. The answer is A. Smoking during pregnancy carriesthe risk of preterm birth. Smoking during pregnancy isassociated with smaller, premature newborns, but notwith tachypnea, specific birth defects, hypoglycemia, ormacrosomia.4. The answer is D. Smoking should be listed on theproblem list of anyone who smokes and on the child’schart of any child in a smoking household. Surveys maydemonstrate to patients how important the physicianviews the impact of smoking on their health and quantifiesthe habit. Some smokers say that their physiciansnever told them to quit and some will respond to briefinterventions, but almost never in one session. Smokefreeoffices are necessary without exception. One need notwait for a “propitious” or adequate length of time for initiatingconversation about the desirability of smokingcessation. Even 5 minutes devoted to the subject has beenshown statistically to have eventual long-term success,compared with never mentioning smoking dangers andthe wisdom of cessation at all.5. The answer is A. Reactive airway disease and exacerbationsof known asthma are more likely in children ofhouseholds with smokers living in the abode than thosewithout smokers. Ear and upper respiratory infectionsdecrease if the smoking is stopped. Although cigarettesmoking by the parents is not known to cause childhoodasthma, the smoke can serve as a respiratory irritant thatprecipitates the asthma. In addition, otitis media is morelikely in smoking households. No causal relationshipbetween parental cigarette smoking and sudden infantdeath syndrome or childhood malignancies has beenestablished.6. The answer is C. The risk of lung cancer begins significantlyto subside at 10 years after cessation of smoking,and it approaches the expected risk of non-smokersby about 13 years. This estimate is on less secure groundwith the passage of time due to the increasing proportionof lung cancers found in non-smokers. Still, the vast majorityof lung cancer patients have smoked heavily ( 1 packper day) for more than 20 years before contracting thedisease.7. The answer is A. He has his first cigarette before breakfast(i.e., “before his feet hit the floor”). This patient isamong the 30% or so of smokers who are truly addicted,as opposed to those whose impulses to smoke occur incertain situations, such as after dinner, in times of “stress”or when out with friends rather than “on the clock.”8. The answer is E. If he suffered a myocardial infarction2 weeks ago, the vasoconstrictive effects of nicotine are aclear danger. Recent myocardial infarction, unstableangina, cardiac dysrhythmia, or true hypersensitivityreaction to the patch (not just local erythema or pruritus)are the only real contraindications. The length of the criticalperiod after a myocardial infarction is generally notgiven in the literature. However, following perioperativeguidelines for elective surgery, and allowing for somewhatmore leeway for smoking versus an assumed compellingcase for even elective surgery, 3 months would be a goodestimate.9. The answer is D. Bupropion is contraindicated wherethere is history of seizures. Most suitable in situationswhere the compulsion to smoke appears to be psychologicalrather addictive, bupropion is contraindicated in thepresence of a history of seizures, bulimia, presence ofmonoamine oxidase inhibitors, headache, nausea, orrecent head trauma.10. The answer is D, 1 week. The 1-week delay beforereusing a site in rotation is recommended so that contactirritation can be avoided.