AKT revision

1. A 23-year-old woman who is 12 weeks into her first pregnancy has failed to stop smoking by simple means asks whether you can help. You would like to balance the patient’s needs against best available evidence. Which one of the following options would be most appropriate?

A. Acupuncture
B. Buproprion
C. Nicotine lozenges
D. Nicotine patches
E. arenicline

Answer: C

There is no evidence that acupuncture works, buproprion and varenicline are contraindicated in both pregnancy and breastfeeding. It would seem prudent to minimize the duration of exposure of the fetus to nicotine—thus nicotine lozenges would be preferable to the longer acting patches.

- The following patient, who has failed to stop smoking by simple means, asks whether you can help. You would like to balance the patient’s needs against best available evidence.

A. Acupuncture
B. Buproprion
C. Nicotine lozenges
D. Nicotine patches
E. Varenicline

2. A 17-year-old boy whose grandfather has just died of lung cancer, who is still at school and smokes 10 cigarettes per day. He seems motivated.

Answer: D

The initial options would be between nicotine lozenges and patches. Since he is still at school (and teachers tend to object to chewing gum), D would be preferable.

3. A 52-year-old man with a history of seizures who relapsed after stopping nicotine replacement therapy (NRT) 6 months before and would prefer to try something else.

Answer: E

Buproprion is contraindicated due to the seizures and there is no evidence for acupuncture. While NRT may be used again, it would be reasonable to go along with the patient’s wishes.

4. A 32-year-old woman who considers herself a 'social smoker' in that she smokes approximately 20 cigarettes per week

Answer: C

There is some evidence that even 'light' smokers can be helped by smoking cessation therapy. This is an important subgroup (12 % of smokers do not smoke daily).

5. A 60-year-old man with ischaemic heart disease and mild COPD who has quit successfully with varenicline but fears relapse.

Answer: E

Acupuncture has no evidence of efficacy and there is no evidence that buproprion prevents relapse. NRT is an option (but he has ischaemic heart disease) and there is evidence that varenicline will prevent relapse if prescribed for a further 3 months.

6.A 65-year-old woman who would like help to reduce her habit but who does not wish to stop completely at the moment.

Answer: C

There is evidence that if the requests of such patients are granted, then they are more likely to quit in the future. There is, however, no evidence of long-term health benefit from 'cutting down'. NRT is licensed for this use and the evidence is actually for nicotine chewing gum. The choice of lozenges rather than patches is therefore for this reason as well as preventing the double effect of a patch (long acting) and a cigarette.