Tobacco, alcohol and toxic exposure practice questions for the lifestyle medicine boards
This domain covers treating tobacco use disorder, screening and treatment for alcohol and other substances, and environmental exposures.
ABLM exam domain: Tobacco Cessation and Other Toxic Exposures
8%of the ABLM exam
~12of 150 physician questions
~10of 120 health professional questions
128questions on this domain in the bank
What the exam expects you to know
ABLM builds the exam on the lifestyle medicine core competencies. For this domain they include:
Health effects of tobacco, alcohol and other common substances, and the benefits of quitting
Screening tools for substance use and diagnostic criteria for common substance use disorders
Patient-centered treatment plans that combine behavioral therapy and pharmacotherapy
USPSTF recommendations for tobacco use
Referral to a substance use disorder specialist when indicated
High-yield areas
Varenicline, combination nicotine replacement and bupropion: dosing, safety and the EAGLES trial
USPSTF tobacco recommendations, including the evidence on e-cigarettes for cessation
Alcohol screening with AUDIT-C, standard drinks, and medications for alcohol use disorder
Cannabis, opioids and stimulants: recognition and first steps
Environmental exposures such as radon and lead
How to study it
Pharmacotherapy questions reward precision: which medication, at what point, and what to watch for. Pair that with the counseling side, since the best answers usually combine both.
Free practice questions: Tobacco, alcohol and toxic exposure
4 questions from the bank, with the full rationale and source. Pick your answer, then open the rationale.
Question 1 of 4 · moderateTobacco Cessation and Other Toxic Exposures
A 62-year-old inpatient with alcohol withdrawal develops delirium and cannot reliably describe nausea, anxiety, or sensory symptoms. He is receiving monitored treatment, and the team needs a replacement for CIWA-Ar to follow agitation and sedation. Which instrument is specifically suitable for that purpose under ASAM guidance?
Richmond Agitation-Sedation Scale (RASS)
Clinical Opiate Withdrawal Scale (COWS)
Alcohol Use Disorders Identification Test (AUDIT)
Prediction of Alcohol Withdrawal Severity Scale (PAWSS)
Generalized Anxiety Disorder 7-item scale (GAD-7)
Show answer and rationale
Answer: A. Richmond Agitation-Sedation Scale (RASS)
A. Correct. ASAM VI.9 names RASS among structured instruments suitable for alcohol withdrawal delirium. Unlike CIWA-Ar, it does not depend on reliable patient reporting of the listed subjective symptoms. It complements clinical and vital-sign monitoring.
B. COWS assesses opioid withdrawal, not the agitation and sedation target in alcohol withdrawal delirium.
C. AUDIT screens alcohol-use patterns and related harms; it is not a serial delirium or sedation monitoring instrument.
D. PAWSS estimates risk of complicated alcohol withdrawal. Risk prediction before or during admission is not the same task as serial assessment of current agitation and sedation.
E. GAD-7 measures anxiety symptoms by self-report. It is neither suitable for this delirious patient nor a sedation-monitoring instrument.
Question 2 of 4 · moderateTobacco Cessation and Other Toxic Exposures
A 22-year-old man smokes high-potency cannabis every day and asks whether the link to psychosis is overstated. In the EU-GEI case-control study by Di Forti and colleagues, which compared people with first-episode psychosis with population controls at 11 sites in Europe and Brazil, which finding was reported?
Daily use of any cannabis carried no excess odds of psychosis
Low-potency cannabis carried higher odds than high-potency
Removing high-potency cannabis could prevent half of London's cases
Site psychosis rates were unrelated to local cannabis patterns
Daily high-potency use had nearly 5 times the odds of psychotic disorder
Show answer and rationale
Answer: E. Daily high-potency use had nearly 5 times the odds of psychotic disorder
A (incorrect): Incorrect. Daily use was associated with an adjusted OR of 3.2 compared with no cannabis use.
B (incorrect): Incorrect. The highest odds were seen with daily high-potency use (OR 4.8).
C (incorrect): Incorrect. The population attributable fraction was 30.3% in London; the 50.3% estimate was for Amsterdam.
D (incorrect): Incorrect. Adjusted incidence rates of psychotic disorder across sites correlated positively with the prevalence of daily and high-potency cannabis use among controls.
E (correct): Correct. Daily cannabis use was associated with increased odds of psychotic disorder compared with no cannabis use (adjusted OR 3.2), rising to nearly five times the odds for daily use of high-potency (THC 10% or more) cannabis (OR 4.8).
Source: Di Forti M, Quattrone D, Freeman TP, et al. The contribution of cannabis use to variation in the incidence of psychotic disorder across Europe (EU-GEI): a multicentre case-control study. Lancet Psychiatry. 2019;6(5):427-436. Summary Methods (first-episode psychosis cases aged 18 to 64 at 11 sites; low potency THC <10% vs high potency >=10%) and Findings (901 patients, 1,237 controls; daily use adjusted OR 3.2; daily high-potency OR 4.8; PAF 12.2% overall, 30.3% London, 50.3% Amsterdam). https://pmc.ncbi.nlm.nih.gov/articles/PMC7646282/
Question 3 of 4 · moderateTobacco Cessation and Other Toxic Exposures
A 68-year-old man with coronary artery disease and heart failure with reduced ejection fraction usually walks outdoors for 30 minutes each day. Wildfire smoke has kept the local Air Quality Index at 190 (unhealthy) for several days. Which advice is most appropriate?
Exercise indoors in cleaner air, using a portable air cleaner
Keep the usual outdoor routine but shorten each walk and take more breaks
Keep the usual outdoor routine but use an N95 respirator as the main precaution
Exercise at home while opening windows to dilute smoke that has entered
Walk outdoors at a cooler time of day when smoke may be lighter
Show answer and rationale
Answer: A. Exercise indoors in cleaner air, using a portable air cleaner
At AQI 190, a person with heart disease is in a sensitive group. The EPA guide advises considering moving physical activity indoors to cleaner air. A portable air cleaner sized for the room can lower indoor particle exposure. Indoors is not automatically safe: activity should be limited where indoor air is poor, too. An N95 may reduce inhaled particles during unavoidable exposure but is not a reason to maintain strenuous outdoor activity. Seek prompt clinical advice for concerning symptoms such as palpitations, unusual fatigue, or shortness of breath.
Source: US EPA and partner agencies. Wildfire Smoke: A Guide for Public Health Officials. Revised 2026. https://www.epa.gov/system/files/documents/2026-06/wildfire-guide-for-public-health-officials-2026.pdf [EPA-452/B-26-001, June 2026: page 40 section 2.5A, cardiovascular disease; page 50 section 3.2, Reduce Activity; pages 57-58, portable air cleaners; pages 114-115 Table 5.1, Unhealthy AQI 151-200 and sensitive groups]
Question 4 of 4 · easyTobacco Cessation and Other Toxic Exposures
A 40-year-old man who has smoked cigarettes since his teens asks whether quitting now is too late to matter. In the 50-year prospective study of 34,439 male British doctors by Doll and colleagues, about how much life expectancy did stopping smoking at age 40 gain?
About 9 years
About 1 year
About 3 years
About 6 years
About 20 years
Show answer and rationale
Answer: A. About 9 years
A (correct): Correct. Cessation at age 60, 50, 40 or 30 gained about 3, 6, 9 or 10 years of life expectancy, respectively; men who continued smoking died on average about 10 years younger than lifelong nonsmokers.
B (incorrect): Incorrect. Even stopping at 60 gained about 3 years; stopping at 40 gained about 9.
C (incorrect): Incorrect. About 3 years was the gain for stopping at age 60.
D (incorrect): Incorrect. About 6 years was the gain for stopping at age 50.
E (incorrect): Incorrect. Continuing smokers died about 10 years younger than nonsmokers, so a 20-year gain is not possible; stopping at 40 gained about 9 years.
Source: Doll R, Peto R, Boreham J, Sutherland I. Mortality in relation to smoking: 50 years' observations on male British doctors. BMJ. 2004;328(7455):1519. Abstract Participants (34,439 male British doctors, 1951 to 2001) and Results (continuing cigarette smokers born 1900 to 1930 died about 10 years younger; cessation at age 60, 50, 40 or 30 gained about 3, 6, 9 or 10 years of life expectancy). https://pmc.ncbi.nlm.nih.gov/articles/PMC437139/
For exam preparation only, not clinical advice.
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