smoking cessation
Doctor Information
Sharlene Dillon, age 31
PMH:
Epilepsy diagnosed age 8
Seizure free for 5 years
Medication
Epilim 100mg daily
No drug allergies
PMH:
Epilepsy diagnosed age 8
Seizure free for 5 years
Medication
Epilim 100mg daily
No drug allergies
Patient Information
Sharlene Dillon age 31
Opening line: I wanna quit the cigs doc
History: You have a new boyfriend who thinks that smoking is disgusting and you promised him you would come in and get help to stop. You have tried on your own, going cold turkey, reducing the number every day, but you just can’t stick with it. You really like this guy and want to make it work, so here you are!
If asked only: You have been smoking since you were 16, initially about 20 a day, now about 7-10 a day. You thought it wasn't too bad as they are only roll ups but John, your boyfriend keeps telling you all the horrible things that can happen. You tend to smoke on your work breaks with a few co-workers, and also in the pub when you meet after work for a drink and a chat with your mates.
You used to drink a lot of alcohol and smoke cannabis too but you have stopped both of these. You had a fairly rough childhood, part of which was spent in foster care thanks to your alcohol mother. You never met your dad. You got pregnant when you were 18 but gave the baby up for adoption. You decided to make some changes when you turned 25 - by going to college, getting a degree in economics, and now you work full time for the council. You met John last year - and things are going well. You think he might propose at Christmas this year. He has been on your back since you met to give up cigarettes. He keeps telling you about lung cancer and harms to a baby if you were to get pregnant. This is your second chance, and you don’t want to blow it.
You were diagnosed with Epilepsy age 8, and used to have grand-mal seizures. Last time you had a seizure was about 5 years ago, but to be honest you haven’t attended any of your reviews since then, and you don’t take your Epilim anymore. No drug allergies
Ideas: You will do anything to stop smoking
Concerns: If you don’t succeed, John might leave you, and you are worried it will make you slip back to your previous way of life.
Expectations: Those E-cigarettes look good, or a tablet - you don’t mind
Examination not required in this station.
Opening line: I wanna quit the cigs doc
History: You have a new boyfriend who thinks that smoking is disgusting and you promised him you would come in and get help to stop. You have tried on your own, going cold turkey, reducing the number every day, but you just can’t stick with it. You really like this guy and want to make it work, so here you are!
If asked only: You have been smoking since you were 16, initially about 20 a day, now about 7-10 a day. You thought it wasn't too bad as they are only roll ups but John, your boyfriend keeps telling you all the horrible things that can happen. You tend to smoke on your work breaks with a few co-workers, and also in the pub when you meet after work for a drink and a chat with your mates.
You used to drink a lot of alcohol and smoke cannabis too but you have stopped both of these. You had a fairly rough childhood, part of which was spent in foster care thanks to your alcohol mother. You never met your dad. You got pregnant when you were 18 but gave the baby up for adoption. You decided to make some changes when you turned 25 - by going to college, getting a degree in economics, and now you work full time for the council. You met John last year - and things are going well. You think he might propose at Christmas this year. He has been on your back since you met to give up cigarettes. He keeps telling you about lung cancer and harms to a baby if you were to get pregnant. This is your second chance, and you don’t want to blow it.
You were diagnosed with Epilepsy age 8, and used to have grand-mal seizures. Last time you had a seizure was about 5 years ago, but to be honest you haven’t attended any of your reviews since then, and you don’t take your Epilim anymore. No drug allergies
Ideas: You will do anything to stop smoking
Concerns: If you don’t succeed, John might leave you, and you are worried it will make you slip back to your previous way of life.
Expectations: Those E-cigarettes look good, or a tablet - you don’t mind
Examination not required in this station.
Examination Findings
Not required for this scenario
Mark scheme
Data Gathering
|
POSITIVE INDICATORS
Organised and systematic in gathering information from history taking and examination - clear picture of smoking habits Data gathering does appears to be guided by the probabilities of disease |
NEGATIVE INDICATORS
Makes immediate assumptions about the problem Intervenes rather than using appropriate expectant management Is disorganised/unsystematic in gathering information Data gathering does not appear to be guided by the probabilities of disease. |
Clinical Management Skills
|
POSITIVE INDICATORS
Explains benefits of smoking cessation Able to discuss different methods, their risks and benefits Develops a management plan (including prescribing and referral) that is appropriate and in line with current best practice Management approaches reflect an appropriate assessment of risk Makes appropriate prescribing decisions Refers appropriately & co-ordinates care with other healthcare professionals Manages risk effectively, safety netting appropriately Encourages the patient to participate in appropriate health promotion and disease prevention strategies |
NEGATIVE INDICATORS
Fails to consider common conditions in the differential diagnosis Does not suggest how the problem might develop or resolve Fails to make the patient aware of relative risks of different approaches Decisions on whether/what to prescribe are inappropriate or idiosyncratic. Decisions on whether & where to refer are inappropriate. Follow-up arrangements are absent or disjointed |
Inter Personal Skills
|
POSITIVE INDICATORS
Identify patient’s agenda, health beliefs & preferences / does makes use of verbal & non-verbal cues. Works with the patient to develop a shared management plan Uses explanations that are relevant and understandable to the patient Shows sensitivity for the patient’s feelings in all aspects of the consultation including physical examination |
NEGATIVE INDICATORS
Doesn't enquire about patients ICE Takes a doctor centered approach towards management Uses an explanation that is filled with jargon, or forgets to explain at all Doesn't show any sympathy / empathy towards the patient's situation Fails to empower patient |
Management
You can manage smoking cessation in primary care, but the recommended treatment is through an NHS stop smoking service. There are local branches all over the country, and patients can self refer. You can locate your nearest centre at www.smokefree.nhs.uk.
However some patients do not wish to attend community clinics and would rather see you or a colleague in your practice. This is fine.
First make a good assessment - what they smoke and when, patterns (like at the pub), previous quit attempts, and how keen they are to stop now.
There is a lot of practical advice you can give to prepare a patient for stopping smoking. Start with making a list of reasons why you want to stop. Then decide on a stop date- a couple of weeks from now (try not to stop during a stressful period). This gives you a chance to get rid of all your smoking paraphernalia, and maybe get other people involved, or tell everyone that you are stopping. Having support can make a big difference. Thankfully this lady clearly has a very supportive boyfriend in this matter. Prepare yourself to have withdrawal symptoms, and what you will do when they happen. Keeping busy, finding hobbies or doing exercises are common things that people find useful. Equally, think about situations that make you likely to smoke - your coffee break, the pub etc, and make plans to avoid them.
There are three main types of drug treatment to help with smoking cessation - Nicotine replacement therapy (NRT), buproprion, and varenicline. They cannot be used in combination with each other, but nicotine patches can be used with other forms of NRT.
Think first about any contraindications. Buproprion can increase the risk the seizures (so not suitable for this lady), and varenicline can increase depression and suicidal ideation. Both are contraindicated in pregnancy and breastfeeding. They are also only available in tablet form. NRT comes as a patch, gum, lozenge, microtab and inhalator.
NRT: the strength of patch to start with depends on the number of cigarettes smoked per day (16 hour patch for up to 10/d, and 24 hour patch for 10-20/day.) A full table of doses and regimes can be found at http://cks.nice.org.uk/smoking-cessation#!prescribinginfosub:3. It is normally taken for 8-12 weeks, then reduced gradually, for people that continue to stay abstinent from smoking. Add in a second formulation to gain better control and reduce cravings if required.
If you are prescribing NRT, then bear in mind that it is not effective unless combined with close follow up through a specialised service, either by you, your practice or other providers. Patients taking NRT without this support are no more likely to quit than using willpower alone.
Buproprion: initiate while still smoking, then stop smoking 1-2 weeks later. The dose is 150mg od for 6 days then 150mg bd for 7-9 weeks. If the quit attempt is successful you can stop the drug without tapering down, or taper down if required, but if unsuccessful, the drug should be discontinued.
Varenicline: similar to buproprion, it is start 1-2 weeks before smoking stops with a one week titration programme - day 1-3 500micrograms/d, day 4-7 500micrograms twice daily, then 1mg bd for 12 weeks. If the patient has succeeded, a further 12 week course can be prescribed to keep them abstinent.
We should probably discuss E-cigarettes / nicotine inhalers / vapers in this section. There appears to be an ongoing debate as to how good these are as an alternative to smoking. From a public health perspective, they seem are deemed good enough, as most local smoking cessation services would consider a permanent swap to E-Cigarettes a successful 'Quit'. Research into the long term effects of E-cigarettes are ongoing, however, at the time of writing, it appears to be considerably safer than traditional smoking.
However some patients do not wish to attend community clinics and would rather see you or a colleague in your practice. This is fine.
First make a good assessment - what they smoke and when, patterns (like at the pub), previous quit attempts, and how keen they are to stop now.
There is a lot of practical advice you can give to prepare a patient for stopping smoking. Start with making a list of reasons why you want to stop. Then decide on a stop date- a couple of weeks from now (try not to stop during a stressful period). This gives you a chance to get rid of all your smoking paraphernalia, and maybe get other people involved, or tell everyone that you are stopping. Having support can make a big difference. Thankfully this lady clearly has a very supportive boyfriend in this matter. Prepare yourself to have withdrawal symptoms, and what you will do when they happen. Keeping busy, finding hobbies or doing exercises are common things that people find useful. Equally, think about situations that make you likely to smoke - your coffee break, the pub etc, and make plans to avoid them.
There are three main types of drug treatment to help with smoking cessation - Nicotine replacement therapy (NRT), buproprion, and varenicline. They cannot be used in combination with each other, but nicotine patches can be used with other forms of NRT.
Think first about any contraindications. Buproprion can increase the risk the seizures (so not suitable for this lady), and varenicline can increase depression and suicidal ideation. Both are contraindicated in pregnancy and breastfeeding. They are also only available in tablet form. NRT comes as a patch, gum, lozenge, microtab and inhalator.
NRT: the strength of patch to start with depends on the number of cigarettes smoked per day (16 hour patch for up to 10/d, and 24 hour patch for 10-20/day.) A full table of doses and regimes can be found at http://cks.nice.org.uk/smoking-cessation#!prescribinginfosub:3. It is normally taken for 8-12 weeks, then reduced gradually, for people that continue to stay abstinent from smoking. Add in a second formulation to gain better control and reduce cravings if required.
If you are prescribing NRT, then bear in mind that it is not effective unless combined with close follow up through a specialised service, either by you, your practice or other providers. Patients taking NRT without this support are no more likely to quit than using willpower alone.
Buproprion: initiate while still smoking, then stop smoking 1-2 weeks later. The dose is 150mg od for 6 days then 150mg bd for 7-9 weeks. If the quit attempt is successful you can stop the drug without tapering down, or taper down if required, but if unsuccessful, the drug should be discontinued.
Varenicline: similar to buproprion, it is start 1-2 weeks before smoking stops with a one week titration programme - day 1-3 500micrograms/d, day 4-7 500micrograms twice daily, then 1mg bd for 12 weeks. If the patient has succeeded, a further 12 week course can be prescribed to keep them abstinent.
We should probably discuss E-cigarettes / nicotine inhalers / vapers in this section. There appears to be an ongoing debate as to how good these are as an alternative to smoking. From a public health perspective, they seem are deemed good enough, as most local smoking cessation services would consider a permanent swap to E-Cigarettes a successful 'Quit'. Research into the long term effects of E-cigarettes are ongoing, however, at the time of writing, it appears to be considerably safer than traditional smoking.