NICOTINE DEPENDENCY

GRACE FORMAN

50 YEARS, FEMALE

Role-play cases simulate real clinical practice to guide how candidates respond to clinical scenarios and real life practice.

Name: Grace Foreman
Age: 50 years
Gender: Female
Occupation: Cashier and floor staff at Tesco

Presenting Complaint:
"I’m struggling to stop smoking, doctor. I heard I can get medication to stop smoking."

Open History:
Grace has a 15-year-old granddaughter, Samantha, who finds smoking disgusting and refuses to visit because of the smell. Grace desperately wants to quit smoking to spend more time with Samantha and go on a family holiday together. Samantha constantly reminds Grace of the health risks of smoking including lung cancer and refuses to visit due to the smell, which makes her feel sick. Despite several attempts to quit on her own, including going cold turkey and reducing the number of cigarettes gradually, she has not been successful. The situation is emotionally painful for her as she misses the time with her granddaughter.

Detailed History:

Smoking History: Grace started smoking at 19, initially around 10 cigarettes a day, increasing to 20 a day in her mid-30s. Currently, she smokes about 5-7 cigarettes daily, having tried to cut down over the years.
Social Pressure: Grace smokes during work breaks with coworkers and in the pub after work. Her coworkers often tease her about her unsuccessful attempts to quit.
Substance Use: Grace used to drink alcohol heavily and smoke cannabis and roll-your-own cigarettes but quit these habits when Samantha was born.
Background: She had a difficult childhood, including time in foster care due to her parents' substance abuse. Grace became pregnant at 18 and struggled as a single mother. At 35, she decided to make positive changes when her daughter, Jeanie, got pregnant at 17, aiming to be a better role model for Samantha. Both Grace and Jeanie are committed to giving Samantha a better life.
Family Concerns: Samantha frequently talks about the risks of lung cancer, and Grace is genuinely concerned about her health and the impact of smoking on her relationship with her granddaughter.

Past Medical History:

No long-term medical conditions
Occasional anxiety related to work and financial issues, but not severe enough to seek medical help
No known drug allergies

Social History:
Grace loves her job at Tesco but finds it very busy and stressful, particularly during promotion seasons, which exacerbates her smoking. She has struggled to get promoted to floor manager and suspects her smoking habit, particularly the smell, might be a factor.

Patient's Perspective:

Ideas: Grace is determined to quit smoking and is willing to do anything to achieve this.
Concerns: She fears that if she doesn’t succeed in quitting, the family holiday will be ruined, and she won’t be able to bond with her granddaughter. She also worries that Samantha’s refusal to visit will strain their relationship permanently.
Expectations: Grace is interested in learning about nicotine patches and feels it is not working and asks, "Can I use just any?" "Can I have medication instead?"

Response Guidelines:

No particular instructions for specific reactions.

You are a doctor in your routine clinic, ready to begin your day of consultations. A patient has been booked to see you,

Name: Mrs Grace Foreman

Age: 50 years

Gender: Female

Occupation: Cashier and floor worker at Tesco

Past Medical History: None. NKDA

Medical Notes:

2 Months ago:
Attended an NHS Health Check. Nil Medical Concerns.

All vital signs within normal parameters.

Long history of smoking, currently smoking 5-7 cigarettes daily, wants to quit smoking. Smoking cessation advice accepted.
Says had some anxiety related to work and financial issues, but under control. No known drug allergies.
Applauded efforts to stop smoking, informed of OTC options, says will speak to pharmacist.

Today;
Appointment booked online, reasons for booking not available.

Marking Scheme for Managing Smoking Cessation Case

1. Data Gathering
Good Indicators:

Thoroughly explores the patient's smoking history, including the number of cigarettes smoked daily and duration of smoking habit.
Inquires about previous attempts to quit smoking and methods used.
Assesses the patient's motivation for quitting and identifies specific triggers for smoking.
Asks about the impact of smoking on the patient’s personal life, particularly relationships with family members.
Explores past substance abuse and alcohol use to understand the broader context of the patient's health behaviors.
Inquires about the patient's current stressors and their coping mechanisms.
Assesses for any symptoms of nicotine dependence or withdrawal.
Asks about any previous or current use of smoking cessation aids (e.g., nicotine patches, medications).
Gathers information about the patient's mental health, including anxiety and any other relevant psychological factors.

Negative Indicators:

Fails to gather a comprehensive smoking history.
Does not inquire about previous quit attempts or the reasons for their failure.
Ignores the patient’s motivation and specific reasons for wanting to quit smoking.
Overlooks the impact of smoking on the patient’s personal and family life.
Fails to ask about past substance abuse and alcohol use.
Neglects to explore the patient's current stressors and coping strategies.
Does not assess for symptoms of nicotine dependence or withdrawal.
Fails to gather information on previous or current use of smoking cessation aids.
Ignores the patient’s mental health and any associated psychological factors.

2. Interpersonal Skills
Good Indicators:

Displays empathy and understanding towards the patient's struggle with quitting smoking.
Actively listens to the patient’s concerns and motivations for quitting.
Encourages the patient and provides reassurance about the possibility of successfully quitting.
Uses open-ended questions to facilitate discussion and gather detailed information.
Maintains a non-judgmental attitude throughout the consultation.
Acknowledges the patient’s efforts and previous attempts to quit smoking.
Provides clear and concise information about smoking cessation options.
Encourages the patient to express their feelings and concerns about quitting.

Negative Indicators:

Shows lack of empathy or understanding towards the patient’s situation.
Interrupts or talks over the patient, not allowing them to fully express their concerns.
Provides discouraging or negative feedback about the patient’s previous quit attempts.
Uses closed-ended questions that limit the patient’s ability to provide detailed information.
Adopts a judgmental or condescending tone.
Fails to acknowledge the patient’s efforts to quit smoking.
Provides unclear or overly technical information about smoking cessation options.
Does not encourage the patient to share their feelings and concerns.

3. Clinical Management
Good Indicators:

Provides clear and evidence-based information about smoking cessation aids (e.g., nicotine patches, medications).
Discusses the benefits and potential side effects of various smoking cessation options.
Creates a tailored quit plan based on the patient’s preferences and previous experiences.
Encourages the use of behavioral strategies to manage cravings and triggers.
Offers information on available support resources, such as counseling, support groups, or quitlines.
Schedules follow-up appointments to monitor progress and provide ongoing support.
Emphasizes the importance of a smoke-free environment and the positive impact on the patient’s health and relationships.
Provides written materials or resources for further reading and support.

Negative Indicators:

Fails to provide clear or evidence-based information about smoking cessation aids.
Does not discuss the benefits and potential side effects of various options.
Offers a generic quit plan without considering the patient’s preferences and previous experiences.
Ignores the importance of behavioral strategies to manage cravings and triggers.
Fails to offer information on available support resources.
Does not schedule follow-up appointments to monitor progress.
Neglects to emphasize the importance of a smoke-free environment and its impact.
Fails to provide written materials or resources for further support.

These are the key issues in this clinical scenario.

Key Focus Areas for Consultation

Assess Grace’s Motivation: Acknowledge her strong desire to quit for the sake of her granddaughter and future health.
Explore Previous Attempts: Discuss her past efforts to quit smoking, including what worked and what didn’t.
Support Systems: Identify support systems and possible triggers, including stress from work and social pressures.
Treatment Options: Explain the various options for smoking cessation, including nicotine patches, medications, and support groups.
Create a Plan: Develop a personalized quit plan, incorporating her preferences and addressing her concerns.
Awareness of Smoking Cessation Advice
Awareness of e-Cigarrettes, NRTs and medication therapy and their role in smoking cessation (including side effects and contraindications).
Awareness of indications for referral.

Follow-Up Plan

Schedule follow-up appointments to monitor progress and provide ongoing support.
Offer resources such as counseling, support groups, and educational materials on smoking cessation.
Discuss potential challenges and strategies to overcome them, emphasizing her goals and the positive impact on her relationship with Samantha.

Tips for Doctors to Have a Good Consultation in a Smoking Cessation Case

Build Rapport and Show Empathy: Start the consultation with a warm greeting and a friendly demeanor.
Acknowledge the patient's struggle and show empathy for their situation.
Use phrases like "I understand how challenging it can be to quit smoking" to validate their feelings.

Use Open-Ended Questions: Ask questions that encourage the patient to share more about their experience and feelings.
Examples include, "Can you tell me more about your attempts to quit smoking?" or "What motivates you to quit smoking now?"

Listen Actively: Give the patient your full attention and avoid interrupting them.
Use nods and verbal cues like "I see" or "Go on" to encourage them to continue speaking.
Reflect back what the patient says to show understanding, e.g., "It sounds like you want to quit smoking for your granddaughter."

Gather Comprehensive History: Take a detailed smoking history, including duration, frequency, and previous quit attempts.
Ask about triggers and patterns, such as smoking during work breaks or social settings.
Inquire about past substance use and any associated health issues.

Explore Motivation and Barriers: Discuss the patient's reasons for wanting to quit, such as family relationships or health concerns.
Identify any barriers or challenges they face in quitting, such as stress or social pressure.
Offer reassurance and support for overcoming these barriers.

Provide Clear and Tailored Information: Explain the available smoking cessation aids, including how they work and potential side effects.
Discuss the benefits of quitting smoking for both health and personal relationships.
Tailor your advice to the patient's specific situation and preferences.

Develop a Quit Plan: Work with the patient to create a realistic and personalized quit plan.
Set a quit date and discuss strategies to manage cravings and triggers.
Encourage the use of nicotine replacement therapy (NRT) or medications if appropriate.

Offer Behavioral Support: Suggest behavioral techniques, such as avoiding smoking triggers, practicing stress management, and seeking social support.
Provide information on counseling services, support groups, or quitlines.

Arrange Follow-Up: Schedule follow-up appointments to monitor progress and provide ongoing support.
Offer to adjust the quit plan as needed based on the patient's feedback and experiences.

Provide Educational Resources: Give the patient written materials or links to reputable websites for further reading.
Share resources that can help them stay motivated, such as success stories or educational videos.

Encourage a Smoke-Free Environment: Discuss the importance of creating a smoke-free home and work environment.
Encourage the patient to involve family members or friends in their quit journey for additional support.

Be Non-Judgmental: Maintain a non-judgmental attitude throughout the consultation.
Avoid criticizing or blaming the patient for their smoking habits.

Acknowledge Efforts and Setbacks: Recognize and praise the patient's efforts to quit smoking, even if they have faced setbacks.
Encourage them to view relapses as learning experiences rather than failures.