PUID: 62 || PLAB 2 Mock 1 :: Counseling Lifestyle3: Breast Feeding Smoking Cessation

Practice a case with the AI patient 🤖

Summary

A 6-week postpartum woman who is breastfeeding attends a GP clinic seeking help to quit smoking. The task is to deliver a structured counselling consultation, assess risks and readiness to quit, give safe evidence-based advice (including NRT in lactation), arrange support/referral, and provide safety-netting and follow-up.

Key Points

Station focus & tasking

• Identify the “sentinel event”: postnatal smoking while breastfeeding; keep all questions and counselling anchored to this.

• Use the 90-second reading time to pre-plan: confirm setting (GP), task (counselling + referral to local stop-smoking service), and must-do outputs (advice + follow-up + safety-net + resources).

• Avoid irrelevant tangents (e.g., routine vaccine schedule) and keep data gathering relevant to management.

Maternal & infant risks to explore/acknowledge

• Maternal: cough, breathlessness, chest pain, wheeze/exacerbations, infections; previous asthma/COPD; mood (PPD/anxiety) and stress triggers.

• Infant/household: passive smoke exposure, indoor/car smoking, partner/household smokers, safe-sleep environment.

Readiness & habit profile (builds management)

• Open question first (“Can you tell me about your smoking since the birth?”), then specifics:

  • Quantity: cigarettes/day, time to first cigarette, dependence cues.

  • Duration/trajectory: smoked in pregnancy? stopped/restarted—why?

  • Triggers: stress, night feeds, social context.

  • Past quit attempts: what worked/failed (patch, gum, apps, services).

  • Supports/barriers: partner’s stance, other smokers at home, willpower concerns.

Examination/red flags (targeted)

• If symptomatic: focused resp exam; consider CXR if persistent red flags via usual pathways.

Important Considerations

• Empathic, non-judgemental tone; reinforce and praise motivation (“coming in today is a big step”).

• Capacity/consent, shared decisions, clear language, and check understanding per GMC Good medical practice (Domain 2).

• Be precise; don’t over-promise referrals/investigations; keep to what is realistic in primary care.

• If unsure of a fact, say you’ll verify before prescribing—accuracy and patient safety first.

Diagnostic Approach (Structured, 6–7 minutes)

1. Intro & identifiers: confirm name/age; acknowledge postpartum period; agenda set (“talk through smoking and supports to quit”).

2. ICE: ideas, concerns (effects on baby/NRT safety), expectations (help quitting).

3. Habit profile: quantity, timing, duration, triggers, previous quit aids, partner/household smoking, indoor/car smoking.

4. Health screen: maternal red flags (cough >3 weeks, haemoptysis, chest pain, breathlessness), mental health; infant wellbeing (feeding/latching; exposure).

5. Summarise & signpost to management: “I’ll share safe options while breastfeeding and how we’ll support you to quit.”

Management

Education (brief, tailored)

• Harms to mother and infant; benefits of quitting now; reinforce motivation and autonomy (patient-centred).

Pharmacological support (lactation-safe)

• Nicotine Replacement Therapy (NRT) is safe to use while breastfeeding and increases quit rates; available in multiple forms; in England it’s free on prescription during pregnancy and for 1 year post-birth. Advise short-acting forms (e.g., gum/lozenges/inhalator) and/or patches as appropriate. Encourage dosing right after a feed to minimise levels by next feed. nhs.uk+1

• Do NOT offer varenicline or bupropion while breastfeeding (current NICE NG209). NICE+1

Behavioural support & referral

• Offer referral or self-referral to NHS Stop Smoking Services; explain they provide structured support, NRT planning, and relapse prevention. GP/pharmacist/health visitor can refer, or patient can phone/locate local services directly. nhs.uk+2nhs.uk+2

• Consider signposting to local “Quit Your Way”/ICS services where relevant. nhsggc.scot+1

Practical harm-reduction if relapse/while quitting

• No indoor or car smoking; if a lapse occurs, smoke outdoors, then wash hands, rinse mouth/brush teeth, and change outer clothing before contact with baby. (Reinforces safety-netting taught in OSCE feedback.)

• Keep baby out of smoky environments; promote smoke-free home.

Partner & environment

• Ask about partner/household smokers; offer partner referral to services to boost success. Provide strategies for trigger times (night feeds, stress).

E-cigarettes

• If asked: less harmful than smoking, but not NHS-prescribed; focus on NRT + behavioural support as first-line during breastfeeding. (If the patient chooses to vape, still advise a smoke-free home and same hygiene steps.)

Follow-up & safety-net (must include in station)

• Follow-up: arrange review in 1–2 weeks to check progress, side-effects, and adjust NRT; further review at ~4 weeks.

• Safety-net: return/urgent advice for persistent cough (>3 weeks), haemoptysis, chest pain, breathlessness, or concerns about baby’s health.

• Resources/leaflets: give NHS leaflets/URLs from trusted sites (not generic “Google”).

Communication Skills

• Start with an open question, then focused questions; avoid stock phrases and excessive signposting; use clear, plain English; check understanding and agreement with the plan.

• Motivational interviewing touches: elicit change talk, reflect, summarise, offer choices, agree a quit date.

• Maintain kindness, courtesy, respect, and support shared decisions (GMP Domain 2).

Ethical Considerations

• Non-judgemental, patient-centred care; respect choices while promoting health.

• Accuracy and honesty: if uncertain about a drug’s safety in lactation, state you’ll verify before prescribing (duty of candour, safe prescribing).

• Confidentiality and appropriate documentation of advice, risks discussed, decisions, and follow-up.

Additional Resources

• NHS: Breastfeeding & smoking; NRT is safe in breastfeeding; options and access post-birth. nhs.uk+1

• NICE NG209 (2025 update): Tobacco: preventing uptake, promoting quitting and treating dependence—do not offer varenicline/bupropion in breastfeeding. NICE+1

• NHS Stop Smoking Services (referral & self-referral routes). nhs.uk+1

• LactMed (Nicotine; Varenicline)—compatibility of NRT; lack of data & avoidance of varenicline in nursing mothers. NCBI+2NCBI+2

• GMC Good medical practice (2024)—communication, shared decisions, safe prescribing, documentation.

• GMC/Examiner top tips—stay relevant; avoid stock phrases; don’t over-promise; structured, logical consultation.