EXAMINER ONLY INFORMATION

QUESTIONS

Q1. How would you assess Michael’s smoking history and level of nicotine dependence?

• Prompt: What tools or questions would you use?
• Prompt: How would you explore his motivation and past quit attempts?

Q2. What evidence-based smoking cessation options would you offer Michael?

• Prompt: What pharmacological and non-pharmacological strategies are available?
• Prompt: How would you tailor these options to his concerns?

Q3. How would you use motivational interviewing to explore Michael’s readiness to quit?

• Prompt: What are key strategies in motivational interviewing?
• Prompt: How would you handle ambivalence about quitting?

Q4. What screening and preventive health measures should be considered for Michael?

• Prompt: What conditions are smokers at higher risk for?
• Prompt: What investigations should be arranged?

Q5. How would you support Michael in maintaining long-term smoking cessation?

• Prompt: What are common relapse triggers?
• Prompt: What follow-up strategies would you implement?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: How would you assess Michael’s smoking history and level of nicotine dependence?

Michael’s smoking history and nicotine dependence should be assessed systematically using structured questions and validated tools.

1. History of Smoking

• Number of cigarettes per day (currently 20/day)
• Duration of smoking (30 years = 30 pack-years)
• Previous quit attempts – methods used, reasons for relapse
• Triggers for smoking – stress, habit, social influences
• Motivation to quit – rated on a 1-10 scale
• Readiness for change – using the Stages of Change model

2. Assessment of Nicotine Dependence

• Fagerström Test for Nicotine Dependence (FTND):
  • How soon after waking does he smoke? (First cigarette within 30 minutes suggests high dependence)
  • Difficulty refraining from smoking in restricted areas?
  • Number of cigarettes per day?
  • Smoking during illness?

3. Evaluation of Health Impact

• Symptoms of smoking-related diseases (morning cough, breathlessness suggest COPD)
• Comorbidities: Hypertension, hyperlipidaemia, and cardiovascular risk
• Passive smoking impact on family members

A thorough assessment helps guide individualised smoking cessation strategies.

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Q2: What evidence-based smoking cessation options would you offer Michael?

1. Behavioural Strategies

• Brief intervention using the 5 A’s approach: Ask, Advise, Assess, Assist, Arrange
• Motivational interviewing techniques
• Counselling support (Quitline, psychologist referral)

2. Pharmacological Interventions

• Nicotine Replacement Therapy (NRT): Patches + short-acting forms (gum, lozenges)
• Varenicline (Champix): Reduces cravings and pleasure from smoking
• Bupropion (Zyban): Dopaminergic antidepressant that aids cessation

3. Addressing Barriers

• Fear of weight gain – discuss dietary and exercise strategies
• Withdrawal symptoms – explain transient nature and coping mechanisms

4. Follow-up and Relapse Prevention

• Regular follow-up within 1-2 weeks
• Ongoing encouragement and adjustment of therapy

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Q3: How would you use motivational interviewing to explore Michael’s readiness to quit?

1. Establish Rapport and Explore Ambivalence

• Open-ended questions: “What do you enjoy about smoking?” “What concerns do you have about quitting?”
• Reflective listening: Validate concerns and reinforce motivation

2. Use the ‘Readiness Ruler’ (1-10 Scale)

• If low: Explore barriers and strategies to increase readiness
• If moderate-high: Reinforce positive reasons to quit

3. Elicit Change Talk

• “How would your life be different if you quit?”
• “What would need to happen for you to feel ready?”

4. Strengthen Self-Efficacy

• Highlight past successes and coping strategies
• Offer incremental steps, such as cutting down before quitting

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Q4: What screening and preventive health measures should be considered for Michael?

1. Respiratory and Cardiovascular Risk Assessment

• Spirometry – to assess for COPD
• ECG – if cardiovascular risk is high
• Lipid profile and fasting glucose – given metabolic risk

2. Cancer Screening

• Lung cancer screening (low-dose CT if eligible)
• Bowel cancer screening (FOBT >50 years)
• Skin check for smoking-related malignancies

3. Vaccination

• Influenza and pneumococcal vaccine

Screening helps detect smoking-related illnesses early, allowing timely intervention.

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Q5: How would you support Michael in maintaining long-term smoking cessation?

1. Identify and Manage Relapse Triggers

• Stress management – mindfulness, exercise
• Social situations – coping mechanisms
• Alcohol use – minimising triggers

2. Monitor and Adjust Treatment

• Regular follow-up appointments
• Adjust NRT or pharmacotherapy as needed

3. Encourage Positive Reinforcement

• Track progress with CO monitoring or symptom improvement
• Set small, achievable goals

Sustained support increases the likelihood of successful long-term smoking cessation.

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SUMMARY OF A COMPETENT ANSWER

• Thoroughly assesses smoking history, triggers, and nicotine dependence
• Provides evidence-based pharmacological and behavioural interventions
• Uses motivational interviewing to explore readiness and reinforce change
• Implements appropriate preventive health screening for smoking-related risks
• Develops a personalised relapse prevention plan

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PITFALLS

• Failure to assess nicotine dependence properly
• Overprescribing medication without addressing behavioural aspects
• Not considering COPD despite chronic cough
• Lack of follow-up and relapse prevention strategies

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REFERENCES

• RACGP – Supporting smoking cessation: A guide for health professionals
• Australian Government – Quitline
• Department of Health and Ageing – My QuitBuddy app

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MARKING

Each competency area is on the following scale from 0 to 3.

☐ Competency NOT demonstrated
☐ Competency NOT CLEARLY demonstrated
☐ Competency SATISFACTORILY demonstrated
☐ Competency FULLY demonstrated

1. Communication and Consultation Skills

1.1 Communicates effectively and empathetically about smoking cessation.
1.3 Uses motivational interviewing techniques to assess readiness to quit.

2. Clinical Information Gathering and Interpretation

2.1 Takes a comprehensive smoking history, including pack-years and dependence level.
2.3 Identifies comorbidities related to smoking (COPD, cardiovascular disease).

3. Diagnosis, Decision-Making and Reasoning

3.1 Assesses nicotine dependence using validated tools (e.g., Fagerström test).
3.3 Identifies and discusses withdrawal symptoms and relapse risk factors.

4. Clinical Management and Therapeutic Reasoning

4.1 Provides evidence-based smoking cessation strategies.
4.4 Prescribes pharmacotherapy (NRT, varenicline, bupropion) where appropriate.

5. Preventive and Population Health

5.1 Provides brief interventions and referral to smoking cessation programs.

6. Professionalism

6.2 Addresses potential stigma and ensures patient-centred care.

7. General Practice Systems and Regulatory Requirements

7.1 Uses MyMedicare and chronic disease management plans where relevant.

8. Procedural Skills

8.2 Conducts spirometry if COPD is suspected.

9. Managing Uncertainty

9.1 Adjusts smoking cessation strategies based on patient motivation and relapse risk.

10. Identifying and Managing the Patient with Significant Illness

10.2 Identifies complications such as cardiovascular disease or COPD.

Competency at Fellowship Level

☐ CLEARLY BELOW STANDARD
☐ BELOW EXPECTED STANDARD
☐ BORDERLINE
☐ AT EXPECTED STANDARD
☐ ABOVE STANDARD