Helping smokers make decisions: the enhancement of brief intervention for general medical practice

Primary care clinicians are often encouraged by government agencies to intervene systematically with all smokers. Pressure of time and pessimism about their own efficacy and patients' capacity to change are some of the reasons why clinicians do not feel it is appropriate to always advise every patient about unhealthy behaviours. Developments in patient centred approaches to the consultation and progress in the addictions field suggest that new consulting methods could be constructed which are more satisfying than giving brief advice to change. The aim of this study was to develop a structured, teachable and acceptable intervention for clinicians to help patients consider their smoking during general medical consultations. Patient centred strategies derived from the stages of change model and motivational interviewing and its adaptations were explored in experimental consultations with 20 volunteer smokers. Feedback from them and from general practice registrars trained in the use of the method informed its development. Acceptability to clinicians was assessed by semi structured telephone interviews with 24 general practice registrars who participated in a randomised controlled trial assessing the effectiveness of the method. Anonymous, written questionnaires were also completed by 20 of the registrars who recruited ten or more patients into the trial. The method is described. Key components are: establishing rapport, assessing motivation and confidence, and then depending on the response, asking standard scaling questions, asking about pros and cons of smoking, non-judgmental information sharing, brainstorming solutions and negotiating attainable goals and follow-up. The clinicians used the method with a total of 270 smokers, taking an average of 9.69 min with each patient. Evaluation reveals that it is acceptable to the group of general practice registrars. Longer consultation time was seen as the main drawback. We conclude that acceptable methods for opportunistic health promotion can be developed by taking into account patient centred approaches to the consultation, developments from the addictions field and the practical problems faced by clinicians. The process can be further enhanced by considering feedback from those who are likely to receive and use the interventions.