Brief and early intervention: experience from studies of harmful drinking
John B. Saunders Head, Centre for Drug and Alcohol Studies, Royal Prince Alfred Hospital and University of Sydney, Sydney, NS W
Kim Foulds Research Medical Officer, Centre for Drug and Alcohol Studies, Royal Prince Alfred Hospital and University of Sydney, Sydney, NS W
Abstract:
Brief and early interventions represent an innovative strategy for the prevention of harm from alcohol and other drugs. The pioneering study of early intervention, undertaken by Kristenson et al. (1983)aspart of a preventive medicine programme, demonstrated the efficacy of this approach for problem drinking. Subsequent studies have confirmed these findings. Brief and early interventions have been shown to be effective in a wide range of health care settings, including hospital wards and outpatient clinics, general practice, private health screening facilities and community-based health screening programmes. What is required now is the ascertainment of the most effective settingsfor brief and early interventions and the incentives needed for incorporation into routine practice. (Aust NZ J Med 1992; 22: 224-230.) Key words: Brief intervention, early intervention, alcoholism - prevention and control, hazardous drinking, alcoholism - therapy, primary health care, ambulatoy care.
INTRODUCTION rief and early intervention are innovative strategies for the prevention of harm from alcohol and other drugs. Although no precise definitions of these terms exist, brief intervention generally denotes a single session of therapy of five-30 minutes' duration which is offered to a greater proportion of people than would be reached by specialist services.' It is directed at both persons with dependence and those with less severe alcohol and drug use. Early intervention is a pro-active approach, which combines a systematic process of case detection and brief therapy, which is offered typically at the point of first contact. Therapy is provided before patients would normally present for treatment and in the main is directed at individuals whose alcohol or other drug use is at an early or mild stage. The aim is to reduce the risk of harm and of progression to dependence. Early intervention may involve several sessions of therapy. In practice, the approach is often both brief and early. The present review will concentrate on brief and, in particular early inter-
B
224
Aust NZ J Med 1992; 22
ventions for alcohol problems. However, relevant literature from the smoking cessation literature will be cited, particularly in relation to the incorporation of these approaches into health care practice.
RESEARCH METHODS Traditional Treatment Programmes The emergence of brief and early interventions as an efficacious approach to problem drinking was the result of several lines of research. The growing realisation of the inadequacies of traditional treatment programmes, of the neglect of nondependent drinkers with alcohol-related problems and evidence from natural history studies all contributed to the move toward earlier identification and management. The shift away from traditional, intensive specialist inpatient programmes was partially prompted by research undertaken by Edwards et al.2,3In a controlled trial, they demonstrated that the outcome for patients with alcohol-related harm admitted to inpatient programmes was not significantly better than that for outpatient treatment.* Further work SAUNDERS AND FOULDS
revealed that, for patients with established dependence, intensive outpatient treatment bestowed little extra benefit over a single session of a d ~ i c e . ~
Broad Bases of Treatment Findings from epidemiological studies facilitated the move towards a 'broader base of treatment'. They demonstrated a larger number of alcoholrelated problems than could be accounted for by the alcoholic p~pulation.~ Most harm seemed to be experienced by individuals who were not physically dependent. Whereas the physically dependent accounted for 2 6 % of the adult population, alcoholrelated harm was being experienced by 10-209'0 of the population. Furthermore, natural history studies demonstrated that a large proportion of those with harmful, but non-dependent, drinking resolved their drinking problem with apparently minimal interventi~n.~ Thus it was established that a new approach to the management of harmful drinking was required. Subsequent research focused on the investigation of the efficacy of brief and early interventions within various health care settings. A pioneering study of early intervention, undertaken by Kristenson et al in Malmo, was part of a preventive medicine programme aimed at reducing cardiovascular disease among middle-aged men.6 Individuals with harmful alcohol consumption, as determined by serum gammaglutamyltransferase (GGT) levels were identified. After the physically dependent and those undergoing or seeking treatment for drinking problems were excluded, they were randomly assigned to one of two groups. Those in the control group were notified by letter that they had an abnormal liver test and were advised to restrict their alcohol intake. Subjects in the intervention group were given more detailed feedback of their alcohol consumption and any alcohol related problems, were advised to reduce their alcohol intake and were given appointments for further counselling. Follow-up at five years demonstrated a significant effect of intervention, with the intervention group experiencing a reduction in the rate of hospitalisation (61%) and mortality (50%) when compared with the control group. Community-Based Health Screening Programmes A recently published study utilising a communitybased health screening programme was undertaken in Tromso, Norway.' An invitation to participate in the programme was extended primarily to residents aged between 20 and 62 years. Those identified as 'early-stage risk' drinkers (measured by BRIEF AND EARLY INTERVENTION - HARMFUL DRINKING
alcohol consumption and elevated GGT) were randomised to a control group and two intervention groups. The minor intervention comprised a single session discussing possible causes of an elevated G G T and the handing over of a pamphlet containing information about alcohol and GGT. Once other possible causes were excluded, the elevated GGT in the major intervention group was directly attributed to alcohol consumption. Subjects were offered advice on how to reduce intake, given the pamphlet and offered monthly consultations until their GGT level was normalised. At one year follow-up significant reductions in alcohol intake and G G T levels were demonstrated for both intervention groups when compared to the control group. There was, however, no significant difference in the outcome of the two intervention groups.
Hospital-Based Studies Hospital-based studies of early intervention include the study undertaken in male medical wards by Chick et al. from Edinburgh.8 Patients were screened by questionnaire and those who reported an alcohol consumption of greater than 60 g per day or reported alcohol-relatedproblems were randomly assigned to a single session of counselling or no intervention. A comparison of the two groups at one year follow-up year demonstrated a significant improvement in alcohol-related problems and GGT in the intervention group. A controlled trial undertaken by Elvy et al. among general hospital patients, although adopting a different therapeutic approach, similarly demonstrated the efficacy of early intervention.' Subjects were identified by systematic screening. Those in the active treatment group were approached by one of the researchers, confronted with their selfreported drinking problems and asked if they would accept referral to a counsellor. The subjects' general practitioners were informed of the referral. Followup at 12 months showed that those in the referral group reported fewer alcohol-relatedproblems, had fewer marital difficulties, a more satisfactory work record, less depression and fewer concerns about their alcohol consumption than the control group. Outpatient Clinics Persson investigated the efficacy of early intervention among persons attending outpatient clinics in a Swedish hospital." Nondependent drinkers with no history of treatment or abuse of other drugs were randomly assigned to an intervention or control group. Subjects in the intervention group were offered monthly sessions, at which time the results of laboratory tests were discussed and related Aust NZ J Med 1992; 22
225
to their alcohol consumption. At 12 months followup a significant reduction in alcohol consumption, GGT and numbers of sick days was found in the intervention group. Unfortunately, difficulties in the measurement of intake and G G T among the controls does not enable the reduction in these two measures to be directly attributed to the intervention.
General Practices The potential for significant public health gains ensured that research also concentrated on general practice. A trial by Wallace, Cutler and Haines among 47 general practices in the United Kingdom demonstrated that a significantly greater percentage of patients assigned to a single session of counselling (with the option of further sessions if mutually agreed) reduced their intake below the target level of 350 g when compared with the control group." The treatment effect was particularly marked among male patients, with a significant reduction in G G T also demonstrated. No corresponding reduction in GGT among females was found. Anderson randomly assigned patients from eight general practices in Oxfordshire to receive followup only, comprehensive assessment without specific therapy or assessment followed by a session comprising advice to reduce consumption below a specific target level and the teaching of strategies to achieve At one year follow-up, there were significantly greater reductions in alcohol intake in men receiving the active intervention compared to the two control groups. No such treatment effect, however, was found for women. The WHO Collaborative Study The largest study of early intervention conducted to date is the WHO collaborative study on early interventi~n.'~*'~ This study was designed to test the efficacy of three forms of brief therapy to reduce hazardous and harmful alcohol consumption in various primary health care settings and in various cultures. Our centre at Royal Prince Alfred Hospital, Sydney recruited subjects from hospital outpatient clinics, hospital physical rehabilitation services, general practices and a private health screening service (Medicheck). A satellite project was conducted by the Early Intervention Unit at Royal Darwin Hospital. The 551 subjects recruited in Sydney were randomly assigned to a no-treatment control group, five minutes simple structured advice, simple advice and 15 minutes brief counselling in problem solving strategies, or simple advice and extended counselling, involving two further sessions to monitor progress. At six month follow-up, weekly alcohol consumption and the 226 Aust NZ J Med 1992; 22
frequency of drinking to intoxication were found to be significantly reduced in the intervention groups when compared with the control group. Average weekly consumption was reduced by 35% in the brief counselling group compared with 14% in the control group. A substantial reduction (two or more points on an ordinal scale) in frequency of intoxication was demonstrated by 46% in the intervention groups, compared with 35% in the control group. Furthermore, only 13% of the intervention groups showed an increase in frequency of intoxication, compared with 26% in the control group. Thus there was a net benefit in terms of intoxication frequency for one third of subjects recruited. The attainment of this substantial body of evidence for the efficacy of brief and early interventions compels us to consider how best to implement these techniques into health care (and other) settings. It is one thing to demonstrate significant benefit from intervention in a controlled trial, and another to ensure the intervention is incorporated into medical practice. The history of medicine is littered with examples of interventions demonstrated to be beneficial which have been poorly taken up in clinical practice. Examples are cervical cancer screening and smoking cessation programmes.
Smoking Cessation As the issue of where and how best to implement brief and early interventions for alcohol problems is only now being seriously explored, it is useful to consider the experiences of those who sought to implement smoking cessation programmes into medical practice. Some of the difficulties faced by researchers in the translation of a proven intervention from the research arena to general medical practice are illustrated by the implementation of the Smokescreen programme. T h e Smokescreen programme was developed in 1980 'to meet the requirements of medical practitioners who expressed their great need for a programme to help patients stop ~moking'.'~The original protocol required six visits to the general practitioner over a six month period by those patients found to be suitable for intervention. A randomised controlled trial by Richmond et al., conducted in a four doctor general practice, recruited over 90% of smokers and demonstrated an impressive 36% success rate at three year follow-up for those patients participating in the Smokescreen programme." A study by Copeman et al. recruited 38 out of 50 general practitioners who attended one of five Smokescreen workshops held in Queensland.ls At the end of 12 months only 18 of the 38 doctors had SAUNDERS AND FOULDS
was designed to be ‘simple, straightforward [and] easy-to-implement’. They argued that it was necessary to make a compromise between an approach that resulted in the greatest cessation rate and an approach which could be adopted by busy practitioners.
recruited patients into the Smokescreen programme and kept records of their progress. The mean number of patients enrolled per recruiting doctor was 6.7. It was argued that this represented only approximately 7% of the eligible patients present in the practices of the recruiting doctors. Over half of the general practitioners did not attempt to recruit all their known smoking patients but rather those with smoking-related diseases or those thought likely to ‘give the programme a trial’. The general practitioners estimated that only 25-30% of the patients to whom the programme was mentioned actually commenced. These difficulties were compounded by the reluctance of patients to attend all six visits, with the number of patients attending the scheduled visits steadily decreasing from the first to the last visit. Silagy, in a similar study, demonstrated a similar, relatively low recruitment rate among 45 general practitioners who had attended a Smokescreen workshop and purchased the kit.lg Of the 80% responding at a three-month follow-up, just over 80% of the doctors had recruited less than five patients into the programme. No doctor had enrolled more than 30 patients. It was this low rate of utilisation of a successhl programme that caused Chapman to argue that the issue of ‘user friendliness’ of the intervention programme must be addressed when attempting to implement within regular health care practice.20 The seminal study examining the efficacy of brief intervention with smokers in general practice was undertaken by Russell et a1.” Smokers attending five group practices in London were randomly assigned to one of four groups: a no-treatment control, a questionnaire only control, general practitioner advice to stop smoking, and advice plus leaflet and warning of follow-up. Follow-up at 12 months demonstrated that 5 5 % more patients who received 1-2 minutes advice from their general practitioner had ceased smoking, compared with a no-treatment control group. A similar smoking cessation programme that evaluated a very brief intervention was the ‘Sick of Smoking’ programme developed by Wilson et ~ 1 Being more a brief intervention than the original Smokescreen protocol, it was designed to appeal to a larger number of general practitioners and be practical to use with a greater number of patients. Although the smoking cessation rate attained was lower, the uptake and utilisation of the programme were greater. A pragmatic approach to implementation was similarly adopted by researchers at the National Cancer Institute of the United The smoking cessation protocol developed for physicians BRIEF AND EARLY INTERVENTION
Recruitment Strategies Implementation is concerned with not only the utilisation but also the uptake of an intervention programme. Wilson et al. stated that only recently had attention been turned from ‘a concern with the content of programme materials to the factors that influence uptake of new programmes and resources’.22 A study that examined some of the factors that influence uptake was undertaken by Kottke et aLZ4 Two methods of recruitment of physicians in the United States to deliver smoking cessation interventions were compared. A mailed invitation to participate in a trial of a smoking intervention was sent to 110 family physicians (‘Round 1’) and 1108 internists and cardiologists (‘Round 2’). Participation rates were 6.0% and 2.7% respectively. For ‘Round 3’ a strategy based on the theories of social recruitment was devised. Repeated face-to-face efforts were made at the ofices of 126 physicians. Six months after the initial contact, 58% of the physicians were participating in the trial. Although some methodological problems associated with the study were acknowledged, it was argued that the bulk of the difference in uptake could be attributed to the recruitment strategies. The personal approach was also adopted by Fullard et al. in their controlled trial, although to achieve different aims.25A ‘facilitator’ introduced a screening package into the intervention group of general practices to determine whether the screening rate of major risk factors for cardiovascular disease in middle-aged patients would be significantly influenced. The facilitator introduced the package into the practice, trained the staff (primarily the practice nurse) in its use and provided continuing advice and support. During the two or . so~ years ~ of the study it was found that there was a two to fivefold increase between the intervention and control practices in the recording of the various risk factors.
- HARMFUL DRINKIN(
.7
J
Environmental Resources for Brief and Early Interventions What needs to be considered now are the most effective settings for brief and early interventions and the incentives needed for incorporating it into routine practice. A large throughput of the population and patients’ expectations combine to Aust NZ J Med 1992; 22 227
make primary health care an important setting for the implementation of brief and early interventions. It has been estimated that 87% of the population will consult a doctor at least once a year.26Medical practitioners are regarded by the public as an authoritative source of information and advice on Given the opportunities for intervention, it is important to examine those factors that militate against the incorporation of proven techniques into primary health care. Numerous barriers exist to the assimilation of brief and early interventions into the everyday workload of medical and nursing practitioners in primary health care. One such disincentive is the practitioner’s perceptions of having insufficient knowledge and skills to deal with patients with alcohol problems. Competing demands on the practitioner’s time and the lack of financial incentive to intervene are also significant barriers to intervention. The lack, in many cases, of immediate professional reward for any preventive activity undertaken, and the organisation of health care can all have a negative influence on the incorporation of brief and early interventions. Successful implementation will require both the recognition of these ‘barriers to implementation’ and the development of strategies to overcome them. Supportive Environment Kottke et al. assert that practitioners need a supportive environment if they are to adopt and maintain new behaviours (such as brief and early interventions).28 Personal resources, such as knowledge, skills, perceived self efficacy, confidence and commitment, must be accompanied by multiple environmental resources (supportive practice organisation, adequate financial compensation, perceived patient demand for preventive information and services, endorsement by professional societies) if preventive behaviours are to be sustained. They argue that creating a supportive environment will require the numerous barriers identified be addressed by individuals and institutions in multiple roles. Consequently, perceived lack of patient demand would have to be addressed by patients, voluntary organisations, patient activity feedback systems, government agencies. Other barriers such as absence of knowledge of need, lack of skills, perceived legitimacy and practice organisation would have to be addressed by professional organisations, universities and the practitioner. It is only through this multi-pronged assault on the identified barriers, and the resultant supportive environment, that utilisation of brief intervention is likely to be sustained. 228 Aust NZ J Med 1992; 22
The determination of where to concentrate, or disperse, resources on the implementation of brief and early interventions will require the consideration, at each proposed setting, of the likelihood of encountering the ‘at risk‘ population, the perceived legitimacy of providing intervention, the personal resources available and the ability to provide a supportive environment. Given finite resources, it is inevitable that some examination of the costeffectiveness of providing intervention at each setting will also have to be undertaken. General Practice and Research General practice is often cited as an ideal setting for the implementation of brief and early interv e n t i o n ~ .General ~ ~ , ~ ~practitioners are accessible to a large proportion of the community; part of their role is perceived to be the provision of preventive health a d v i ~ e . ~They ~ , ~ ~are identified as the foremost source of information and advice on alcohol3*and they have been shown to be effective in changing alcohol-related b e h a v i ~ u r s . ~ ~ - ’ ~ ~ ~ ~ Evidence gathered from the implementation of smoking cessation programmes into general practice and research demonstrating the poor identification of heavy drinkers by general practitioner^^^ and their unwillingness to intervene might seem to augur unfavourably for the incorporation of brief and early interventions into routine practice. Nevertheless, given the potentially large public health benefits to be gained if brief and early interventions were successfully implemented, it is important to address these barriers to effective intervention. The General Hospital The general hospital is also regarded as an appropriate setting for the identification.and intervention of problem Similar barriers to implementation of brief intervention exist. Rowland et al. demonstrated that despite brief education about alcohol and the provision of a short screening instrument, the screening rates of junior doctors remained fairly low (although there was a significant increase from pre-education level^).^',^^ Concern was expressed at not only the low level of screening but also the poor assimilation of the screening instrument into routine history taking. It was assumed that many of the doctors perceived the alcohol screening to be an ‘extra piece of work to be fitted into their duties’ rather than an integral component of the medical history. Even if screening were to become an integral part of history taking, the attitude toward giving brief intervention to those found to be ‘at risk’ has been shown to be less than positive. Both doctors and SAUNDERS AND FOULDS
nurses have been demonstrated to have a more negative attitude toward intervention, with nurses believing that intervention should only be given to those who seek it.37 Community Health Surveys and Programmes Community health surveys and programmes have also been suggested as an effective setting for the implementation of brief intervention. Although intervention has been demonstrated to be successful in these programmes, immense resources are required to administer them. A project designed by the Addiction Research Foundation, Canada, aimed to assess the impact of brief intervention with heavy drinkers identified in a community drinking survey.38 Difficulties, however, were experienced when attempting to recruit identified heavy drinkers into the drinking management programme. A pilot study found that only 14% of the identified heavy drinkers agreed to participate. It was suggested that ‘general population screening and voluntary recruitment into even short-term intervention programmes may not be feasible for the population most at risk of developing alcohol problem^'.^^ Although the efficacy of brief intervention in the workplace has not been proven, it seems an appropriate setting for the incorporation of these techniques. Suggestions for implementation strategies include the placement of a general health screening and intervention package within the Occupational Health setting (delivered to all or by invitation), or distributing self-help material to all employee^.^^ Barriers such as perceived intrusiveness and lack of confidentiality would need to be overcome.
CONCLUSION We have now reached the point where there is good evidence of the efficacy of brief and early interventions for reducing harmful alcohol consumption and cigarette smoking. Structured advice of one to five minutes’ duration results in a statistically significant and clinically relevant improvement in outcome. More intensive intervention increases therapeutic benefit, but at the expense of being less attractive to the therapist and less feasible to incorporate into regular health care. The challenge now is to develop implementation strategies and incentives for practitioners so that the public health benefits of these techniques can be realised. H References 1. Babor TF, Campbell R, Room R, Saunders JB. A dictionary of alcohol and other drug terms. Geneva: World Health Organization (in press). 2. Edwards G, Guthrie S. A comparison of inpatient and outpatient treatment of alcohol dependence. Lancet 1967; i: 555-9. BRIEF AND EARLY INTERVENTION - HARMFUL DRINKING
3. Edwards G, Orford J, Egert S, Guthrie S, Hawker A, Hensman C er al. Alcoholism: a controlled trial oftreatment’ and ‘advice’. J Stud Alcohol 1977; 38: 1004-31. 4. Auth BJ, Warheit GJ. Estimating the prevalence of problem drinking and alcoholism in the general population: an overview of epidemiological studies. Alcohol Health Res World 1982; 2: 11-9. 5. Vaillant G. The natural history of alcoholism. Cambridge: Harvard University Press, 1983. World Health Organization. Problems related to alcohol consumption. Report of a WHO Expert Committee. WHO Technical Report Series No. 650. Geneva: World Health Organization, 1980. 6. Kristenson H, Ohlin H, Hulter-Nosslin MS, Trell E, Hood B. Identification and intervention of heavy drinking in middle-aged men: results and follow-up of 24-60 months of long-term study with randomised controls. Alcoholism (NY) 1983; 7: 203-9. 7. Nilssen 0. The Tromso study: identification of and a controlled intervention on a population of early-stage risk drinkers. Prev Med 1991; 20: 518-28. 8. Chick J, Lloyd G, Crombie E. Counselling problem drinkers in medical wards: a controlled study. Br Med J 1985; 290: 965-7. 9. Elvy GA, Wells JE, Baird KA. Attempted referral as intervention for problem drinking in the general hospital. Br J Addict 1988; 83: 83-9. 10. Persson J. Early intervention in patients with excessive alcohol consumption: a controlled study. Alcohol Alcohol 1991; SUPPI 1: 473-6. 11. Wallace P, Cutler S, Haines A. Randomised controlled trial of general practitioner intervention in patients with excessive alcohol consumption. Br Med J 1988; 297: 663-8. 12. Scott E, Anderson P. Randomized controlled trial of general practitioner intervention in women with excessive alcohol consumption. Aust Drug Alc Rev 1990; 10: 313-21. 13. Anderson P, Scott E. Randomized controlled trial ofgeneral practitioner intervention in men with excessive alcohol consumption. Br J Addict (in press). 14. Saunders JB. The WHO Project on early detection and treatment of harmful alcohol consumption. Aust Drug Alc Rev 1987; 6: 303-8. 15. Saunders JB, Hanratty SJ. Early intervention for harmful alcohol consumption. Proceedings of a National Workshop on Early and Brief Interventions. National Drug and Alcohol Research Centre, Sydney, 1990. 16. Richmond RL. Smokescreen:how to help your patients stop smoking. Pt Mgt 1986; September: 91-101. 17. Richmond RL, Austin A, Webster IW. Three year evaluation of a programme by general practitioners to help patients stop smoking. Br Med J 1986; 292: 803-6. 18. Copeman RC, Swannell RJ, Pincus DF, Woodhead KA. Utilization of the ‘Smokescreen’ smoking-cessation programme by general practitioners and their patients. Med J Aust 1989; 151: 83-7. 19. Silagy C. Utilization of the ‘Smokescreen’ smoking-cessation programme. Med J Aust 1989; 151: 486. 20. Chapman S. General practitioner anti-smoking programmes; which one? Med J Aust 1990; 152: 508-9. 21. Russell MAH, Wilson C, Taylor C, Baker CD. Effect of general practitioners’advice against smoking. Br Med J 1979; 2: 231-5. 22. Wilson DH, Wakefield MA, Steven ID, Rohrsheim RA, Esterman AJ, Graham NMH. ‘Sick of Smoking’: evaluation of a targeted minimal smoking cessation intervention in general practice. Med J Aust 1990; 152: 518-21. 23. Glynn TJ, Manley MW. Physicians, cancer control and the treatment of nicotine dependence: defining success. Health Ed Res 1989; 4: 479-87. Aust NZ J Med 1992; 22
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24. Kottke TE, Solberg LI, Conn S, Maxwell P, Thomasberg M, Brekke ML, Brekke MJ. A comparison of two methods to recruit physicians to deliver smoking cessation interventions. Arch Intern Med 1990; 150: 1477-81. 25. Fullard E, Fowler G, Gray M. Promoting prevention in primary care: controlled trial of low technology, low cost approach. Br Med J 1987; 294: 1080-2. 26. Australian Bureau of Statistics. Aust Hlth Survey 1983. Sydney, Catalogue No. 4311.0, 1986. 27. Saunders JB, Roche AM, Moosburger RE. Barriers to effective intervention for alcohol and other drug problems. NSW Medical Education Project on Alcohol and Other Drugs. Royal Prince Alfred Hospital, 1990. 28. Kottke TE, Solberg LI, Brekke ML. Initiation and maintenance of patient behavioural change: what is the role of the physician? J Gen Intern Med 1990; 5: S62-S67. 29. Redman S, Cockburn J, Reid ALA, Sanson-Fisher RW. Alcohol consumption and alcohol-related problems: prevalence amongst a general practice population. Aust Drug Alc Rev 1987; 6: 245-52. 30. Bauman A, Mant A, Middleton L, Mackertich M, Jane E. Do general practitioners promote health): a needs assessment. Med J Aust 1989; 151: 262-8. 31. Wallace PG, Brennan PJ, Haines AP. Are general practitioners doing enough to promote healthy lifestyle? Findings of the Medical Research Council’s general practice research
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32.
33. 34. 35. 36. 37. 38. 39.
framework study on lifestyle and health. Br Med J 1987; 294: 940-2. Moore R, Makkai T, McAllister I. Perceptions and patterns of drug use: changes since the drug offensive. Department of Community Services and Health, Canberra, 1989. Reid ALA, Hennrikus D, Webb G, Sanson-Fisher R. General practitioners’ detection of patients with high alcohol intake. Br Med J 1986; 293: 735-7. Elvy G. Approaches to screening and early intervention in New Zealand. Aust Drug Alc Rev 1986; 5: 305-7. Rowland N, Maynard AK, Kennedy PF, Wintersgill W, Stones WD. Teaching doctors to take alcohol histories: a limited success story. Med Educ 1988; 22: 530-3. Rowland N, Maynard A, Kennedy P, Stone W, Wintersgill W. Doctors and alcohol screening - the gap between attitudes and action. Hlth Educ J 1988; 47: 133-6. Tolley K, Rowland N. Identification of alcohol-related problems in a general hospital setting: a cost-effectiveness evaluation. Br J Addict 1991; 86: 429-38. Babor T, Ritson E, Hodgson R. Alcohol-related problems in the primary health care setting: a review of early intervention strategies. Br J Addict 1986; 81: 23-46. Rollnick S, Gold R. Brief intervention for alcohol problems in the workplace. Occasional Paper, No 14. National Drug and Alcohol Research Centre, 1990.
SAUNDERS AND FOULDS
John B. Saunders Head, Centre for Drug and Alcohol Studies, Royal Prince Alfred Hospital and University of Sydney, Sydney, NS W
Kim Foulds Research Medical Officer, Centre for Drug and Alcohol Studies, Royal Prince Alfred Hospital and University of Sydney, Sydney, NS W
Abstract:
Brief and early interventions represent an innovative strategy for the prevention of harm from alcohol and other drugs. The pioneering study of early intervention, undertaken by Kristenson et al. (1983)aspart of a preventive medicine programme, demonstrated the efficacy of this approach for problem drinking. Subsequent studies have confirmed these findings. Brief and early interventions have been shown to be effective in a wide range of health care settings, including hospital wards and outpatient clinics, general practice, private health screening facilities and community-based health screening programmes. What is required now is the ascertainment of the most effective settingsfor brief and early interventions and the incentives needed for incorporation into routine practice. (Aust NZ J Med 1992; 22: 224-230.) Key words: Brief intervention, early intervention, alcoholism - prevention and control, hazardous drinking, alcoholism - therapy, primary health care, ambulatoy care.
INTRODUCTION rief and early intervention are innovative strategies for the prevention of harm from alcohol and other drugs. Although no precise definitions of these terms exist, brief intervention generally denotes a single session of therapy of five-30 minutes' duration which is offered to a greater proportion of people than would be reached by specialist services.' It is directed at both persons with dependence and those with less severe alcohol and drug use. Early intervention is a pro-active approach, which combines a systematic process of case detection and brief therapy, which is offered typically at the point of first contact. Therapy is provided before patients would normally present for treatment and in the main is directed at individuals whose alcohol or other drug use is at an early or mild stage. The aim is to reduce the risk of harm and of progression to dependence. Early intervention may involve several sessions of therapy. In practice, the approach is often both brief and early. The present review will concentrate on brief and, in particular early inter-
B
224
Aust NZ J Med 1992; 22
ventions for alcohol problems. However, relevant literature from the smoking cessation literature will be cited, particularly in relation to the incorporation of these approaches into health care practice.
RESEARCH METHODS Traditional Treatment Programmes The emergence of brief and early interventions as an efficacious approach to problem drinking was the result of several lines of research. The growing realisation of the inadequacies of traditional treatment programmes, of the neglect of nondependent drinkers with alcohol-related problems and evidence from natural history studies all contributed to the move toward earlier identification and management. The shift away from traditional, intensive specialist inpatient programmes was partially prompted by research undertaken by Edwards et al.2,3In a controlled trial, they demonstrated that the outcome for patients with alcohol-related harm admitted to inpatient programmes was not significantly better than that for outpatient treatment.* Further work SAUNDERS AND FOULDS
revealed that, for patients with established dependence, intensive outpatient treatment bestowed little extra benefit over a single session of a d ~ i c e . ~
Broad Bases of Treatment Findings from epidemiological studies facilitated the move towards a 'broader base of treatment'. They demonstrated a larger number of alcoholrelated problems than could be accounted for by the alcoholic p~pulation.~ Most harm seemed to be experienced by individuals who were not physically dependent. Whereas the physically dependent accounted for 2 6 % of the adult population, alcoholrelated harm was being experienced by 10-209'0 of the population. Furthermore, natural history studies demonstrated that a large proportion of those with harmful, but non-dependent, drinking resolved their drinking problem with apparently minimal interventi~n.~ Thus it was established that a new approach to the management of harmful drinking was required. Subsequent research focused on the investigation of the efficacy of brief and early interventions within various health care settings. A pioneering study of early intervention, undertaken by Kristenson et al in Malmo, was part of a preventive medicine programme aimed at reducing cardiovascular disease among middle-aged men.6 Individuals with harmful alcohol consumption, as determined by serum gammaglutamyltransferase (GGT) levels were identified. After the physically dependent and those undergoing or seeking treatment for drinking problems were excluded, they were randomly assigned to one of two groups. Those in the control group were notified by letter that they had an abnormal liver test and were advised to restrict their alcohol intake. Subjects in the intervention group were given more detailed feedback of their alcohol consumption and any alcohol related problems, were advised to reduce their alcohol intake and were given appointments for further counselling. Follow-up at five years demonstrated a significant effect of intervention, with the intervention group experiencing a reduction in the rate of hospitalisation (61%) and mortality (50%) when compared with the control group. Community-Based Health Screening Programmes A recently published study utilising a communitybased health screening programme was undertaken in Tromso, Norway.' An invitation to participate in the programme was extended primarily to residents aged between 20 and 62 years. Those identified as 'early-stage risk' drinkers (measured by BRIEF AND EARLY INTERVENTION - HARMFUL DRINKING
alcohol consumption and elevated GGT) were randomised to a control group and two intervention groups. The minor intervention comprised a single session discussing possible causes of an elevated G G T and the handing over of a pamphlet containing information about alcohol and GGT. Once other possible causes were excluded, the elevated GGT in the major intervention group was directly attributed to alcohol consumption. Subjects were offered advice on how to reduce intake, given the pamphlet and offered monthly consultations until their GGT level was normalised. At one year follow-up significant reductions in alcohol intake and G G T levels were demonstrated for both intervention groups when compared to the control group. There was, however, no significant difference in the outcome of the two intervention groups.
Hospital-Based Studies Hospital-based studies of early intervention include the study undertaken in male medical wards by Chick et al. from Edinburgh.8 Patients were screened by questionnaire and those who reported an alcohol consumption of greater than 60 g per day or reported alcohol-relatedproblems were randomly assigned to a single session of counselling or no intervention. A comparison of the two groups at one year follow-up year demonstrated a significant improvement in alcohol-related problems and GGT in the intervention group. A controlled trial undertaken by Elvy et al. among general hospital patients, although adopting a different therapeutic approach, similarly demonstrated the efficacy of early intervention.' Subjects were identified by systematic screening. Those in the active treatment group were approached by one of the researchers, confronted with their selfreported drinking problems and asked if they would accept referral to a counsellor. The subjects' general practitioners were informed of the referral. Followup at 12 months showed that those in the referral group reported fewer alcohol-relatedproblems, had fewer marital difficulties, a more satisfactory work record, less depression and fewer concerns about their alcohol consumption than the control group. Outpatient Clinics Persson investigated the efficacy of early intervention among persons attending outpatient clinics in a Swedish hospital." Nondependent drinkers with no history of treatment or abuse of other drugs were randomly assigned to an intervention or control group. Subjects in the intervention group were offered monthly sessions, at which time the results of laboratory tests were discussed and related Aust NZ J Med 1992; 22
225
to their alcohol consumption. At 12 months followup a significant reduction in alcohol consumption, GGT and numbers of sick days was found in the intervention group. Unfortunately, difficulties in the measurement of intake and G G T among the controls does not enable the reduction in these two measures to be directly attributed to the intervention.
General Practices The potential for significant public health gains ensured that research also concentrated on general practice. A trial by Wallace, Cutler and Haines among 47 general practices in the United Kingdom demonstrated that a significantly greater percentage of patients assigned to a single session of counselling (with the option of further sessions if mutually agreed) reduced their intake below the target level of 350 g when compared with the control group." The treatment effect was particularly marked among male patients, with a significant reduction in G G T also demonstrated. No corresponding reduction in GGT among females was found. Anderson randomly assigned patients from eight general practices in Oxfordshire to receive followup only, comprehensive assessment without specific therapy or assessment followed by a session comprising advice to reduce consumption below a specific target level and the teaching of strategies to achieve At one year follow-up, there were significantly greater reductions in alcohol intake in men receiving the active intervention compared to the two control groups. No such treatment effect, however, was found for women. The WHO Collaborative Study The largest study of early intervention conducted to date is the WHO collaborative study on early interventi~n.'~*'~ This study was designed to test the efficacy of three forms of brief therapy to reduce hazardous and harmful alcohol consumption in various primary health care settings and in various cultures. Our centre at Royal Prince Alfred Hospital, Sydney recruited subjects from hospital outpatient clinics, hospital physical rehabilitation services, general practices and a private health screening service (Medicheck). A satellite project was conducted by the Early Intervention Unit at Royal Darwin Hospital. The 551 subjects recruited in Sydney were randomly assigned to a no-treatment control group, five minutes simple structured advice, simple advice and 15 minutes brief counselling in problem solving strategies, or simple advice and extended counselling, involving two further sessions to monitor progress. At six month follow-up, weekly alcohol consumption and the 226 Aust NZ J Med 1992; 22
frequency of drinking to intoxication were found to be significantly reduced in the intervention groups when compared with the control group. Average weekly consumption was reduced by 35% in the brief counselling group compared with 14% in the control group. A substantial reduction (two or more points on an ordinal scale) in frequency of intoxication was demonstrated by 46% in the intervention groups, compared with 35% in the control group. Furthermore, only 13% of the intervention groups showed an increase in frequency of intoxication, compared with 26% in the control group. Thus there was a net benefit in terms of intoxication frequency for one third of subjects recruited. The attainment of this substantial body of evidence for the efficacy of brief and early interventions compels us to consider how best to implement these techniques into health care (and other) settings. It is one thing to demonstrate significant benefit from intervention in a controlled trial, and another to ensure the intervention is incorporated into medical practice. The history of medicine is littered with examples of interventions demonstrated to be beneficial which have been poorly taken up in clinical practice. Examples are cervical cancer screening and smoking cessation programmes.
Smoking Cessation As the issue of where and how best to implement brief and early interventions for alcohol problems is only now being seriously explored, it is useful to consider the experiences of those who sought to implement smoking cessation programmes into medical practice. Some of the difficulties faced by researchers in the translation of a proven intervention from the research arena to general medical practice are illustrated by the implementation of the Smokescreen programme. T h e Smokescreen programme was developed in 1980 'to meet the requirements of medical practitioners who expressed their great need for a programme to help patients stop ~moking'.'~The original protocol required six visits to the general practitioner over a six month period by those patients found to be suitable for intervention. A randomised controlled trial by Richmond et al., conducted in a four doctor general practice, recruited over 90% of smokers and demonstrated an impressive 36% success rate at three year follow-up for those patients participating in the Smokescreen programme." A study by Copeman et al. recruited 38 out of 50 general practitioners who attended one of five Smokescreen workshops held in Queensland.ls At the end of 12 months only 18 of the 38 doctors had SAUNDERS AND FOULDS
was designed to be ‘simple, straightforward [and] easy-to-implement’. They argued that it was necessary to make a compromise between an approach that resulted in the greatest cessation rate and an approach which could be adopted by busy practitioners.
recruited patients into the Smokescreen programme and kept records of their progress. The mean number of patients enrolled per recruiting doctor was 6.7. It was argued that this represented only approximately 7% of the eligible patients present in the practices of the recruiting doctors. Over half of the general practitioners did not attempt to recruit all their known smoking patients but rather those with smoking-related diseases or those thought likely to ‘give the programme a trial’. The general practitioners estimated that only 25-30% of the patients to whom the programme was mentioned actually commenced. These difficulties were compounded by the reluctance of patients to attend all six visits, with the number of patients attending the scheduled visits steadily decreasing from the first to the last visit. Silagy, in a similar study, demonstrated a similar, relatively low recruitment rate among 45 general practitioners who had attended a Smokescreen workshop and purchased the kit.lg Of the 80% responding at a three-month follow-up, just over 80% of the doctors had recruited less than five patients into the programme. No doctor had enrolled more than 30 patients. It was this low rate of utilisation of a successhl programme that caused Chapman to argue that the issue of ‘user friendliness’ of the intervention programme must be addressed when attempting to implement within regular health care practice.20 The seminal study examining the efficacy of brief intervention with smokers in general practice was undertaken by Russell et a1.” Smokers attending five group practices in London were randomly assigned to one of four groups: a no-treatment control, a questionnaire only control, general practitioner advice to stop smoking, and advice plus leaflet and warning of follow-up. Follow-up at 12 months demonstrated that 5 5 % more patients who received 1-2 minutes advice from their general practitioner had ceased smoking, compared with a no-treatment control group. A similar smoking cessation programme that evaluated a very brief intervention was the ‘Sick of Smoking’ programme developed by Wilson et ~ 1 Being more a brief intervention than the original Smokescreen protocol, it was designed to appeal to a larger number of general practitioners and be practical to use with a greater number of patients. Although the smoking cessation rate attained was lower, the uptake and utilisation of the programme were greater. A pragmatic approach to implementation was similarly adopted by researchers at the National Cancer Institute of the United The smoking cessation protocol developed for physicians BRIEF AND EARLY INTERVENTION
Recruitment Strategies Implementation is concerned with not only the utilisation but also the uptake of an intervention programme. Wilson et al. stated that only recently had attention been turned from ‘a concern with the content of programme materials to the factors that influence uptake of new programmes and resources’.22 A study that examined some of the factors that influence uptake was undertaken by Kottke et aLZ4 Two methods of recruitment of physicians in the United States to deliver smoking cessation interventions were compared. A mailed invitation to participate in a trial of a smoking intervention was sent to 110 family physicians (‘Round 1’) and 1108 internists and cardiologists (‘Round 2’). Participation rates were 6.0% and 2.7% respectively. For ‘Round 3’ a strategy based on the theories of social recruitment was devised. Repeated face-to-face efforts were made at the ofices of 126 physicians. Six months after the initial contact, 58% of the physicians were participating in the trial. Although some methodological problems associated with the study were acknowledged, it was argued that the bulk of the difference in uptake could be attributed to the recruitment strategies. The personal approach was also adopted by Fullard et al. in their controlled trial, although to achieve different aims.25A ‘facilitator’ introduced a screening package into the intervention group of general practices to determine whether the screening rate of major risk factors for cardiovascular disease in middle-aged patients would be significantly influenced. The facilitator introduced the package into the practice, trained the staff (primarily the practice nurse) in its use and provided continuing advice and support. During the two or . so~ years ~ of the study it was found that there was a two to fivefold increase between the intervention and control practices in the recording of the various risk factors.
- HARMFUL DRINKIN(
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Environmental Resources for Brief and Early Interventions What needs to be considered now are the most effective settings for brief and early interventions and the incentives needed for incorporating it into routine practice. A large throughput of the population and patients’ expectations combine to Aust NZ J Med 1992; 22 227
make primary health care an important setting for the implementation of brief and early interventions. It has been estimated that 87% of the population will consult a doctor at least once a year.26Medical practitioners are regarded by the public as an authoritative source of information and advice on Given the opportunities for intervention, it is important to examine those factors that militate against the incorporation of proven techniques into primary health care. Numerous barriers exist to the assimilation of brief and early interventions into the everyday workload of medical and nursing practitioners in primary health care. One such disincentive is the practitioner’s perceptions of having insufficient knowledge and skills to deal with patients with alcohol problems. Competing demands on the practitioner’s time and the lack of financial incentive to intervene are also significant barriers to intervention. The lack, in many cases, of immediate professional reward for any preventive activity undertaken, and the organisation of health care can all have a negative influence on the incorporation of brief and early interventions. Successful implementation will require both the recognition of these ‘barriers to implementation’ and the development of strategies to overcome them. Supportive Environment Kottke et al. assert that practitioners need a supportive environment if they are to adopt and maintain new behaviours (such as brief and early interventions).28 Personal resources, such as knowledge, skills, perceived self efficacy, confidence and commitment, must be accompanied by multiple environmental resources (supportive practice organisation, adequate financial compensation, perceived patient demand for preventive information and services, endorsement by professional societies) if preventive behaviours are to be sustained. They argue that creating a supportive environment will require the numerous barriers identified be addressed by individuals and institutions in multiple roles. Consequently, perceived lack of patient demand would have to be addressed by patients, voluntary organisations, patient activity feedback systems, government agencies. Other barriers such as absence of knowledge of need, lack of skills, perceived legitimacy and practice organisation would have to be addressed by professional organisations, universities and the practitioner. It is only through this multi-pronged assault on the identified barriers, and the resultant supportive environment, that utilisation of brief intervention is likely to be sustained. 228 Aust NZ J Med 1992; 22
The determination of where to concentrate, or disperse, resources on the implementation of brief and early interventions will require the consideration, at each proposed setting, of the likelihood of encountering the ‘at risk‘ population, the perceived legitimacy of providing intervention, the personal resources available and the ability to provide a supportive environment. Given finite resources, it is inevitable that some examination of the costeffectiveness of providing intervention at each setting will also have to be undertaken. General Practice and Research General practice is often cited as an ideal setting for the implementation of brief and early interv e n t i o n ~ .General ~ ~ , ~ ~practitioners are accessible to a large proportion of the community; part of their role is perceived to be the provision of preventive health a d v i ~ e . ~They ~ , ~ ~are identified as the foremost source of information and advice on alcohol3*and they have been shown to be effective in changing alcohol-related b e h a v i ~ u r s . ~ ~ - ’ ~ ~ ~ ~ Evidence gathered from the implementation of smoking cessation programmes into general practice and research demonstrating the poor identification of heavy drinkers by general practitioner^^^ and their unwillingness to intervene might seem to augur unfavourably for the incorporation of brief and early interventions into routine practice. Nevertheless, given the potentially large public health benefits to be gained if brief and early interventions were successfully implemented, it is important to address these barriers to effective intervention. The General Hospital The general hospital is also regarded as an appropriate setting for the identification.and intervention of problem Similar barriers to implementation of brief intervention exist. Rowland et al. demonstrated that despite brief education about alcohol and the provision of a short screening instrument, the screening rates of junior doctors remained fairly low (although there was a significant increase from pre-education level^).^',^^ Concern was expressed at not only the low level of screening but also the poor assimilation of the screening instrument into routine history taking. It was assumed that many of the doctors perceived the alcohol screening to be an ‘extra piece of work to be fitted into their duties’ rather than an integral component of the medical history. Even if screening were to become an integral part of history taking, the attitude toward giving brief intervention to those found to be ‘at risk’ has been shown to be less than positive. Both doctors and SAUNDERS AND FOULDS
nurses have been demonstrated to have a more negative attitude toward intervention, with nurses believing that intervention should only be given to those who seek it.37 Community Health Surveys and Programmes Community health surveys and programmes have also been suggested as an effective setting for the implementation of brief intervention. Although intervention has been demonstrated to be successful in these programmes, immense resources are required to administer them. A project designed by the Addiction Research Foundation, Canada, aimed to assess the impact of brief intervention with heavy drinkers identified in a community drinking survey.38 Difficulties, however, were experienced when attempting to recruit identified heavy drinkers into the drinking management programme. A pilot study found that only 14% of the identified heavy drinkers agreed to participate. It was suggested that ‘general population screening and voluntary recruitment into even short-term intervention programmes may not be feasible for the population most at risk of developing alcohol problem^'.^^ Although the efficacy of brief intervention in the workplace has not been proven, it seems an appropriate setting for the incorporation of these techniques. Suggestions for implementation strategies include the placement of a general health screening and intervention package within the Occupational Health setting (delivered to all or by invitation), or distributing self-help material to all employee^.^^ Barriers such as perceived intrusiveness and lack of confidentiality would need to be overcome.
CONCLUSION We have now reached the point where there is good evidence of the efficacy of brief and early interventions for reducing harmful alcohol consumption and cigarette smoking. Structured advice of one to five minutes’ duration results in a statistically significant and clinically relevant improvement in outcome. More intensive intervention increases therapeutic benefit, but at the expense of being less attractive to the therapist and less feasible to incorporate into regular health care. The challenge now is to develop implementation strategies and incentives for practitioners so that the public health benefits of these techniques can be realised. H References 1. Babor TF, Campbell R, Room R, Saunders JB. A dictionary of alcohol and other drug terms. Geneva: World Health Organization (in press). 2. Edwards G, Guthrie S. A comparison of inpatient and outpatient treatment of alcohol dependence. Lancet 1967; i: 555-9. BRIEF AND EARLY INTERVENTION - HARMFUL DRINKING
3. Edwards G, Orford J, Egert S, Guthrie S, Hawker A, Hensman C er al. Alcoholism: a controlled trial oftreatment’ and ‘advice’. J Stud Alcohol 1977; 38: 1004-31. 4. Auth BJ, Warheit GJ. Estimating the prevalence of problem drinking and alcoholism in the general population: an overview of epidemiological studies. Alcohol Health Res World 1982; 2: 11-9. 5. Vaillant G. The natural history of alcoholism. Cambridge: Harvard University Press, 1983. World Health Organization. Problems related to alcohol consumption. Report of a WHO Expert Committee. WHO Technical Report Series No. 650. Geneva: World Health Organization, 1980. 6. Kristenson H, Ohlin H, Hulter-Nosslin MS, Trell E, Hood B. Identification and intervention of heavy drinking in middle-aged men: results and follow-up of 24-60 months of long-term study with randomised controls. Alcoholism (NY) 1983; 7: 203-9. 7. Nilssen 0. The Tromso study: identification of and a controlled intervention on a population of early-stage risk drinkers. Prev Med 1991; 20: 518-28. 8. Chick J, Lloyd G, Crombie E. Counselling problem drinkers in medical wards: a controlled study. Br Med J 1985; 290: 965-7. 9. Elvy GA, Wells JE, Baird KA. Attempted referral as intervention for problem drinking in the general hospital. Br J Addict 1988; 83: 83-9. 10. Persson J. Early intervention in patients with excessive alcohol consumption: a controlled study. Alcohol Alcohol 1991; SUPPI 1: 473-6. 11. Wallace P, Cutler S, Haines A. Randomised controlled trial of general practitioner intervention in patients with excessive alcohol consumption. Br Med J 1988; 297: 663-8. 12. Scott E, Anderson P. Randomized controlled trial of general practitioner intervention in women with excessive alcohol consumption. Aust Drug Alc Rev 1990; 10: 313-21. 13. Anderson P, Scott E. Randomized controlled trial ofgeneral practitioner intervention in men with excessive alcohol consumption. Br J Addict (in press). 14. Saunders JB. The WHO Project on early detection and treatment of harmful alcohol consumption. Aust Drug Alc Rev 1987; 6: 303-8. 15. Saunders JB, Hanratty SJ. Early intervention for harmful alcohol consumption. Proceedings of a National Workshop on Early and Brief Interventions. National Drug and Alcohol Research Centre, Sydney, 1990. 16. Richmond RL. Smokescreen:how to help your patients stop smoking. Pt Mgt 1986; September: 91-101. 17. Richmond RL, Austin A, Webster IW. Three year evaluation of a programme by general practitioners to help patients stop smoking. Br Med J 1986; 292: 803-6. 18. Copeman RC, Swannell RJ, Pincus DF, Woodhead KA. Utilization of the ‘Smokescreen’ smoking-cessation programme by general practitioners and their patients. Med J Aust 1989; 151: 83-7. 19. Silagy C. Utilization of the ‘Smokescreen’ smoking-cessation programme. Med J Aust 1989; 151: 486. 20. Chapman S. General practitioner anti-smoking programmes; which one? Med J Aust 1990; 152: 508-9. 21. Russell MAH, Wilson C, Taylor C, Baker CD. Effect of general practitioners’advice against smoking. Br Med J 1979; 2: 231-5. 22. Wilson DH, Wakefield MA, Steven ID, Rohrsheim RA, Esterman AJ, Graham NMH. ‘Sick of Smoking’: evaluation of a targeted minimal smoking cessation intervention in general practice. Med J Aust 1990; 152: 518-21. 23. Glynn TJ, Manley MW. Physicians, cancer control and the treatment of nicotine dependence: defining success. Health Ed Res 1989; 4: 479-87. Aust NZ J Med 1992; 22
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24. Kottke TE, Solberg LI, Conn S, Maxwell P, Thomasberg M, Brekke ML, Brekke MJ. A comparison of two methods to recruit physicians to deliver smoking cessation interventions. Arch Intern Med 1990; 150: 1477-81. 25. Fullard E, Fowler G, Gray M. Promoting prevention in primary care: controlled trial of low technology, low cost approach. Br Med J 1987; 294: 1080-2. 26. Australian Bureau of Statistics. Aust Hlth Survey 1983. Sydney, Catalogue No. 4311.0, 1986. 27. Saunders JB, Roche AM, Moosburger RE. Barriers to effective intervention for alcohol and other drug problems. NSW Medical Education Project on Alcohol and Other Drugs. Royal Prince Alfred Hospital, 1990. 28. Kottke TE, Solberg LI, Brekke ML. Initiation and maintenance of patient behavioural change: what is the role of the physician? J Gen Intern Med 1990; 5: S62-S67. 29. Redman S, Cockburn J, Reid ALA, Sanson-Fisher RW. Alcohol consumption and alcohol-related problems: prevalence amongst a general practice population. Aust Drug Alc Rev 1987; 6: 245-52. 30. Bauman A, Mant A, Middleton L, Mackertich M, Jane E. Do general practitioners promote health): a needs assessment. Med J Aust 1989; 151: 262-8. 31. Wallace PG, Brennan PJ, Haines AP. Are general practitioners doing enough to promote healthy lifestyle? Findings of the Medical Research Council’s general practice research
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