611 Butler.qxd

Background. Theoretical and clinical developments suggest that opportunistic interventions could be developed that are more effective and satisfying to use than brief advice to quit smoking. Motivational consulting was influenced by the ‘stages of change’ model, self-efficacy theory, motivational interviewing, and the patient-centred clinical method. Aim. To compare the clinical and cost-effectiveness of motivational consulting with brief advice to quit smoking. Method. Pragmatic randomized trial in 21 general practices in South Wales: 536 cigarette smokers consulting with 24 general practice registrars were randomized to receive motivational consulting (270 patients) or brief advice (266 patients) during one consultation. Costs of training physicians and the extra consultation time for motivational interviewing were assessed. Outcomes were documented on 418 subjects (78%) at six-month follow-up. Results. Significantly more patients in the motivational consulting group reported not smoking in the previous 24 hours (P = 0.01), delaying their first cigarette of the day more than five minutes after waking (P = 0.01), making an attempt to quit lasting at least a week during follow-up (P = 0.04), and being in a more ready stage of change (P = 0.05). Non-significant trends favoured motivational consulting for selfreport abstention from smoking for one month, making an attempt to quit, and for reducing smoking. The advantage of motivational consulting was greatest among those initially not thinking of giving up in the following six months. Cost of training was £69.50 per physician, and cost of extra consultation time was £13.59 per patient. Conclusions. Motivational consulting produces better outcomes than brief advice, especially among those not ‘ready to change’. This supports the stages of change model. Overall, however, few patients quit. More intensive training might produce better outcomes.