Although the leading causes of death in the United States remain heart disease, cancer, and cerebrovascular disease (stroke), in their landmark paper Actual Causes of Death in the United States, McGinnis and Foege (1993) concluded that 50% of U.S. mortality is caused by 10 lifestyle-related behaviors, including tobacco use, poor dietary habits, lack of physical activity, alcohol misuse, illicit drug use, and risky sexual practices. In a 2004 update, Mokdad and colleagues found that more than one third of U.S. mortality in 2000 was linked to four behaviors: tobacco use, alcohol consumption, poor diet, and physical inactivity. Changing the health behaviors of Americans has the greatest potential impact of any current approach for decreasing morbidity and mortality and for improving the quality of life across diverse populations (Whitlock et al., 2002).

A growing body of evidence demonstrates that brief interventions integrated into routine primary care can effectively address the most common and important health risk behaviors encountered in family medicine, including smoking cessation, healthy diet, regular physical activity, appropriate alcohol use, and responsible use of contraceptives. Simple, direct, and brief advice from the physician to change lifestyle habits has been shown to be effective in encouraging smoking cessation, reducing problem drinking, and modifying some cardiovascular risk factors associated with activity and diet (Whitlock et al., 2002). If 60% to 90% of practicing physicians regularly advised patients not to smoke, an additional 63,000 smokers would quit each year (Hollis, 2000). This approach works, and patients expect and want it. More than 95% of adults report that they expect their physicians to give them information about health behaviors and assistance in changing negative ones (Vogt et al., 1998). Not surprisingly, clinician advice has been associated with increased satisfaction with medical care.

Behavioral counseling interventions have expanded beyond the limits of one-on-one interactions between physicians and patients. Physicians' efforts are enhanced when the entire health care team takes appropriate and complementary roles in delivering interventions. For example, many components of successful interventions can take place outside the traditional physician-patient encounter. The patient can complete a health risk assessment while waiting to see the doctor; a trained staff member can do in-office counseling after the clinical encounter; a patient may be referred to a community-based program; and a follow-up visit or telephone call may be arranged. To emphasize the potential impact of a team approach, if a health care team member provides an additional 10 minutes of targeted assistance to one half of the patients who received brief advice on smoking cessation from the physician, the number of people expected to quit increases from 63,000 to 630,000 (Hollis, 2000). The use of additional resources, however, does not lessen the central importance of the clinician-patient relationship in promoting behavioral change. Effective clinician communication is essential in promoting behavior change.

Appreciating the impact of behavioral change interventions requires a broad population-based perspective. A family physician may become discouraged if only 5% to 14% of those receiving an intervention make clinically significant changes, such as quitting smoking. However, even modest effects result in tremendous benefits to the community when systematically applied to the large number of those in need. The potential for substantial public health benefit from office-based behavioral change interventions will be realized only when these interventions are applied broadly and regularly (see Chapter 7).

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