"The facts concerning the recent carnival of smoking in Connecticut" and elsewhere.

The behavior of health care practitioners toward their patients can greatly affect the patients' motivation for change. Mark Twain's story, "The Facts Concerning the Recent Carnival of Crime in Connecticut," is used to illustrate how traditional strategies for motivating patients to change can have the paradoxic effect of inhibiting change and growth. We use a theory of human motivation, referred to as self-determination theory, to explain this effect and suggest alternative strategies for facilitating patient motivation. Empirical tests of the theory have shown that people will accept more responsibility for behavior change when motivated internally rather than externally. In the doctor-patient relationship, this internal motivation for change can be facilitated when doctors allow choice, provide relevant information, and acknowledge the patient's perspective. We propose a simple, three-question model, consistent with self-determination theory, for physicians to use with patients who smoke and are not yet ready to try quitting.