Am Fam Physician. 2001 Nov 1;64(9):1520.
to the editor: I read with great interest the article by Dr. Rustin, “Assessing Nicotine Dependence.”1 Dr. Rustin provides an excellent introduction to the concept of “motivational interviewing.” The CAGE questionnaire and other tools are used to determine the intensity of a patient's nicotine dependence. The patient's readiness to change the dependent behavior also is evaluated during the session. This thorough evaluation could lead to a potentially lengthy encounter. I agree with the statement concerning the time constraints of average office visits for a family practice physician.2
Once a patient's level of motivation for change is evaluated using the CAGE questionnaire, Miller and Rollnick address time constraints through use of the mnemonic FRAMES.3,4 This method permits the therapeutic process to continue with elements intuitively familiar to physicians, allowing an effective and brief patient encounter. FRAMES begins with Feedback, which involves discussing assessment results with the patient and may include such items as laboratory results or the modified Fagerstrom test mentioned in the article. Also included in this brief encounter is an emphasis on personal Responsibility, and Advice clearly stating the initial steps for behavioral change. Similarly, Menu and Empathy denote, respectively, a list of options and vocalized understanding of the patient's stated and unstated responses. Finally, the therapist, by instilling a sense of Self-efficacy within the patient, can promote the optimism needed to achieve success in this endeavor.5 The FRAMES approach is useful for brief or single-visit interventions dealing with substance abuse. Additionally, this approach is applicable to the behavioral changes needed by patients for a wide variety of medical conditions commonly encountered by family physicians.6
Assessing nicotine dependence or other health-associated behaviors is an important first step for evaluating a patient's readiness to change. The reality for busy health professionals necessitates use of existing skills (FRAMES method) with effective assessment strategies (tools from the article) to maximize patient motivation for change and selection of the optimum treatment regimen.
1. Rustin TA. Assessing nicotine dependence. Am Fam Physician. 2000;62:579–84,591–2.
2. Jorenby DE, Fiore MC. The Agency for Healthcare Policy and Research smoking cessation clinical practice guideline: basics and beyond. Prim Care. 1999;26:513–28.
3. Miller WR, Rollnick S. Motivational interviewing: preparing people to change addictive behavior. New York: Guilford Press, 1991:30–5.
4. Miller WR. Motivational interviewing: research, practice, and puzzles. Addict Behav. 1996;21:835–42.
5. Frank JD, Frank JB. Persuasion and healing: a comparative study of psychotherapy. 3d ed. Baltimore: Johns Hopkins University Press, 1991:132–53.
6. Sippel JM, Osborne ML, Bjornson W, Goldberg B, Buist AS. Smoking cessation in primary care clinics. J Gen Intern Med. 1999;14:670–6.
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