Intervention development for integration of conventional tobacco cessation interventions into routine CAM practice.

BACKGROUND: Practitioners of complementary and alternative medicine (CAM) therapies are an important and growing presence in health care systems worldwide. A central question is whether evidence-based behavior change interventions routinely employed in conventional health care could also be integrated into CAM practice to address public health priorities. Essential for successful integration are intervention approaches deemed acceptable and consistent with practice patterns and treatment approaches of different types of CAM practitioners - that is, they have context validity. Intervention development to ensure context validity was integral to Project CAM Reach (CAMR), a project examining the public health potential of tobacco cessation training for chiropractors, acupuncturists and massage therapists (CAM practitioners). This paper describes formative research conducted to achieve this goal. METHODS: Intervention development, undertaken in three CAM disciplines (chiropractic, acupuncture, massage therapy), consisted of six iterative steps: 1) exploratory key informant interviews; 2) local CAM practitioner community survey; 3) existing tobacco cessation curriculum demonstration with CAM practitioners; 4) adapting/tailoring of existing curriculum; 5) external review of adaptations; 6) delivery of tailored curriculum to CAM practitioners with follow-up curriculum evaluation. RESULTS: CAM practitioners identified barriers and facilitators to addressing tobacco use with patients/clients and saw the relevance and acceptability of the intervention content. The intervention development process was attentive to their real world intervention concerns. Extensive intervention tailoring to the context of each CAM discipline was found unnecessary. Participants and advisors from all CAM disciplines embraced training content, deeming it to have broad relevance and application across the three CAM disciplines. All findings informed the final intervention. CONCLUSIONS: The participatory and iterative formative research process yielded an intervention with context validity in real-world CAM practices as it: 1) is patient/client-centered, emphasizing the practitioner's role in a healing relationship; 2) is responsive to the different contexts of CAM practitioners' work and patient/client relationships; 3) integrates relevant best practices from US Public Health Service Clinical Practice Guidelines on treating tobacco dependence; and 4) is suited to the range of healing philosophies, scopes of practice and practice patterns found in participating CAM practitioners. The full CAMR study to evaluate the impact of the CAMR intervention on CAM practitioners' clinical behavior is underway.

Tobacco Cessation Training for Complementary and Alternative Medicine Practitioners: Results of a Practice-Based Trial.

INTRODUCTION: Brief behavioral intervention (BI) is a tobacco-cessation best practice well established among conventional healthcare practitioners. Complementary and alternative medicine (CAM) practitioners treat significant numbers of tobacco users, but do not systematically receive BI training. The CAM Reach study developed and evaluated a tobacco cessation BI training program/practice system intervention adapted specifically for CAM practitioners, and evaluated in real-world CAM practices. STUDY DESIGN: Single-arm intervention. Data were collected in 2010-2014 and analyzed in 2015. SETTING/PARTICIPANTS: Private practices of 30 chiropractors, 27 acupuncturists, 42 massage therapists (N=99), in metropolitan Tucson, Arizona. INTERVENTION: Eight-hour tobacco cessation BI continuing education workshop, in-office BI skills practice/assessment, and system intervention. Training tailored to the CAM practice setting addressed tobacco cessation best practices from the U.S. Public Health Service Guidelines. MAIN OUTCOME MEASURES: Seventeen items (assessing practitioner behavior, motivation, and self-efficacy with tobacco cessation) comprising three factors, Tobacco Cessation Activity, Tobacco Cessation Motivation, and Non-CAM Tobacco Cessation Comfort, were assessed at baseline and 3, 6, 9, and 12 months post-training by practitioner self-report. Research staff visited practices at approximately the same intervals to directly observe changes in clinical practice systems. RESULTS: At 3 months, there were significant increases in practitioners' tobacco cessation activities, motivation and confidence in helping patients quit tobacco, and comfort with providing information and referrals for guideline-based tobacco cessation aids (p<0.0001). Practitioners significantly increased rates of discussing cessation medications with patients (AOR=3.76, 95% CI=1.84, 7.68), and routinely asking about tobacco use in clinical practice (AOR=2.62, 95% CI=1.11, 6.20). Increases occurred across all three practitioner types and were sustained at 12 months-despite heterogeneity in professional training, practice patterns/organization, and practice business models. CONCLUSIONS: Results suggest CAM practitioners are willing and able to offer BIs, and are an important, yet overlooked channel for promoting tobacco cessation and use of evidence-based cessation aids.

Diet and biomarkers of oxidative damage in women previously treated for breast cancer.

This study sought to evaluate the relationship between dietary intake of fat, polyunsaturated fat, saturated fat, arachidonic acid, and selected dietary antioxidants and levels of oxidative damage as measured by urinary levels of 8-hydroxy-2'-deoxyguanosine (8-OHdG) and 8-epi-prostaglandin F2alpha (8-iso-PGF2alpha) in women previously treated for breast cancer. Two hundred two study subjects participating in the Women's Healthy Eating and Living (WHEL) study were included in this ancillary study. Dietary intakes and concentrations of urinary 8-OHdG and 8-iso-PGF2alpha were measured at baseline and 12 mo in the 179 women included in the analytical cohort. Study subjects demonstrated a significant reduction in dietary total, polyunsaturated, and saturated fat intake and a significant increase in vitamins E and C and beta-carotene intake from baseline to 12 mo. Linear mixed-models analysis using baseline and Year 1 data indicated that vitamin E intake was inversely associated with both 8-OHdG and 8-iso-PGF2alpha. 8-Iso-PGF2alpha is increased with increased body mass index (BMI) and polyunsaturated fatty acid (PUFA) intake, indicating an increase in lipid peroxidation with greater BMI and higher PUFA intake. 8-OHdG was inversely related to age but positively related to arachidonic acid, indicating an increase in DNA damage with higher intake of arachidonic acid (meat). The results of this nested case-controlled study provide potential mechanisms by which a high fruit and vegetable, low-fat diet might reduce the recurrence rate of or early-stage breast cancer.

Measuring dietary change in a diet intervention trial: comparing food frequency questionnaire and dietary recalls.

Measurement of dietary change was assessed in a systematic quota subsample (n = 397) of women recruited into the Women's Healthy Eating and Living Study between 1996 and 1998, a multicenter, randomized dietary intervention trial among breast cancer survivors. Women from the intervention and comparison arms completed the Arizona Food Frequency Questionnaire (AFFQ) and 24-hour dietary recalls at baseline (prerandomization) and at year 1 (postrandomization). Both dietary measurement methods demonstrated significant changes in intake of key intervention-associated nutrients at year 1 in the intervention group subjects compared with minimal or no change in the comparison group subjects. The reliability of the AFFQ and recalls was measured in the comparison group and showed correlations of 0.63 and 0.43, respectively. Both instruments captured differences in dietary intake associated with the diet intervention. These results demonstrate the utility of using a multimode, multimethod approach (AFFQ and 24-hour dietary recalls) to measure differences in self-reported dietary intake over time as shown in this dietary intervention trial being conducted among breast cancer survivors.

On the importance of using multiple methods of dietary assessment.

BACKGROUND: Plasma carotenoid concentrations reflect intake of vegetables and fruits, the major food sources of these compounds. This study compared the ability of 2 measures of dietary intake (24-hour diet recalls and food frequency questionnaires [FFQs]) to corroborate plasma carotenoid concentrations in a subset of women participating in a diet intervention trial. METHODS: Plasma carotenoid concentrations and dietary intakes, estimated from 24-hour diet recalls and FFQs, were examined at baseline and 1 year later in a subset of 395 study participants (197 intervention and 198 comparison group). We used longitudinal models to examine associations between estimated intakes and plasma carotenoid concentrations. These analyses were stratified by study group and adjusted for body mass index (BMI), plasma cholesterol concentration, and total energy intake. We conducted simulations to compare mean-squared errors of prediction of each assessment method. RESULTS: In mixed-effects models, the estimated carotenoid intakes from both dietary assessment methods were strongly associated with plasma concentrations of alpha-carotene, beta-carotene, and lutein. Furthermore, modeling the 2 sources of intake information as joint predictors reduced the prediction error. CONCLUSION: These findings underscore the importance of using multiple measures of dietary assessment in studies examining diet-disease associations.