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R e v i e w s / C o m m e n t a r i e s / P o s i t i o n S t a t e m e n t s
T E C H N I C A L R E V I E W
Smoking and Diabetes
DERA HAIRE!"#SH$% PHD tables and summarizing study content andcriteria, and summarizing these studies andreview articles. Articles included were pub-lished in peer-
R$SSELL E& 'LAS'#W% PHD
TI((AN) L& TIS% *A
reviewed journals within thelast 10 years in English. In a ewinstances,a
rticles o particular merit within the past 1!years are presented. "hese proce dures"he objective o this review is to summarize the literature on diabetes and smo#ing related to
epidemiological ris#s, eicacy and cost-eectiveness o di revealed a relatively small number o stud-ies speci c to diabetes and smo#ing, espe-cially on intervention re
erent cessation approaches, andimplications or clinical practice. $ver %00 studies were reviewed, with special emphasis placedon publications within the past 10 years. Intervention studies that included patients with dia- betes but did not re
search. "hereore, ineach section we present articles relevant tosmo#ing in general, ocusing on studies o medical patients &many o which includediabetic patients, but do not separate re
p ort results separately by disease are included. 'iabetes-speci c studies arehighlighted. "here are consistent results rom both cross-sectional and prospective studiesshowing enhanced ris# or micro- and macrovascular disease, as well as premat u re mortal it yrom the combination o smo#ing and diabetes. "he general cessation literature is e(tensive, sultsgenerally well-designed, and encouraging regarding the impact o cost-eective practicalor them vs. other patients), and then pres-o ice-based interventions. In particu l ar, system-based approaches that ma#e smo#ing a rou-
ent the more limited literature speci callytine part o oice contacts and provide multiple prompts, advice, assistance, and ollow-up sup-
p related to diabetes and smo#ing. "ogether,o rt are eective. Although there is minimal inormation on the eectiveness o cessationthese studies allow or the e(trapolationo ndings rom the general literature thatare p
i n t erventions speci cally or people with diabetes, there is no reason to assume that cessationi n tervention would be more or less eective in this population. "here is a clear need to increasethe re*uency o smo#ing cessation advice and counseling or patients with diabetes given thes
ertinent to people with diabetes.trong and consistent data on smo#ing prevalence+ combined ris#s o smo#ing and diabetes or
m or bid it y, mortali t y, and several complications+ and the proven eicacy and cost-eect iv enes s P REVALENCE #( S*#+IN' , o cessation strategies. "his section presents actors associated
with smo#ing prevalence in the general population and its impact on health. "hesociodemographic characteristics associ-ated with prevalence are discussed. "his isollowed by the more limited re
Diabetes Care 2- .0 012030% 333
and medical oice in promoting smo#ingcessation and on the cost-eectiveness o smo#ing cessation. e then review data
that suggest the importance o care settingsin promoting optimal diabetes care as it
sea rch onmarize tobacco control issues across smo#ing prevalence among individuals
with diabetes.multiple levels the patient, the healthT4e 56r5ose o7 t4is review is to s6m!c are provid er, the health care setting, and igarette smo#ing is the leading avoid-
able cause o mortality in the /..,account-ing or 2,000 deaths each year &1).Among cigarette smo#ers, !%3 o deathsor men and 23 o deaths or womenw
n ally, policy implications. e rst estab-lish the health threat associated withtobacco use in general and then summarizeits heightened impact on morbidity andm
relates to smo#ing cessation. 4inally, impli-cations or health care policy and uturerese arch are discussed.
ortality among people with diabetes. "his ere attributable to cigarette smo#ing &%).In general, smo#ing prevalence hasd
includes a review o the patient perspec-tives associated with diabetes care andmanagement, which oten enhance thecontinuation o smo#ing &e.g., absence o advice to *uit, priority given to other tre
LITERAT$RE REVIEW ANDAN A L)S IS , A review o7 t4e 8iterat6reecreased over the past 10 years because o on smo#ing in general and smo#ing relative e(tensive public health eorts &2,2a),to type 1 and type % diabetes was con-ducted. "he literature was reviewed byestablishing criteria or relevant studies,conducting computer searches, re
including policy changes and ma#ing the population aware o the health hazards o active and passive smo#ing &enviro
at-ment objectives, weight concerns). e ne(tconsider the types o interventions thathave proven most eective, ocusing espe-cially on the role o the health care pro
nmentalviewing tobacco e(posure). 'espite these gures,
the bibliographies o #ey articles, compilingand reviewing ull articles, constru
%56%73 o American adults continue tosmo#e &), with variations revider cting ported by eth-
nic group. 4or e(ample, 8oyce et al. &!)re p orted that Arican-Americans typicallysmo#e %! cigarettes per day, but are moreli#ely to be nicotine dependent. 'emo-graphic actors associated with higher smo#ing prevalence include lower socioe-conomic status and lower educational level."hose with less than a high school educa-tion are more li#ely to be current, ever, andheavy smo#ers and the least li#ely to *uit.In contrast , years o education are associ-
4rom the 'epartment o ommunity 9ealth &'.9.-:.), aint ;ouis /niversity chool o
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Technical Review: Smoking and diabetes
ated with never smo#ing and increa sed drug use &11). Carious pharmacological, resistance, raised plasma glucose concen-trations, and overt diabetes &%1).cessation rates &5). biochemical, and psychological processes
interact in nicotine addiction &1%,12). ig-a
"he prevalence o smo#ing among "he relationship o smo#ing to meta- people with diabetes appears to mirror thato the general population, at least atyounger ages. In 177, using results o the?ehavioral 8is# 4actor urveillance ys-tem, a cross-sectional telephone interv
rettes are an ideal vehicle or nicotine deliv- bolic control has also been postulated &%%).hiodera et al. &%2) reery, ta#ing only s or nicotine to reach the ported that hormonal
brain via inhalation. Dicotine then triggers
euphoric eects as well as sedative or an(i-olytic eects associated with neuro
responses, speci cally growth hormon e,
arginine vasopressin, and cortisol res ponses,iew hor- were signi cantly higher in type 1 di a betic
that assessed chronic disease ris# actors inindividuals across 2 states, over 2,000
people re
monal processes. "he biological power o nicotine ma#es smo#ing patterns re
versus nondiabetic smo#ers and concludedthat smo#ing might intersistant ere with the tim-
to change. At the same time, the daily cir-cumstances, activities, and emotions towhich smo#ing is conditioned tie this behavior to rituals o daily lie, contributingto the diiculty o brea#ing the addiction&12,1). In addition,
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*a9rovas968ar 9om58i9ations and
morta8it:
*i9rovas968ar 9om58i9ations o7
smoking and diabetes
with other microvascular complications o diabetes. As re ported by Glein et al. &!0),
igarette smo#ing is associated with mor-mo#ing is related to the premature devel- most epidemiological resea rch has not bidity and premature death among non-diabetic individuals primarily due to
c
opment o multiple complications o dia- betes &%,2). Dephropathy has been
re
ound a positive relationship betweensmo#ing and reti no pathy, although there
ardiovascular illness &%).
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Technical Review: Smoking and diabetes
such as c ardiovascular or lung disease o health care provider signi cantly increase these ndings revealed that the longer theduration o treatment, the higher the ces-sation rates. peci c
patients &many o whom have diabetes)."he ollowing section rst reviews the gen-eral evidence identiying treatment charac-teristics associated with successul cessation,
with emphasis on intervention in medicalo
smo#ing cessation rates relative to no inter-vention. "here does not appear to be anyadvantage to counseling &or interv
all y, counseling beyond7 wee#s achieved cessation rates o %2.73&!3 I %0.56%.1). hen compared with
single sessions, our to seven sessions werethe most eective in achieving cessationwith an estim ated cessation rate o %%.53&!3 I 1.6%!.2), ollowed by two tot
en tion)delivered by a single type o proessional.8at her, the data con rm the importance o
ice settings. e then evaluate the limitedthe smo#ing cessation message being con-sistently and repeatedly delivered by mevidence on smo#ing cessation interven- ulti -
tions in diabetes care and apply the generall
ple health care providers (57,60–64).itera tu re to this special population. "he(ormat o7 9onta9t& Th ere are generally hree sessions with an estimated cessation
rate o 17.73 &!3 I 1!.76%1.). In sum-m
cessation rates re p orted here should be three ormats or smo#ing cessation inter-i nter preted in light o two points. 4irst, theventions sel-help, individual, or grou p ary, the eicacy o a smo#ing cessationdata generally come rom eectiveness stud-ies in which all patients in a practice areincluded &using intent-to-t reat analyses),not only highly motivated patients &whoa
counseling. urry &5!) concluded that sel-help materials, de ned as videotapes or audiotapes, manuals or boo#lets, commu-nity programs, and telephone hotlines,may increase cessation rates relative to noi
int ervention increases the longer the dura-tion o treatment over a period o multiplesessions or person-to-person contacts &!).P4 arma9ot4era5: and 9essation& Var ious
re typically recruited or clinical trials orms o pharmacothera py, via gum, patch,research). econd, many studies re p ort on nt ervention. 9owever, sel-help ormats and sprays, have been e(amined or eec-the success rates engendered by a singleepisode o smo#ing cessation advice or
counseling, despite evidence that consis-tent and repeated messages re
were not as eective as interventions withtiveness in promoting smo#ing cessation.everal meta-analyses concerning the use o
nicotine gum and patches have been pub-lished &560), concluding that nicotinegum signi cantly improves abstinence. "heA9uidelines, with #ey interven- ere signi cantly more li#ely to achievetion ndings summarized in "able 1. "reat- 1%-month abstinence &%53) comparedment characteristics associated wit hsmo#ing cessation and supported by this
evidence are summarized below. ome o the !! #ey studies evaluating these charac-teristics are also highlighted in di
with a placebo group &103 )H ndingssu p p orted by "onnesen et al. &%) and
ort &direct contact with health care 9jalm arson et al. &2). provider), and general pro blem-solving 4inal ly, the data regarding the use o
erent &e.g., coping s#ills training, stress manage-ment, relapse prevention). Aversive tech-ni*ues have generally been replaced bynicotine replacement therapies &!).
an tid e pressants &,!), clonidine, andsections. It is important to note that boththe number o randomized trials and themethodological *uality o these studies aree
an(iolytics is not conclusive &!). 9owever,9urt et al. &5) ound in a double-blind
place bo-controlled trial o sustained releaseD6ration and n6mber o7 treatment ses!
sions& D6ration o7 an intervention is
d
(em plary and permitted the development orm, bupropion yielded 1-year cessationrates o 1%.3 &placebo), 1.53 &100 mgg
o evidence-based guidelines derived romcom prehensive meta-analyses &!). e ned by length o treatment in wee#s,roup), %%.3 &1!0 mg group), and %2.13
while number o treatment sessions isd
T:5e o7 4ea8t4 9are 5rovider& As noted in &200 mg group). In addition, bupro p ion"able 1, interventions delivered by any typee ned by number o contacts. In general,subjects had reduced weight gain, ma#ing
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Tab8e ,*eta!ana8:ti9 res68ts e=amining smoking o6t9omes. estimated odds ratios and 9essation rates b: treatment 94ara9teristi9s
Estimated odds Estimated cessationh aracteris tics Dumber o arms ratio &!3 I) rate &!3 I)
"ype o health care provider &n 1 studies)
Do provider &reerence grou p ) 27 1 .0 7 .%=ultiple provid ers 1 2.7 &%.56!.5) %!.! &17.162%.) Donmedical health care provider &psychologist, social wor#er, % 2 1.7 &1.!6%.%) 1.1 &1%.0615.2)
coun selor)roup counseling 1! %.% &1.562.0) 1!.2 &11.61.%)
Intensity levels o person-to-person contact &n !5 studies) Do contact &reerence grou p ) 1 .0 7 .7=inimal contact & 2 min) 1 1.% &1.061.!)K 10. &7.61%.!)?rie counseling & 2 to 10 min) %5 1. &1.%61.) 1%.1 &10.061.2)ounseling & 10 min) 50 %. &%.16%.) 17. &15.76%0.5)
"ypes o content &n 2 studies) Do contact &reerence grou p ) %! 1 .0 7 .7Aversive smo#ingL %.1 &1.06.%)M 1.! &.56%.%)In tratreatment social support %1 1.7 &1.6%.!) 1!.% &11.261.1)>eneral problem solvingN ! 1.5 &1.%6%.%) 12. &10.261.1)Ouit day &speci c *uit date) 20 1.2 &0.6%.0) 11.! &.61!.)E(t rat reatment social supportP 15 1.2 &0.76%.0) 11.% &.061!.!)=otivat ionJJ 0 1.1 &0.61.!) .7 &.!61%.%)eight, diet, or nutrition management 1 1.1 &0.761.5) .7 &5.5612.0)E(ercise or tness inormation or program 7 1.1 &0.561.0) .5 &.761.2)ontingency contractKK 12 1.0 &0.61.5) .1 &!.561%.)8ela(ation or breathing techni*ues 1! 0.7 &0.!61.2) .! &.2610.)
igarette adingLL 17 0. &0.61.1) 5. &2.5612.2)'uration o treatment sessions &n !! studies)
% ee#s &reerence grou p) 10 1 1 .0 1 0 .% ee#s to wee#s 1 1.5 &1.26%.0) 1!.5 &1%.617.2) ee#s to 7 wee#s 1% 1.5 &1.%6%.1) 15.1 &1%.61.)
7 ee# s 1! %. &%.%62.%) %2.7 &%0.56%.1) Dumber o treatment sessions &n !! studies)
1 ession &reerence grou p ) 5 1 .0 1 0 .%62 essions 1! %.0 &1.56%.) 17.7 &1!.76%1.)6 essions %! %.! &%.%6%.) %%.5 &1.6%!.2)
essions 1% 1. &1.%6%.!) 15. &11.6%%.0)
Dumber o arms reers to the number o treatment groups included in the category. JActual !3 lower con dence estimate e*uals 0.+ Kactual !3 lower con d
en ceestimate e*uals 1.02+ Ltechni*ues that involve smo#ing in an unpleasant or concentrated manner+ Mactual !3 lower con dence estimate e*uals 1.0+ providing sup- port, help, or encouragement as part o the treatment+ Ntraining to identiy and cope with events or problems that increase the li#elihood o smo#ing,
including copings#ill training, relapse prevention, and stress management+ Ptechni*ues to help smo#ers increas e social support outside o treatment+ JJinterventions designed
to bolster patientsF resolve to *uit + KKproviding re
wa rds or cigarette abstinence and incurring costs or unpleasant conse*uences or smo#ing+ LLreducing the number o cigare
ttessmo#ed. =odi ed rom etter et al. &1).
this a particularly promising tool to assistsmo#ers in cessation &5a,5b). ?ased onthe low ris# or side eects, the use o phar-macotherapy to promote smo#ing cessa-tion is recommended when used inconjunction with behavioral counseling./se in special populations, such as those
who are pregnant, is also recommended i the bene ts o *uitting outweigh the lim-ited ris#s &,7).
review establishing A9uidelines is that repeated interven-tions, provided by multiple healthcare p
roessionals and rein orced over time, areSmoking 9essation de8iver: s:stems much more eective than single session rec-$ne o the most important and consistent ndings rom the comprehensive literature
ommendations or brie counseling &!).uch an approach denotes the importance
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Technical Review: Smoking and diabetes
studies are needed to identiy and under-stand actors associated with diabetes man-agement &e.g., stress posed by ollowingthe dietary regimen, medication manage-ment, etc.) and how these actors mayi
o an integrated system o care in systemat-ically reducing smo#ing rates. All patientsshould be screened or use o tobacco andhave their status documented on a re
int erventions in both physician oice set-tings &7,0) and mail-based interventions&1,%). "he use o multimedia #ios#s,Igular nternet orld ide eb6based applica-
basis. creening systems in clinical settings
i
tions, and small handheld computers haveshown promise &2) but have not beenused to prevent smo#ing initiation or toenhance *uitting success among smo#erswith diabetes speci c
ncrease the probability o consistent assess- n uence the ability to achieve successul
ment and documentation o tobacco use&,70). 4ollow-up assessment o smo#ingstatus and abstinence should also be con-ducted on a routine basis at regular interv
cessation. In addition, these data stronglysuggest that systems o care, promotin g
ally. routine smo#ing identi cation and coun-seling need to be a priority o routine dia-
betes management. 4urther re
als&!). Additional assessments within the rst Cessation s:stems 7or smokers wit4
diabetes
search on% wee#s o *uitting have proven to be eec- de livery systems via system-wide clinic or tive in aiding patients to maintain absti-nence &71). 8einorcement o the decisionto *uit and strategies encouraging re
"here is minimal literature evaluating treat- technology-based intervent ions, has not been conducted speci c to smo#ers withdiabetes and is strongly re
ment characteristics or delivery system ssla pse pe ci c to diabetes and smo#ing. "o date, comme nded.
p revention promote long-term abstinence.only two intervention studies that address$nly about hal o smo#ers seeing a pri-smo#ing cessation limited to people with
diabetes are identi ed. ArdCost!e77e9tiveness o7 9essation
9o6nse8ingmary care physician in the past year ron et al. &)conducted a randomized study with 50diabetic smo#ers, cont rasting brie advice
with intensive advice to stop smo#ing. "hestudy included a ollow-up home visit. 9al o the subjects cited an attempt to *uitresulting rom the intensive counseling."h
re ported being as#ed about their smo#ing mo#ing cessation is one o the ew inter-ventions that can saely and cost-e&), with a smaller number being advised
to *uit &7%). =alarcher et al. &72) e(amineddata rom the Dational 9ealth Interv
ec-
tively be recommended or all patients.ummings et al. &101) published an in u-ential early analysis on the cost-e
ie wurveys rom 1, 17!, and 10 and e ctive-noted positive trends toward more physi-cians oering smo#ing cessation advice todiabetic patients, however 13 o diabetic
patients did not receive any advice to *uitsmo#ing. ?arriers commonly re
ness o counseling smo#ers to *uit thatdemonstrated physician counseling to beas or more cost-eective than other ro
ere was, however, only one veriied*uitter at the end o 5 months. awic#i etal. &!) conducted a prospective random-ized controlled intervention st udy with7 diabetic smo#ers that contrasted inten-sive behavior therapy over 10 wee#s with1! min o unstru
u-tine health care practices, such as treati ng
ported by hy pe rtension, screening or cholesterol ,and other medical practices. Eddy &10%)i
p roviders in delivering cessation advice arelac# o time and reimbursement or smo#-ing cessation services, actual or perc
dent i ed smo#ing cessation as the Qgoldei ved ctu red outpatient physi- st andardR against which other prevent ive
behaviors should be evaluated. ince theseearly articles, virtually all subse*uent stud-ies &102610) and reviews &102,107) have
c
lac# o #nowledge and s#ill in cessationcounseling, and low e(pectations re
cia n advice. =ean number o cigarett esgarding decreased in the behavior therapy grou p
the eicacy o such counseling &!7,7).Additional provider training is needed inthe A9uidelinesemphasizing the public health signi c
when compared with the control grou p.9owever at the 5-month ollow-up, overall*uit rates as con rmed by cotinine testing&a metabolite o nicotine) was 103 anddid not dier signi cantly by group. "hereis also little evidence re
on rmed and even strengthened these ndings. =ost recent studies have esti-mated that smo#ing cessation counselingcosts between S1,000 and S2,000 per year o lie saved. Even more encouraging is theact that it oten costs less than S%,000 per *uality adjusted lie year saved.
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Haire-Joshu, lasgow, and Tibbs
included as part o a societal tobacco control general, weight gain ater cessation may neg-atively aect the desire to *uit &!), withattempts to prevent weight gain during ces-sation potentially enhancing the ris# o relapse &115). 9owever, a review by
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Technical Review: Smoking and diabetes
adolescents. Adolescents with diabetesappear to initiate smo#ing at a rate e*uiva-lent to nondiabetic adolescents.
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most eective medical actions that can be ta#en with diabetic patients. iovino >, =owery
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Technical Review: Smoking and diabetes
betes in men. ? M % #0555–55", #""5 prospective study o maturity onset dia- among subjects with type I diabetes.1 . Gawa#ami D, "a#atsu#a D, himizu 9, betes mellitus and ris# o coron ary heart % $ M $ *656#4–6#7, #""#
Ishibashi 9 Eects o smo#ing on inci-dence o non-insulin-dependent diabetesmellitus. 'iabetes are 15102610, 1
disease and stro#e in women. Arch ter 5 . awic#i atling , 9ouston A, =ulle tro8e *7*#0–*#5, #""6 2%%62%, 1
=, :ulious , 9ill 8 =ortality in diabeticsubjects an eleven-year ollow-up o acommunity-based population. 'iabet =ed
1. h atu rvedi D, tevens ;, 4uller : hich !! . =orgando A, /.. 'epartment o 9ealthand 9uman ervices, , tamper = A smo#ing increases the ris# o albuminuria in medical settings a stepped-care model.
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In Dicotine Addiction , tapleton :, 8ussell = 7 !. ol b erg ;, Gotte ", ?re##e =, alomeni , % $ M $ *6#75–7", #"!"8andomised controlled trial o nasal nico-tine spray in smo#ing cessation. ;
onn , 'avidson > /sing continuous*uality improvement to increase pre
1 0%. Eddy ' 'avid Eddy ran#s the tests. 9ar -a cet ven tive vard ealth iovino >, ?yers " mo#ing ces-sation and severity o weight gain in anational cohort. D Engl : =ed 2
demiol +omm ealth 5040–46, #""6 1 7 12 0. >old =, >ladstein : ubstance use among12 . 9ughes : Applying harm reduction to
% 2 6 adolescents with diabetes mellitus prelim- smo#ing. "ob ontrol4 (uppl. *)–!,!, 11 inary ndings. : Adolesc 9ealth 1 70 67 , 1 !
1 15.