- S. Endokrin

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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 diabetes 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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Haire-Joshu, lasgow, and Tibbs

*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 diabetes &%,2). Dephropathy has been

re

ound a positive relationship betweensmo#ing and reti no pathy, although there

ardiovascular illness &%).

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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 support, 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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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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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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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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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.

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