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Continued smoking abstinence in diabetic patients in primary care: A cluster randomized controlled multicenter study
Abstract
To assess the effectiveness of an intensive smoking cessation intervention based on the transtheoretical model of change (TTM) in diabetic smokers attending primary care.
A cluster randomized controlled clinical trial was designed in which the unit of randomization (intervention vs. usual care) was the primary care team. An intensive, individualized intervention using motivational interview and therapies and medications adapted to the patient's stage of change was delivered. The duration of the study was 1 year.
A total of 722 people with diabetes who were smokers (345 in the intervention group and 377 in the control group) completed the study. After 1 year, continued abstinence was recorded in 90 (26.1%) patients in the intervention group and in 67 (17.8%) controls (p=0.007). In patients with smoking abstinence, there was a higher percentage in the precontemplation and contemplation stages at baseline in the intervention group than in controls (21.2% vs. 13.7%, p=0.024). When the precontemplation stage was taken as reference (OR=1.0), preparation/action stage at baseline showed a protective effect, decreasing 3.41 times odds of continuing smoking (OR=0.293 95% CI 0.179-0.479, p<0.001). Contemplation stage at baseline also showed a protective effect, decreasing the odds of continuing smoking (OR=0.518, 95% CI 0.318-0.845, p=0.008).
An intensive intervention adapted to the individual stage of change delivered in primary care was feasible and effective, with a smoking cessation rate of 26.1% after 1 year.
Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.
... The characteristics and the relevant findings of the identified studies are outlined in Table 1. Except for the study by Pérez-Tortosa et al. 32 , who reported the findings from a cluster randomized parallel-group trial, all the remaining publications reported the findings from individually randomized parallel-group trials. All studies were published in journals except for the study by Albaroodi et al. 33 which was available as a preprint. ...
... Most studies included individuals with both type I and type II diabetes as study participants [33][34][35][36] , who were mostly men [30][31][32][33][35][36][37][38] , and in their fifties [30][31][32]35,37,38 . Sample sizes varied across the studies; from n=34 22 to n=948 32 ; however, only three studies 30,32,35 reported a priori power calculations to detect a significance in smoking cessation outcome. ...
... Most studies included individuals with both type I and type II diabetes as study participants [33][34][35][36] , who were mostly men [30][31][32][33][35][36][37][38] , and in their fifties [30][31][32]35,37,38 . Sample sizes varied across the studies; from n=34 22 to n=948 32 ; however, only three studies 30,32,35 reported a priori power calculations to detect a significance in smoking cessation outcome. ...
Introduction Tobacco smoking poses a significant threat to the health of individuals living with diabetes. Intensive stand-alone smoking cessation interventions, such as multiple or long (>20 minutes) behavioural support sessions focused solely on smoking cessation, with or without the use of pharmacotherapy, increase abstinence when compared to brief advice or usual care in the general population. However, there is limited evidence so far for recommending the use of such interventions amongst individuals with diabetes. This study aimed to assess the effectiveness of intensive stand-alone smoking cessation interventions for individuals living with diabetes and to identify their critical features.
Methods A systematic review design with the addition of a pragmatic intervention component analysis using narrative methods was adopted. The key terms “diabetes mellitus” and “smoking cessation” and their synonyms were searched in 15 databases in May 2022. Randomised controlled trials which assessed the effectiveness of intensive stand-alone smoking cessation interventions by comparing them to controls, specifically amongst individuals with diabetes were included.
Results A total of 15 articles met the inclusion criteria. Generally, the identified studies reported on the delivery of a multi-component behavioural support smoking cessation intervention for individuals with type one and type two diabetes, providing biochemically verified smoking abstinence rates at six months follow-up. Most studies’ overall risk-of-bias was judged to be of some concern. Despite observing inconsistent findings across the identified studies, interventions consisting of three to four sessions, lasting more than 20 minutes each, were found to be more likely to be associated with smoking cessation success. The additional use of visual aids depicting diabetes related complications may also be useful.
Conclusions This review provides evidence-based smoking cessation recommendations for use by individuals with diabetes. Nonetheless, given that some of the studies’ findings were found to be possibly at risk-of-bias, further research to establish the validity of the provided recommendations is suggested.
... Studies were frequently conducted in the United Kingdom [30,31,36,47,[49][50][51], or the United States [34,[43][44][45][52][53][54]. Most reports (n = 25) focused on individuals with type 2 diabetes [18,19,22,24,29,30,34,[36][37][38][39][42][43][44][45][46][47][48][55][56][57][58][59][60][61]), who were mostly men (n = 39) [19][20][21][22][23][24][25][26][27][28][29][30]32,[34][35][36][38][39][40][41][42][43][44]46,47,[49][50][51]54,[56][57][58][59][61][62][63][64][65][66], and in their 50 s (n = 25) [22][23][24][25][26][27][28]30,32,34,35,[38][39][40]45,47,51,52,57,[59][60][61][62]67,68]. ...
... Studies were frequently conducted in the United Kingdom [30,31,36,47,[49][50][51], or the United States [34,[43][44][45][52][53][54]. Most reports (n = 25) focused on individuals with type 2 diabetes [18,19,22,24,29,30,34,[36][37][38][39][42][43][44][45][46][47][48][55][56][57][58][59][60][61]), who were mostly men (n = 39) [19][20][21][22][23][24][25][26][27][28][29][30]32,[34][35][36][38][39][40][41][42][43][44]46,47,[49][50][51]54,[56][57][58][59][61][62][63][64][65][66], and in their 50 s (n = 25) [22][23][24][25][26][27][28]30,32,34,35,[38][39][40]45,47,51,52,57,[59][60][61][62]67,68]. ...
... Most reports evaluated a smoking cessation intervention/s which was provided on its own (n = 25; Table 1 [15], and Tricco et al. [64] included both types of studies (included in Table 2). Typically, the provided diabetes-specific smoking cessation support consisted of behavioural support, such as counselling (commonly based on the 5As algorithm, Ask, Advise, Assess, Assist and Arrange; n = 9 [14,15,[21][22][23][24][25]38,71], or motivational interviewing; n = 9 [14,15,18,19,34,40,55,59,60]) or were education-based (n = 12) [14,15,30,33,39,43,45,47,48,52,54,72]. Pharmacotherapy for smoking cessation was also provided/recommended in some of the identified studies (n = 13) [14,15,32,34,41,55,59,[61][62][63]69,70,73]. ...
Tobacco smoking is recognised as a priority in diabetes management, yet many individuals with diabetes continue to smoke beyond diagnosis. This paper identifies the most promising smoking cessation strategies by reviewing the literature reporting interventions carried out amongst this study population, and the challenges and barriers to smoking cessation. Stand-alone smoking cessation interventions which included pharmacotherapy were found to be more successful in achieving abstinence than interventions which included smoking cessation as part of a broader intervention for improving diabetes management. Misconceptions about smoking and diabetes management were frequently reported, undervaluing smoking cessation. This emphasizes further the need to inform smokers with diabetes about the link between tobacco use and diabetes complications.
... Most of the research on intensive psychosocial interventions for SUDs in adults with type 2 diabetes has focused on smoking cessation interventions. Psychosocial interventions for smoking cessation either are stand-alone interventions [e.g., 84,85] or more comprehensive diabetes management interventions in which smoking cessation is one component [e.g., 86,87]. Similar to general smoking cessation interventions, interventions for adults with diabetes commonly employ a variety of psychosocial techniques including counseling and education [88,89] and motivational interviewing [84,85]. ...
... Psychosocial interventions for smoking cessation either are stand-alone interventions [e.g., 84,85] or more comprehensive diabetes management interventions in which smoking cessation is one component [e.g., 86,87]. Similar to general smoking cessation interventions, interventions for adults with diabetes commonly employ a variety of psychosocial techniques including counseling and education [88,89] and motivational interviewing [84,85]. ...
... There is mixed evidence regarding the efficacy of psychosocial smoking cessation interventions in adults with diabetes. One randomized controlled trial [85] found a significantly higher rate of smoking abstinence at the 6-month follow-up in patients with diabetes receiving an intensive smoking cessation intervention comprised of motivational interviewing and pharmacotherapy (26.1%) compared to those receiving usual care (17.8%). On the other hand, mixed results were reported in a systematic review and meta-analysis of eight randomized controlled trials of psychosocial smoking cessation interventions in adults with diabetes [90]. ...
Purpose of review:
This paper reviews research on substance use and disorders (SUDs) among adults with diabetes. It describes epidemiological data on SUDs in persons with type 2 diabetes, overviews effects of substance use on diabetes outcomes, and discusses treatments for SUDs in patients with diabetes.
Recent findings:
Rates of current smoking range from 10 to 26% and alcohol use disorders are 0-5%. Rates of illicit SUDs are 3-4%, but there are no population-based studies using nationally representative samples. Smoking increases the risk for long-term diabetes complications and premature death. Alcohol and illicit drug use can also impact long-term diabetes complications by impairing glucose homeostasis and adversely influencing self-management behaviors. There is mixed evidence about psychosocial smoking cessation interventions in adults with diabetes and little on alcohol and illicit SUD interventions. Limited data exist on pharmacotherapies for SUDs in this population, but a recent study suggests that varenicline is safe and effective for treating smoking in patients with diabetes. Substance use is an understudied problem in type 2 diabetes, and addressing substance use holds potential for improving outcomes. Additional large population-based epidemiological studies in those with type 2 diabetes are needed, particularly for alcohol and illicit SUDs. Longitudinal studies should be conducted to better understand the time course of diabetes onset and outcomes in relation to SUDs. Randomized controlled trials are needed to assess safety and efficacy of promising psychosocial and pharmacological interventions.
... The first seven recommended medications that increase the chances of long-term abstinence rates are: Nicotine gum, Bupropion, Nicotine lozenge, Nicotine inhaler, Nicotine patch, Nicotine nasal spray, and Varenicline [32,33]. A combination of medications is often recommended just as counseling and medication is recommended over either method alone [34][35][36]. For example, a combination of lozenges and gum is recommended for smokers with diabetes for a period of up to 12 weeks [33]. ...
... Future studies that assess the smoking cessation rate of such patients are highly recommended. In addition, a long-term cohort studies for data collection and the observation period would probably produce results that are more robust [34]. Furthermore, a collection of data and/or a review and analysis of secondary data from multiple settings is highly encouraged in order to capture information from a different perspective besides a Quitline service. ...
... First, this study was limited to a short time frame (21 months for data collection and 6 months for the observation period) only. Longer study duration with multiple followup evaluations for a period of 1 year would potentially be beneficial in identifying statistically significant associations [34]. It is important to note that, the State of Nevada Quitline operated under constrained financial resources and hence funding to support annual observation period was a hindrance. ...
... Em complementação, estudo multicêntrico avaliativo de um Programa de intervenções grupais composto por oito sessões, em que as pessoas eram motivadas a parar de fumar e aconselhadas sobre como desconstruir o hábito e evitar a recaída, constatou taxa de abstinência de 20% no grupo de intervenção com duração de um ano, e 7% no grupo controle (17) . ...
... Os dados acima são compatíveis com os de um estudo controlado randomizado, no qual as intervenções que incluíam aconselhamento, educação, chamadas telefônicas, envio de cartas e visitas domiciliares realizadas por um enfermeiro, obteve uma taxa de 17% na cessação do tabagismo (17) . ...
Objective:
To understand what factors motivate people to reduce or stop tobacco use and what difficulties they face in this process.
Method:
Qualitative, empirical and interpretative research that used a focal group technique for data collection and Discourse Analysis as a theoretical reference for analysis.
Results:
The responses centered on the following aspects: motivation for reduction or cessation of smoking, family and community support received during treatment, benefits from cessation of tobacco, difficulties encountered and strategies for overcoming triggers.
Final Considerations:
The results showed that the users expressed their desire for cessation of tobacco use and that to achieve this goal, family and group support, professional help and changing habits are key factors for this process.
... Nevertheless, because TTM classifies an individual's readiness into five categories in terms of each behavior, it is difficult for TTMbased interventions to target multiple behaviors simultaneously. To our knowledge, most TTM-instructed diabetic interventions have focused only on a single behavior, or at most two behaviors [10][11][12][13][14]. Therefore, in order to utilize the advantages of TTM and mitigate its limitations in coping with multiple behaviors, we suggest combining it with latent profile analysis, which can classify individuals into homogenous subgroups based on their shared performance in various behaviors. ...
Objective:
To determine whether the joint use of the transtheoretical model and latent profile analysis could help us better understand the shared characteristics of patients with diabetes and explore the association of patients' latent classes and glucose control.
Methods:
Five hundred twenty-three (523) patients with diabetes were included in the study. The questionnaire evaluated patients' stages of change for medication-taking, diet control, exercise, and glucose-monitoring. Latent profile analysis was performed based on the four indicators.
Results:
Patients were classified into four latent groups and defined as follows: good medication-taking/good lifestyle (GM/GL, 41.7%), poor medication-taking/poor lifestyle (PM/PL, 27.7%), good medication-taking/poor lifestyle (GM/PL, 21.6%), and poor medication-taking/good lifestyle (PM/GL, 9.0%). Patients in the PM/PL group were generally younger and better educated while those in the GM/GL group exhibited the opposite pattern. Compared with patients in the PM/PL group, those in the PM/GL and GM/GL groups had significantly lower HbA1c values (PM/GL: standardized β = -0.694, P = 0.007; GM/GL: standardized β = -0.499, P = 0.003).
Conclusion:
With the help of the transtheoretical model and latent profile analysis, future study could cluster homogeneous patients before the initiation of intervention and provide tailored instructions to different types of patients accordingly.
Practice implications:
A combination of the transtheoretical model and latent profile analysis could shed some light into future diabetic interventions.
... O uso de medicamentos subsidiados associados a intervenções e campanhas públicas deve estar previsto nas políticas de combate ao tabagismo 8,33 . A intervenção intensiva e individualizada utilizando entrevista, terapias e medicamentos adaptados ao estágio de mudança motivacional do paciente favorece a abstinência e se mostra viável e eficaz na APS, com taxa de cessação de 26,1% após um ano [34][35][36] . ...
Resumo O hábito de fumar, ou tabagismo, preocupação da Atenção Primária à Saúde (APS), é um grave problema de saúde pública e a principal causa de morte evitável no mundo. A relevância de ações, cujo foco seja facilitar a cessação deste vício, motiva a discussão de estudos que apresentam diferentes abordagens para tal enfrentamento visando contribuir para a formação dos profissionais da APS. Utilizou-se as bases de dados Lilacs, Medline e Web of Science considerando as produções científicas recentes (2010 a 2015). Os descritores foram combinados a operadores boleanos e, após análise dos artigos encontrados, 75 são discutidos nesta revisão por apresentarem estratégias de maior prevalência na APS. Conclui-se que a abordagem individual breve ou intensa a partir do método dos 5A's (Modelo Transteórico) é a mais adotada, assim como os fármacos adesivos de Nicotina e Bupropiona. O uso crescente de tecnologia dura necessita de novos estudos que averiguem os seus impactos no tratamento a tabagistas. Evidenciou-se a necessidade de o profissional de saúde ser mais bem preparado para abordar o tema com os usuários, além de carecer do estímulo e das condições próprias para atuar na equipe de APS refletindo diretamente os avanços científicos em sua prática clínica.
... 23 The systematic Table 4 The smoking pattern (mean and standard deviation) and high-level risk of lung cancer (frequency and percentage) in current and former smokers women from 50 to 69 years (who participated in the breast and colorectal cancer screening programmes) and from 25 to 64 years (who participated in the cervical cancer screening programme) in Spain, 2011-12 review included some Spanish studies, showing good results after 1 year of quitting tobacco treatment: two of the Spanish studies included were done in diabetic and general population, and in both cases >20% of the intervened samples did not smoke 1 year after the intervention. 24,25 Even when the cessation programme is successful in a minority of the participants, there is an effect on the mortality. 26 Also, former smokers who stopped <10 years prior have a decreased risk of lung cancer by one-third 27 and a similar risk as nonsmokers after >20 years of not smoking. ...
Objectives:
The aim of this study was to describe the smoking prevalence, the smoking pattern, and the risk of lung cancer among women who participated in a cancer screening (breast, cervical and colorectal) in Spain.
Methods:
We used data from the Spanish National Health Survey of 2011-12, a cross-sectional study of the adult Spanish population from women in the age of participation in the population cancer screening. We used two definitions of the high risk of lung cancer according to the National Lung Screening Trial (NLST) criteria and the NELSON criteria.
Results:
Participation in screening was 76.6% in breast cancer, 6.6% in colorectal cancer, and 70.3% in cervical cancer. The percentage of current smokers was 17.1 of women who participated breast cancer, 15.4 of women who participated colorectal cancer, and 26.1 of women who participated cervical cancer. According to NLST criteria, the percentage of current smokers women who had a high risk of lung cancer was 23.1 for breast cancer, 23.5 for colorectal cancer and 4.5 for cervical cancer. These figures were higher with the NELSON criteria.
Conclusion:
At least 250 000 women in Spain have a high risk of lung cancer and are participating in a cancer screening programme. These programmes might be an opportunity for implementing specific interventions aiming to reduce this risk.
... The expected small to moderate effect of Cohen's d = 0.30 requires that data from 352 persons are available for sufficiently powered (β = 0.20) independent samples t-tests (α = 0.05). Accounting for the effect of clustering (intraclass correlation coefficient of 0.05) [30,31]suggests that data from 34 medical practices with an average cluster size of 20 should be analyzed (340 patients per group, 680 in total). An estimated 15 % drop-out rate for medical practices means that 40 medical practices should be recruited. ...
Background:
Tobacco consumption is a preventable risk factor for chronic disease and complicates the treatment of medical conditions. Therefore, the German health insurance company AOK NORDWEST has developed a collaborative smoking cessation intervention for individuals with cardiovascular disease, chronic obstructive pulmonary disease and heavy smokers, with the aim of reducing tobacco consumption. The objective of the study ENTER is to evaluate the effectiveness of the collaborative smoking cessation intervention and determine its cost-effectiveness.
Methods/design:
This study is a cluster-randomized controlled trial conducted with 40 medical practices that are being selected from different geographic regions in Germany. Participating medical practices will be randomly allocated to either the intervention or control group. Within the medical practices, a total of 800 patients will be recruited for participation in the study and blinded to group assignment. Patients are included in the study if they are 18 years or older, insured by AOK, heavy smokers (smoke at least 20 cigarettes per day) and/or suffer from chronic obstructive pulmonary disease or cardiovascular disease. Exclusion criteria are patients who are nonsmokers, who have cognitive impairments or who are illiterate. Physicians from medical practices in the intervention group will motivate patients to participate in a smoking cessation program offered by the health insurance, refer them to the program and ask about their program participation. Physicians from medical practices in the control group will provide usual care. Data collection will take place on the date of study inclusion and after 6 and 12 months. The primary outcome is the amount of cigarettes consumed during the past 30 days, 12 months after the initial medical consultation. Secondary outcomes are abstinence from smoking, health-related quality of life and respiratory complaints. Moreover, a process evaluation and health economic analysis will be performed.
Discussion:
The results of this study will help to determine whether the collaborative smoking cessation intervention is an effective and feasible way to promote smoking cessation in the primary care setting and provide evidence regarding its cost-effectiveness.
Trial registration:
German Clinical Trials Register DRKS00006079 . Registered 4 June 2014.
Evidence shows that smoking increases the risk of pre-diabetes and diabetes in the general population. Among persons with diabetes, smoking has been found to increase the risk of all-cause mortality and aggravate chronic diabetic complications and glycemic control. The current paper, which is a joint position statement by the French-Speaking Society on Tobacco (Société Francophone de Tabacologie) and the French-Speaking Society of Diabetes (Société Francophone du Diabète), summarizes the data available on the association between smoking and diabetes and on the impact of smoking and smoking cessation among individuals with type 1, type 2, and gestational diabetes mellitus. It also provides evidence-based information about the pharmacological and behavioral strategies for smoking cessation in these patients.
Background:
Primary care is an important setting in which to treat tobacco addiction. However, the rates at which providers address smoking cessation and the success of that support vary. Strategies can be implemented to improve and increase the delivery of smoking cessation support (e.g. through provider training), and to increase the amount and breadth of support given to people who smoke (e.g. through additional counseling or tailored printed materials).
Objectives:
To assess the effectiveness of strategies intended to increase the success of smoking cessation interventions in primary care settings. To assess whether any effect that these interventions have on smoking cessation may be due to increased implementation by healthcare providers.
Search methods:
We searched the Cochrane Tobacco Addiction Group's Specialized Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and trial registries to 10 September 2020.
Selection criteria:
We included randomized controlled trials (RCTs) and cluster-RCTs (cRCTs) carried out in primary care, including non-pregnant adults. Studies investigated a strategy or strategies to improve the implementation or success of smoking cessation treatment in primary care. These strategies could include interventions designed to increase or enhance the quality of existing support, or smoking cessation interventions offered in addition to standard care (adjunctive interventions). Intervention strategies had to be tested in addition to and in comparison with standard care, or in addition to other active intervention strategies if the effect of an individual strategy could be isolated. Standard care typically incorporates physician-delivered brief behavioral support, and an offer of smoking cessation medication, but differs across studies. Studies had to measure smoking abstinence at six months' follow-up or longer.
Data collection and analysis:
We followed standard Cochrane methods. Our primary outcome - smoking abstinence - was measured using the most rigorous intention-to-treat definition available. We also extracted outcome data for quit attempts, and the following markers of healthcare provider performance: asking about smoking status; advising on cessation; assessment of participant readiness to quit; assisting with cessation; arranging follow-up for smoking participants. Where more than one study investigated the same strategy or set of strategies, and measured the same outcome, we conducted meta-analyses using Mantel-Haenszel random-effects methods to generate pooled risk ratios (RRs) and 95% confidence intervals (CIs).
Main results:
We included 81 RCTs and cRCTs, involving 112,159 participants. Fourteen were rated at low risk of bias, 44 at high risk, and the remainder at unclear risk. We identified moderate-certainty evidence, limited by inconsistency, that the provision of adjunctive counseling by a health professional other than the physician (RR 1.31, 95% CI 1.10 to 1.55; I2 = 44%; 22 studies, 18,150 participants), and provision of cost-free medications (RR 1.36, 95% CI 1.05 to 1.76; I2 = 63%; 10 studies,7560 participants) increased smoking quit rates in primary care. There was also moderate-certainty evidence, limited by risk of bias, that the addition of tailored print materials to standard smoking cessation treatment increased the number of people who had successfully stopped smoking at six months' follow-up or more (RR 1.29, 95% CI 1.04 to 1.59; I2 = 37%; 6 studies, 15,978 participants). There was no clear evidence that providing participants who smoked with biomedical risk feedback increased their likelihood of quitting (RR 1.07, 95% CI 0.81 to 1.41; I2 = 40%; 7 studies, 3491 participants), or that provider smoking cessation training (RR 1.10, 95% CI 0.85 to 1.41; I2 = 66%; 7 studies, 13,685 participants) or provider incentives (RR 1.14, 95% CI 0.97 to 1.34; I2 = 0%; 2 studies, 2454 participants) increased smoking abstinence rates. However, in assessing the former two strategies we judged the evidence to be of low certainty and in assessing the latter strategies it was of very low certainty. We downgraded the evidence due to imprecision, inconsistency and risk of bias across these comparisons. There was some indication that provider training increased the delivery of smoking cessation support, along with the provision of adjunctive counseling and cost-free medications. However, our secondary outcomes were not measured consistently, and in many cases analyses were subject to substantial statistical heterogeneity, imprecision, or both, making it difficult to draw conclusions. Thirty-four studies investigated multicomponent interventions to improve smoking cessation rates. There was substantial variation in the combinations of strategies tested, and the resulting individual study effect estimates, precluding meta-analyses in most cases. Meta-analyses provided some evidence that adjunctive counseling combined with either cost-free medications or provider training enhanced quit rates when compared with standard care alone. However, analyses were limited by small numbers of events, high statistical heterogeneity, and studies at high risk of bias. Analyses looking at the effects of combining provider training with flow sheets to aid physician decision-making, and with outreach facilitation, found no clear evidence that these combinations increased quit rates; however, analyses were limited by imprecision, and there was some indication that these approaches did improve some forms of provider implementation.
Authors' conclusions:
There is moderate-certainty evidence that providing adjunctive counseling by an allied health professional, cost-free smoking cessation medications, and tailored printed materials as part of smoking cessation support in primary care can increase the number of people who achieve smoking cessation. There is no clear evidence that providing participants with biomedical risk feedback, or primary care providers with training or incentives to provide smoking cessation support enhance quit rates. However, we rated this evidence as of low or very low certainty, and so conclusions are likely to change as further evidence becomes available. Most of the studies in this review evaluated smoking cessation interventions that had already been extensively tested in the general population. Further studies should assess strategies designed to optimize the delivery of those interventions already known to be effective within the primary care setting. Such studies should be cluster-randomized to account for the implications of implementation in this particular setting. Due to substantial variation between studies in this review, identifying optimal characteristics of multicomponent interventions to improve the delivery of smoking cessation treatment was challenging. Future research could use component network meta-analysis to investigate this further.
Background: Health behavior risks prevail in older patients and can include unhealthy diet and nutrition, sedentary lifestyle and physical inactivity, alcohol use and abuse and poor oral hygiene. According to the Centers for Disease Control (CDC), most of the sickness, dependency, disability, use of resources, institutionalization and premature morbidity and mortality associated with chronic disease can be avoided through preventive measures and risk reduction. Preventive care is more effective in improving health than routine health care, yet research indicates that many patients do not seem to receive preventive strategies due to provider barriers. Evidence supports that training and education significantly improve practitioner knowledge, their decision to use strategies for behavior change and increases confidence.The emerging body of evidence supports brief motivational interventions as effective strategies that can help patients change health behaviors and affect outcomes. The purpose of this study was to assess nurse practitioner student confidence and attitudes in using a brief motivational intervention. A secondary aim was to assess the degree of completion of each patient’s selected behavioral plan. Methods: This investigator-initiated pilot study examined relationships among 15 nurse practitioner student confidence and attitudes toward delivery and implementation of a Brief Action Planning (BAP) intervention to 104 older adults. Nurse practitioner students received a BAP educational program and delivered BAP to older adults in an inter-professional collaborative practice that addresses the oral health, health promotion, clinical prevention and social services needs of community-dwelling older adults.Results: Findings showed a significant change (p<0.05) in NP effectiveness, confidence, belief in and the ease of learning and incorporating BAP and the value of adding BAP to care. Forty two percent of patients fully completed, 35% partially completed and 23% did not complete their selected plan to change a health behavior.Conclusion: An educational program increased NP confidence, effectiveness and belief in value and use of a brief motivational technique to change a health behavior. Provider training helps decrease barriers to implementing motivational techniques and prevention strategies. BAP shifts thinking about how to help motivate patients toward change, is easy to learn and feasible.
Diabetes is a chronic metabolic condition that poses a significant public health burden. Despite rapid advances in diabetes therapies and technologies, successful diabetes management still lies within the patients’ ability to self-manage their condition. Patient engagement and adherence to diabetes therapies and monitoring have always been a challenge for healthcare providers. Understanding the natural trajectories of diabetes is integral to delivering patient-centered care. Additionally, multiple factors, such as physical, environmental, personal, cultural, social, and psychological, influence patient engagement to diabetes therapy. Ongoing support from families, carers, and interdisciplinary healthcare providers are key to promote patients’ long-term self-care. Healthcare providers also need to build trust and individualize their care approaches to overcome psychological barriers to self-care including stigma, denial, guilt, fear, fatigue, and burnout. This chapter offers a range of practical tools to engage patients with diabetes in their therapy throughout their lifetime journey to maintain good quality of life and focus beyond glycemic control alone.
Breast cancer (BC) is the main cause of cancer mortality among women, and mortality from lung cancer (LC) is increasing among women. The purpose of the present study was to project the mortality rates of both cancers and predict when LC mortality will exceed BC mortality.
The cancer mortality data and female population distribution were obtained from the Spanish National Statistics Institute. Crude rate (CR), age-standardized rate (ASR), and age-specific rate were calculated for the period 1980–2013 and projected for the period 2014–2020 using a Bayesian log-linear Poisson model.
All calculated rates were greater for BC than for LC in 2013 (CR, 27.3 versus 17.3; ASR, 13.5 versus 9.3), and the CR was not projected to change by 2020 (29.2 versus 27.6). The ASR for LC is expected to surpass that of BC in 2019 (12.9 versus 12.7).
By 2020 the LC mortality rates may exceed those of BC for ages 55–74 years, possibly because of the prevalence of smoking among women, and the screening for and more effective treatment of BC. BC screening could be a good opportunity to help smokers quit by offering counseling and behavioral intervention.
Background: Both behavioural support (including brief advice and counselling) and pharmacotherapies (including nicotine replacement therapy (NRT), varenicline and bupropion) are effective in helping people to stop smoking. Combining both treatment approaches is recommended where possible, but the size of the treatment effect with different combinations and in different settings and populations is unclear. Objectives: To assess the effect of combining behavioural support and medication to aid smoking cessation, compared to a minimal intervention or usual care, and to identify whether there are different effects depending on characteristics of the treatment setting, intervention, population treated, or take-up of treatment. Search methods: We searched the Cochrane Tobacco Addiction Group Specialised Register in July 2015 for records with any mention of pharmacotherapy, including any type of NRT, bupropion, nortriptyline or varenicline. Selection criteria: Randomized or quasi-randomized controlled trials evaluating combinations of pharmacotherapy and behavioural support for smoking cessation, compared to a control receiving usual care or brief advice or less intensive behavioural support. We excluded trials recruiting only pregnant women, trials recruiting only adolescents, and trials with less than six months follow-up. Data collection and analysis: Search results were prescreened by one author and inclusion or exclusion of potentially relevant trials was agreed by two authors. Data was extracted by one author and checked by another. The main outcome measure was abstinence from smoking after at least six months of follow-up. We used the most rigorous definition of abstinence for each trial, and biochemically validated rates if available. We calculated the risk ratio (RR) and 95% confidence interval (CI) for each study. Where appropriate, we performed meta-analysis using a Mantel-Haenszel fixed-effect model. Main results: Fifty-three studies with a total of more than 25,000 participants met the inclusion criteria. A large proportion of studies recruited people in healthcare settings or with specific health needs. Most studies provided NRT. Behavioural support was typically provided by specialists in cessation counselling, who offered between four and eight contact sessions. The planned maximum duration of contact was typically more than 30 minutes but less than 300 minutes. Overall, studies were at low or unclear risk of bias, and findings were not sensitive to the exclusion of any of the six studies rated at high risk of bias in one domain. One large study (the Lung Health Study) contributed heterogeneity due to a substantially larger treatment effect than seen in other studies (RR 3.88, 95% CI 3.35 to 4.50). Since this study used a particularly intensive intervention which included extended availability of nicotine gum, multiple group sessions and long term maintenance and recycling contacts, the results may not be comparable with the interventions used in other studies, and hence it was not pooled in other analyses. Based on the remaining 52 studies (19,488 participants) there was high quality evidence (using GRADE) for a benefit of combined pharmacotherapy and behavioural treatment compared to usual care, brief advice or less intensive behavioural support (RR 1.83, 95% CI 1.68 to 1.98) with moderate statistical heterogeneity (I2 = 36%). The pooled estimate for 43 trials that recruited participants in healthcare settings (RR 1.97, 95% CI 1.79 to 2.18) was higher than for eight trials with community-based recruitment (RR 1.53, 95% CI 1.33 to 1.76). Compared to the first version of the review, previous weak evidence of differences in other subgroup analyses has disappeared. We did not detect differences between subgroups defined by motivation to quit, treatment provider, number or duration of support sessions, or take-up of treatment. Authors' conclusions: Interventions that combine pharmacotherapy and behavioural support increase smoking cessation success compared to a minimal intervention or usual care. Updating this review with an additional 12 studies (5,000 participants) did not materially change the effect estimate. Although trials differed in the details of their populations and interventions, we did not detect any factors that modified treatment effects apart from the recruitment setting. We did not find evidence from indirect comparisons that offering more intensive behavioural support was associated with larger treatment effects.
The TOB-G project is funded under the EU 3rd Health Programme which is the main instrument that the Commission uses to implement the EU Health Strategy. The project started in June 2014 and will be completed in September 2017. The project consortium consists of 5 partners from 4 European countries (Belgium, Greece, Ireland and Romania).
The TOB-G project aims to develop and implement an innovative and cost effective approach to prevent chronic diseases related to tobacco dependence by focusing on creating specialized tobacco cessation guidelines for populations of high risk including adolescents, pregnant women, adults with COPD, Cardiovascular disease and diabetes.
The specialized guidelines for high risks groups will be developed according to ENSP’s evidence based and good practices in tobacco cessation. The smoking cessation guidelines contain strategies and recommendations designed to assist clinicians/ doctors in delivering and supporting effective treatments for tobacco use and dependence and will also be available within the context of an e-learning platform for European clinicians.
Overall, the TOB-G project will enhance the overall European capacity in the treatment of tobacco dependence, through offering smoking cessation tools, appropriately assessed and fitted to the specific needs of high risk groups.
According to transtheoretical model (TTM), Stage matched interventions are more effective in quitting. The objective of current study was to investigate the effect of individual counseling, line follow-up, and free nicotine replacement therapy (NRT) on smoking cessation in smokers who are in preparation stage of smoking.
In a randomized clinical trial design, through sending the short message system, potential participants in preparation stage of smoking were recruited and divided into control (n = 60)and treatment (n = 50) groups. The treatment group received an in-person counseling, line follow-up, and free NRT. TTM variables trend; pros and cons of smoking, behavioral and experiential processes, temptation, were assessed at baseline, 3 and 6 months follow-up along with point prevalence and continuous abstinence.
Continuous abstinence at 6-month follow-up were 3.3% (n = 2) in control group and 46% (n = 23) in the treatment group (x (2) = 34.041, P < 0.001). Time Χ group analyses indicated that except cons of smoking (P > 0.05), all TTM constructs had significantly changed; temptation (F = 36.864, P < 0.001), pros (F = 12.172, P < 0.001), experiential processes (F = 3.377, P < 0.001), and behavioral processes (F = 11.131, P < 0.001).
Interventions based on TTM variables increased the quite rate in prepared and motivated people. Our findings suggest that interventions through individual counseling along with free NRT and line follow-up in people who prepare for quitting are beneficial for our country.
Recent studies reported that smoking cessation leads to higher short-term risk of type 2 diabetes than continuing to smoke. However, the duration of increased diabetes risk following smoking cessation needs further investigation. We followed 135,906 postmenopausal women aged 50-79 years enrolled in the Women's Health Initiative between September 1, 1993, and December 31, 1998, over an average of 11 years to examine the association between smoking cessation and risk of diabetes using Cox proportional hazard multivariable-adjusted regression models. Compared with that for never smokers, the risk for diabetes was significantly elevated in current smokers (hazard ratio = 1.28, 95% confidence interval: 1.20, 1.36) but was even higher in women who quit smoking during the first 3 years of follow-up (hazard ratio = 1.43, 95% confidence interval: 1.26, 1.63). Among former smokers, the risk of diabetes decreased significantly as the time since quitting increased and was equal to that of never smokers following a cessation period of 10 years. In new quitters with low cumulative exposure (<20 pack-years), diabetes risk was not elevated following smoking cessation. In conclusion, the risk of diabetes in former smokers returns to that in never smokers 10 years after quitting, and even more quickly in lighter smokers.
Cigarette smoking is a well-known risk factor in many diseases, including various kinds of cancer and cardiovascular disease. Many studies have also reported the unfavorable effects of smoking for diabetes mellitus. Smoking increases the risk of developing diabetes, and aggravates the micro- and macro-vascular complications of diabetes mellitus. Smoking is associated with insulin resistance, inflammation and dyslipidemia, but the exact mechanisms through which smoking influences diabetes mellitus are not clear. However, smoking cessation is one of the important targets for diabetes control and the prevention diabetic complications.
The objective of this study was to analyze the clinical characteristics and levels of glycemic and cardiovascular risk factor control in patients with type 2 diabetes that are in primary health care centers in Catalonia (Spain).
This was a cross-sectional study of a total population of 3,755,038 individuals aged 31-90 years at the end of 2009. Clinical data were obtained retrospectively from electronic clinical records.
A total of 286,791 patients with type 2 diabetes were identified (7.6%). Fifty-four percent were men, mean (SD) age was 68.2 (11.4) years, and mean duration of disease was 6.5 (5.1) years. The mean (SD) A1C value was 7.15 (1.5)%, and 56% of the patients had A1C values ≤7%. The mean (SD) blood pressure (BP) values were 137.2 (13.8)/76.4 (8.3) mmHg, mean total cholesterol concentration was 192 (38.6) mg/dL, mean HDL cholesterol concentration was 49.3 (13.2) mg/dL, mean LDL cholesterol (LDL-C) concentration was 112.5 (32.4) mg/dL, and mean BMI was 29.6 (5) kg/m(2). Thirty-one percent of the patients had BP values ≤130/80 mmHg, 37.9% had LDL-C values ≤100 mg/dL, and 45.4% had BMI values ≤30 kg/m(2). Twenty-two percent were managed exclusively with lifestyle changes. Regarding medicated diabetic patients, 46.9, 22.9, and 2.8% were prescribed one, two, or three antidiabetic drugs, respectively, and 23.4% received insulin therapy.
The results from this study indicate a similar or improved control of glycemia, lipids, and BP in patients with type 2 diabetes when compared with previous studies performed in Spain and elsewhere.
Tobacco use remains the leading cause of preventable death. The outpatient medical clinic represents an important venue for delivering evidence-based interventions to large numbers of tobacco users. Extensive evidence supports the effectiveness of brief interventions. In a retrospective database analysis of 11,827 adult patients captured in the 2005 National Ambulatory Medical Care Survey (of which 2,420 were tobacco users), we examined the degree to which a variety of patient demographic, clinical and physician-related variables predict the delivery of tobacco counseling during a routine outpatient visit in primary care settings. In 2005, 21.7% of identified tobacco users received a tobacco intervention during their visit. The probability of receiving an intervention differed by gender, geographic region and source of payment. Individuals presenting with tobacco-related health conditions were more likely to receive an intervention. Most physicians classified as specialists were less likely to intervene. The provision of tobacco intervention services appears to be increasing at a modest rate, but remains well below desirable levels. It is a priority that brief interventions be routinely implemented to reduce the societal burden of tobacco use. (PsycINFO Database Record (c) 2012 APA, all rights reserved).
Smoking exacerbates the harmful effects of diabetes by increasing risk of diabetes-related complications such as cardiovascular disease, stroke, nephropathy, and neuropathy. To address the smoking cessation needs of people with diabetes, a partnership was formed among diabetes educators, the California Department of Public Health's Diabetes and Tobacco Control Programs, and the California Smokers' Helpline.
A task force composed of 8 diabetes educators voluntarily designed and implemented a statewide educational campaign titled, "Do You cAARd?" The program aimed to promote referrals to the state's tobacco quitline by diabetes educators. Intervention activities included development of a "toolkit" for diabetes educators, presentations at American Association of Diabetes Educators chapter meetings, distribution of pocket-sized smoking cessation materials, and a print media campaign.
The campaign reached 170 diabetes educators directly via educational presentations. A post-campaign online survey of 46 diabetes educators showed 80% had referred clients to the Helpline for smoking cessation support, 76% knew the Helpline's phone number, and 70% had distributed Helpline materials. More than 700 toolkits were downloaded, potentially reaching as many as 75% of California's 900 diabetes educators. The percentage of Helpline calls from people with diabetes and the proportion of callers referred by health care providers also increased over time.
This program partnership serves as a sustainable, efficient, replicable outreach model for smoking cessation.
To assess the feasibility of delivering brief and disease-centred smoking cessation interventions to patients with diabetes mellitus in clinical settings.
We conducted a feasibility study involving two interactive smoking cessation interventions: doctor's advice and visual representation of how tobacco affects diabetes (DA) and DA plus direct referral to a cessation clinic (CC). Follow-up was at 3 and 6 months post intervention. Primary outcome was 7-day-point prevalence abstinence. The study involved male patients recruited from two referral diabetes clinics in Yogyakarta Province, Indonesia during January 2008 to May 2009. Of the 71 patients who smoked during the last month, 33 were randomized to the DA group and 38 to the CC group.
At 6 months follow-up, DA and CC groups had abstinence rates of 30% and 37%, respectively. Of those continuing to smoke, most reported an attempt to quit or reduce smoking (70% in DA and 88% in CC groups). Patients in both groups had increased understanding of smoking-related harm and increased motivation to quit smoking.
This study demonstrates the feasibility of disease-centred doctors' messages about smoking cessation for patients with diabetes, supported by the presence of a CC motivating clinicians to routinely give patients cessation messages.
It is a priority to achieve smoking cessation in diabetic smokers, given that this is a group of patients with elevated cardiovascular risk. Furthermore, tobacco has a multiplying effect on micro and macro vascular complications. Smoking abstinence rates increase as the intensity of the intervention, length of the intervention and number and diversity of contacts with the healthcare professional during the intervention increases. However, there are few published studies about smoking cessation in diabetics in primary care, a level of healthcare that plays an essential role in these patients. Therefore, the aim of the present study is to evaluate the effectiveness of an intensive smoking cessation intervention in diabetic patients in primary care.
Cluster randomized trial, controlled and multicentric. Randomization unit: Primary Care Team. Study population: 546 diabetic smokers older than 14 years of age whose disease is controlled by one of the primary care teams in the study. Outcome Measures: Continuous tobacco abstinence (a person who has not smoked for at least six months and with a CO level of less than 6 ppm measured by a cooximeter) , evolution in the Prochaska and DiClemente's Transtheoretical Model of Change, number of cigarettes/day, length of the visit. Point of assessment: one- year post- inclusion in the study. Intervention: Brief motivational interview for diabetic smokers at the pre-contemplation and contemplation stage, intensive motivational interview with pharmacotherapy for diabetic smokers in the preparation-action stage and reinforcing intevention in the maintenance stage. Statistical Analysis: A descriptive analysis of all variables will be done, as well as a multilevel logistic regression and a Poisson regression. All analyses will be done with an intention to treatment basis and will be fitted for potential confounding factors and variables of clinical importance. Statistical packages: SPSS15, STATA10 y HLM6.
The present study will try to describe the profile of a diabetic smoker who receives the most benefit from an intensive intervention in primary care. The results will be useful for primary care professionals in their usual clinical practice.
Clinical Trials.gov Identifier: NCT00954967.
There is a considerable body of evidence on the effectiveness of specific interventions in individuals who wish to quit smoking. However, there are no large-scale studies testing the whole range of interventions currently recommended for helping people to give up smoking; specifically those interventions that include motivational interviews for individuals who are not interested in quitting smoking in the immediate to short term. Furthermore, many of the published studies were undertaken in specialized units or by a small group of motivated primary care centres. The objective of the study is to evaluate the effectiveness of a stepped smoking cessation intervention based on a trans-theoretical model of change, applied to an extensive group of Primary Care Centres (PCC).
Cluster randomised clinical trial. Unit of randomization: basic unit of care consisting of a family physician and a nurse, both of whom care for the same population (aprox. 2000 people). Intention to treat analysis. Study population: Smokers (n = 3024) aged 14 to 75 years consulting for any reason to PCC and who provided written informed consent to participate in the trial. Intervention: 6-month implementation of recommendations of a Clinical Practice Guideline which includes brief motivational interviews for smokers at the precontemplation - contemplation stage, brief intervention for smokers in preparation-action who do not want help, intensive intervention with pharmacotherapy for smokers in preparation-action who want help, and reinforcing intervention in the maintenance stage. Control group: usual care. Outcome measures: Self-reported abstinence confirmed by exhaled air carbon monoxide concentration of <or= 10 parts per million. Points of assessment: end of intervention period and 1 and 2 years post-intervention; continuous abstinence rate for 1 year; change in smoking cessation stage; health status measured by SF-36.
The application of a stepped intervention based on the stages of a change model is possible under real and diverse clinical practice conditions, and improves the smoking cessation success rate in smokers, besides of their intention or not to give up smoking at baseline.
An integrative model of change was applied to the study of 872 Ss (mean age 40 yrs) who were changing their smoking habits on their own. Ss represented the following 5 stages of change: precontemplation, contemplation, action, maintenance, and relapse. 10 processes of change were expected to receive differential emphases during particular stages of change. Results indicate that Ss (a) used the fewest processes of change during precontemplation; (b) emphasized consciousness raising during the contemplation stage; (c) emphasized self-reevaluation in both contemplation and action stages; (d) emphasized self-liberation, a helping relationship, and reinforcement management during the action stage; and (e) used counterconditioning and stimulus control the most in both action and maintenance stages. Relapsers responded as a combination of contemplaters and people in action would. Results are discussed in terms of developing a model of self-change of smoking and enhancing a more integrative general model of change. (14 ref) (PsycINFO Database Record (c) 2012 APA, all rights reserved)
To evaluate the effectiveness of a nurse-managed smoking cessation intervention in diabetic patients.
This randomized controlled clinical trial involved 280 diabetic smokers (age range 17-84 years) who were randomized either into control (n = 133) or intervention (n = 147) groups at 12 primary care centers and 2 hospitals located in Navarre, Spain. The intervention consisted of a 40-min nurse visit that included counseling, education, and contracting information (a negotiated cessation date). The follow-up consisted of telephone calls, letters, and visits. The control group received the usual care for diabetic smokers. Baseline and 6-month follow-up measurements included smoking status (self-reported cessation was verified by urine cotinine concentrations), mean number of cigarettes smoked per day, and stage of change.
At the 6-month follow-up, the smoking cessation incidence was 17.0% in the intervention group compared with 2.3% in the usual care group, which was a 14.7% difference (95% CI 8.2-21.3%). Among participants who continued smoking, a significant reduction was evident in the average cigarette consumption at the 6-month follow-up. The mean number of cigarettes per day decreased from 20.0 at baseline to 15.5 at 6 months for the experimental group versus from 19.7 to 18.1 for the control group (P < 0.01).
A structured intervention managed by a single nurse was shown to be effective in changing the smoking behavior of diabetic patients.
To evaluate the effectiveness of interventions using a stage based approach in bringing about positive changes in smoking behaviour.
Systematic review.
35 electronic databases, catalogues, and internet resources (from inception to July 2002). Bibliographies of retrieved references were scanned for other relevant publications, and authors were contacted if necessary.
23 randomised controlled trials were reviewed; two reported details of an economic evaluation. Eight trials reported effects in favour of stage based interventions, three trials showed mixed results, and 12 trials found no statistically significant differences between a stage based intervention and a non-stage based intervention or no intervention. Eleven trials compared a stage based intervention with a non-stage based intervention, and one reported statistically significant effects in favour of the stage based intervention. Two studies reported mixed effects, and eight trials reported no statistically significant differences between groups. The methodological quality of the trials was mixed, and few reported any validation of the instrument used to assess participants' stage of change. Overall, the evidence suggests that stage based interventions are no more effective than non-stage based interventions or no intervention in changing smoking behaviour.
Limited evidence exists for the effectiveness of stage based interventions in changing smoking behaviour.
We wanted to identify differences between diabetic patients who smoke and those who do not smoke to design more effective strategies to improve their diabetes care and encourage smoking cessation.
A random sample of adult health plan members with diabetes were mailed a survey questionnaire, with telephone follow-up, asking about their attitudes and behaviors regarding diabetes care and smoking. Among the 1,352 respondents (response rate 82.4%), we found 188 current smokers whose answers we compared with those of 1,264 nonsmokers, with statistical adjustment for demographic characteristics and duration of diabetes.
Smokers with diabetes were more likely to report fair or poor health (odds ratio [OR] = 1.5, P = .03) and often feeling depressed (OR = 1.7, P = .004). Relative to nonsmokers, smokers had lower rates of checking blood glucose levels, were less physically active, and had fewer diabetes care visits, glycated hemoglobin (A1c) tests, foot examinations, eye examinations, and dental checkups (P < or = .01). Smokers also reported receiving and desiring less support from family and friends for specific diabetic self-management activities and had lower readiness to quit smoking than has been observed in other population groups.
Clinicians should be aware that diabetic patients who smoke are more likely to report often feeling depressed and, even after adjusting for depression, are less likely to be active in self-care or to comply with diabetes care recommendations. Diabetic patients who smoke are special clinical challenges and are likely to require more creative and consistent clinical interventions and support.
This study compared diabetes Treatment As Usual (TAU) with Pathways To Change (PTC), an intervention developed from the Transtheoretical Model of Change (TTM), to determine whether the PTC intervention would result in greater readiness to change, greater increases in self-care, and improved diabetes control.
Participants were stratified by diabetes treatment and randomized to treatment with PTC or TAU as well as being randomized regarding receipt of free blood testing strips. The PTC consisted of stage-matched personalized assessment reports, self-help manuals, newsletters, and individual phone counseling designed to improve readiness for self-monitoring of blood glucose (SMBG), healthy eating, and/or smoking cessation. A total of 1029 individuals with type 1 and type 2 diabetes who were in one of three pre-action stages for either SMBG, healthy eating, or smoking were recruited.
For the SMBG intervention, 43.4% of those receiving PTC plus strips moved to an action stage, as well as 30.5% of those receiving PTC alone, 27.0% of those receiving TAU plus strips, and 18.4% of those receiving TAU alone (P < 0.001). For the healthy eating intervention, more participants who received PTC than TAU (32.5 vs. 25.8%) moved to action or maintenance (P < 0.001). For the smoking intervention, more participants receiving PTC (24.3%) than TAU (13.4%) moved to an action stage (P < 0.03). In intention-to-treat (ITT) analysis of those receiving the SMBG intervention, PTC resulted in a greater reduction of HbA(1c) than TAU, but this did not reach statistical significance. However, in those who moved to an action stage for the SMBG and healthy eating interventions, HbA(1c) was significantly reduced (P < 0 0.001). Individuals who received the healthy eating intervention decreased their percentage of calories from fat to a greater extent (35.2 vs. 36.1%, P = 0.004), increased servings of fruit per day (1.89 vs. 1.68, P = 0.016), and increased vegetable servings (2.24 vs. 2.06, P = 0.011) but did not decrease weight. However, weight loss for individuals who received the healthy eating intervention and who increased SMBG frequency as recommended was significantly greater, with a 0.26-kg loss in those who remained in a pre-action SMBG stage but a 1.78-kg loss in those performed SMBG as recommended (P <or= 0. 01).
This study demonstrates that this intervention has the potential of positively impacting the health of broad populations of individuals with diabetes, not just the minority who are ready for change.
To evaluate an intervention programme on smoking cessation in patients with diabetes mellitus in primary healthcare.
Regional controlled intervention study.
Seventeen primary healthcare centres in Sweden.
In the intervention centres, nurses with education in diabetes were given one half-day of training in motivational interviewing and smoking cessation. An invitation to participate in a smoking cessation group was mailed to patients from the intervention centres followed by a telephone call from the patient's diabetes nurse. The nurses who intervened were specially educated in smoking cessation. The control group received a letter containing advice to stop smoking and information about a one-year follow-up.
Daily smokers with diabetes mellitus, 30-75 years of age. In the intervention centres 241 patients fulfilled the criteria and in the control centres 171 patients.
Self-reported smoking habits after one year.
In total, 21% of the smokers accepted group treatment. After 12 months, 20% (42/211) in the intervention centres reported that they had stopped smoking and 7% (10/140) in the control centres; 40% (19/47) of the smokers who had participated in group treatment reported that they had stopped smoking.
A computerized record system for patients in primary healthcare was used to identify diabetic patients who were smokers. The selected group was invited to a stop smoking programme. At a one-year follow-up significantly more patients in the intervention centres had stopped smoking compared with patients in the control centres.
BACKGROUND We wanted to identify differences between diabetic patients who smoke and those who do not smoke to design more effective strategies to improve their diabetes care and encourage smoking cessation.
METHODS A random sample of adult health plan members with diabetes were mailed a survey questionnaire, with telephone follow-up, asking about their attitudes and behaviors regarding diabetes care and smoking. Among the 1,352 respondents (response rate 82.4%), we found 188 current smokers whose answers we compared with those of 1,264 nonsmokers, with statistical adjustment for demographic characteristics and duration of diabetes.
RESULTS Smokers with diabetes were more likely to report fair or poor health (odds ratio [OR] = 1.5, P = .03) and often feeling depressed (OR = 1.7, P = .004). Relative to nonsmokers, smokers had lower rates of checking blood glucose levels, were less physically active, and had fewer diabetes care visits, glycated hemoglobin (A1c) tests, foot examinations, eye examinations, and dental checkups (P ≤ .01). Smokers also reported receiving and desiring less support from family and friends for specific diabetic self-management activities and had lower readiness to quit smoking than has been observed in other population groups.
CONCLUSIONS Clinicians should be aware that diabetic patients who smoke are more likely to report often feeling depressed and, even after adjusting for depression, are less likely to be active in self-care or to comply with diabetes care recommendations. Diabetic patients who smoke are special clinical challenges and are likely to require more creative and consistent clinical interventions and support.
The purpose of this literature review is to report the effectiveness of trials using the Transtheoretical Model of Change for achieving smoking cessation among adolescents.
An integrative literature review was performed. Two reviewers searched the Internet for randomized, controlled trials or observational studies of adolescent smoking cessation trials reported between 1999 and June 2009 that used the Transtheoretical Model of Change.
Six randomized controlled trials remained after all inclusion and exclusion criteria were met. Each study was reviewed qualitatively and odds ratio and quit rates were calculated. Four studies demonstrated an odds ratio of greater than 1.0, and in four studies significantly better quit rates were found in the intervention arm versus the control arm at the endpoint evaluation.
Evidence exists for the effectiveness of stage-based interventions in promoting smoking cessation in adolescents.
Background and aims:
Smoking is known to negatively influence glucose metabolism both in healthy subjects and in patients with diabetes. The aim of this study was to compare glycemic control in patients with type 1 diabetes mellitus who were smokers with those who did not smoke during a prospective long-term follow-up.
Methods and results:
In a single center, 763 patients with type 1 diabetes mellitus were included, 160 (21.0%) of them were smokers. Patients were treated with intensive insulin therapy according to existing guidelines. Glucose control was monitored quarterly, diabetes related complications and cardiovascular risk factors were assessed at least once a year. Glucose control in smokers was significantly worse than in non-smokers at baseline and during follow-up (mean HbA1c during 5047 patient-years of follow-up 7.9 ± 1.3% in smokers and 7.3 ± 1.1% in non-smokers, p < 0.001) despite a higher insulin dosage in smokers (0.71 ± 0.30 U/kg vs. 0.65 ± 0.31 U/kg in non-smokers, p = 0.046). HDL cholesterol was lower in smokers at baseline (1.53 ± 0.45 vs. 1.68 ± 0.51 in non-smokers, p = 0.048). Diabetes related complications tended to occur with a higher frequency in smokers, with a significant difference in macroalbuminuria (9.8% vs. 4.8% in non-smokers, p = 0.047).
Conclusion:
Smoking is associated with worse glucose control in patients with type 1 diabetes mellitus despite the same treatment strategies as in non-smokers. Hyperglycemia, therefore, may contribute to an earlier incidence of diabetes related complications in these patients, in addition to direct toxic effects of smoking.
Smoking substantially increases morbidity and mortality rates in people with diabetes. Previous studies have shown that the prevalence of smoking among people with diabetes is similar to that among people without diabetes. We sought to examine temporal trends in the prevalence of smoking among people with diabetes since 1990.
We analyzed data from the Behavioral Risk Factor Surveillance System for 1990-2001.
The age-adjusted prevalence of smoking among adults with diabetes was 23.6% (men, 25.4%; women, 22.2%) in 1990 and 23.2% (men, 24.8%; women, 21.9%) in 2001. In comparison, the prevalence among participants without diabetes was 24.2% (men, 25.7%; women, 22.8%) in 1990 and 23.2% (men, 24.8%; women, 21.5%) in 2001. Thus, the prevalence of cigarette smoking was similar and remained stable from 1990 through 2001. Among participants with diabetes, significant decreases in the prevalence of smoking occurred among African Americans and those aged >/=65 years.
New efforts and commitments to promote smoking cessation among people with diabetes are needed.
To evaluate the effectiveness in primary care of a stepped smoking cessation intervention based on the transtheoretical model of change.
Cluster randomized trial; unit of randomization: basic care unit (family physician and nurse who care for the same group of patients); and intention-to-treat analysis.
All interested basic care units (n = 176) that worked in 82 primary care centres belonging to the Spanish Preventive Services and Health Promotion Research Network in 13 regions of Spain.
A total of 2,827 smokers (aged 14-85 years) who consulted a primary care centre for any reason, provided written informed consent and had valid interviews.
The outcome variable was the 1-year continuous abstinence rate at the 2-year follow-up. The main variable was the study group (intervention/control). Intervention involved 6-month implementation of recommendations from a Clinical Practice Guideline which included brief motivational interviews for smokers at the precontemplation-contemplation stage, brief intervention for smokers in preparation-action who do not want help, intensive intervention with pharmacotherapy for smokers in preparation-action who want help and reinforcing intervention in the maintenance stage. Control group involved usual care. Among others, characteristics of tobacco use and motivation to quit variables were also collected.
The 1-year continuous abstinence rate at the 2-year follow-up was 8.1% in the intervention group and 5.8% in the control group (P = 0.014). In the multivariate logistic regression, the odds of quitting of the intervention versus control group was 1.50 (95% confidence interval = 1.05-2.14).
A stepped smoking cessation intervention based on the transtheoretical model significantly increased smoking abstinence at a 2-year follow-up among smokers visiting primary care centres.
Smoking contributes to the development of diabetes and diabetes-related complications. Currently, data on smoking prevalence in subjects with diabetes in Germany are lacking. The aim of our analysis was to determine smoking prevalence in adults with Type 2 diabetes mellitus using data from the two population-based studies in Germany.
From the Study of Health in Pomerania (SHIP) (n = 4283) and the 1998 German National Health Interview and Examination Survey (GNHIES 98) (n = 6663) subjects aged 20-79 years were investigated. Descriptive statistics on smoking prevalence and behaviours were calculated for Type 2 diabetes mellitus and compared with the general population using weightings reflecting the European adult population.
Overall, the prevalence of current smokers was lower among persons with than without Type 2 diabetes mellitus in SHIP (17.3% vs. 38.0%) and in GNHIES 98 (24.7% vs. 32.1%). Only in men, there were more former smokers in Type 2 diabetic patients than in subjects without diabetes in both studies. Among current and former smokers, the number of cigarettes smoked was higher among persons with than without Type 2 diabetes mellitus. For men, this finding was consistent in SHIP and GNHIES 98, while in women, this difference was only observed in GNHIES 98.
The associations between smoking and Type 2 diabetes mellitus are likely to reflect behavioural changes secondary to illness or medical counselling. The high proportion of current smokers among Type 2 diabetic patients, particularly men, should be monitored in repeated surveys following the introduction of disease management programmes.
The objective of the study was to evaluate the stages of change for cessation in smoking after the application of American Diabetes Association recommendations in diabetic patients who smoke. This longitudinal descriptive study involved smokers with diabetes mellitus (DM) who were attended for their DM between September 2003 and December 2006. Intervention used was dependent on the stage of change for cessation (according to Prochaska and Di Clemente). For precontemplation subjects, a brief session was carried out where information regarding the risks of smoking in conjunction with DM was given. Patients at the contemplation stage of smoking cessation were offered the chance to participate in a cessation program. Later evaluation was carried out after a follow-up of more than 6 months. Seven hundred thirty-three subjects with DM were evaluated, including 156 smokers (21.28%): 103 (66.02%) in the precontemplation stage, 25 (16.02%) in the contemplation stage, 12 (7.69%) in the preparation stage, 12 (7.69%) in the action stage, and 4 (2.56%) in the maintenance stage. By the last follow-up, 65 (41.6%) subjects had quit smoking (36 ex-smokers), of whom 20 (30.77%) had subsequently relapsed. The use of the American Diabetes Association recommendations for the treatment of tobacco dependence in diabetes treatment results in an increased change of smoking cessation stages in subjects with DM as well as a higher overall percentage in abstinence.
Cigarette smoking is a major risk factor in diabetes and contributes to the development of microvascular and macrovascular complications. Despite this, approximately one third of patients with diabetes smoke. Nicotine is physically and psychologically addictive, with multiple factors contributing to the initiation and continuation of the habit. Cessation is a process in which the smoker progresses through several stages of change, including precontemplation, contemplation, action, maintenance, and relapse. Knowledge of this process is needed for the diabetes health care team to effectively individualize smoking prevention and cessation strategies. This stepped care approach includes preventive, behavioral, and pharmacologic strategies as a component of routine diabetes education.
To examine the relationship between smoking and both glycemic control and microvascular complications in patients with insulin-dependent diabetes mellitus (IDDM).
This was a prevalence survey of 3,250 men and women aged 15-60 years with IDDM from 31 diabetes centers in 16 European countries. Participants completed a questionnaire, had retinal photographs taken, and performed a 24-h urine collection. HbA1c, frequency of hypoglycemic and ketoacidotic episodes, urinary albumin excretion rates, and retinopathy were compared by smoking category.
The prevalence of smoking was 35% in men and 29% in women. Current smokers had poorer glycemic control and, among men, were more likely to have had a ketoacidotic episode than were those who never smoked. Ex-smokers had equivalent glycemic control and marginally more hypoglycemic episodes did than those who never smoked. Current smokers had a higher prevalence of microalbuminuria and total retinopathy than did those who never smoked. Ex-smokers had a higher prevalence of macroalbuminuria and proliferative retinopathy than did those who never smoked, but both had a similar prevalence of microalbuminuria. Adjustment for either current or long-term glycemic control could not fully account for these differences.
Smoking is associated with poorer glycemic control and an increased prevalence of microvascular complications compared with not smoking. Ex-smokers can achieve glycemic control equivalent to and have a prevalence of early complications similar to that of those who never smoked. We suggest that poorer glycemic control can account for some of the increased risk of complications in smokers, and that quitting smoking would be effective in reducing the incidence of complications. Urgent action is required to reduce the high smoking rates in people with IDDM.
Smoking is a serious health risk, particularly for people with diabetes. This study was designed to examine important aspects of smoking in a large group of individuals with diabetes. A survey was mailed to 2,056 individuals with diabetes. The variables examined were the stages of change for smoking, prevalence of quitting advice given by health care providers, and the patterns of readiness for change. The majority (57.8%) of current smokers were in the precontemplation stage. Comparisons on the stage of change indicated that more individuals with Type 2 diabetes have quit while there are more current smokers among those with Type 1 diabetes. Comparisons on current smokers indicated no differences on stage of change across the Type 1 and Type 2 groups, across three subgroups of individuals with Type 2 diabetes, or across duration of diabetes. Those who reported that they were given cessation advice were further along in the stages of change. These results suggest that the majority of individuals with diabetes who smoke are in the precontemplation stage of change and provider advice is important in moving smokers toward change. The current findings underscore the importance of assessing stage of change and providing stage-matched interventions when working with smokers with diabetes.
The objective of this review is to summarize the literature on diabetes and smoking related to epidemiological risks, efficacy and cost-effectiveness of different cessation approaches, and implications for clinical practice. Over 200 studies were reviewed, with special emphasis placed on publications within the past 10 years. Intervention studies that included patients with diabetes but did not report results separately by disease are included. Diabetes-specific studies are highlighted. There are consistent results from both cross-sectional and prospective studies showing enhanced risk for micro- and macrovascular disease, as well as premature mortality from the combination of smoking and diabetes. The general cessation literature is extensive, generally well-designed, and encouraging regarding the impact of cost-effective practical office-based interventions. In particular, system-based approaches that make smoking a routine part of office contacts and provide multiple prompts, advice, assistance, and follow-up support are effective. Although there is minimal information on the effectiveness of cessation interventions specifically for people with diabetes, there is no reason to assume that cessation intervention would be more or less effective in this population. There is a clear need to increase the frequency of smoking cessation advice and counseling for patients with diabetes given the strong and consistent data on smoking prevalence; combined risks of smoking and diabetes for morbidity, mortality, and several complications; and the proven efficacy and cost-effectiveness of cessation strategies.
To comprehensively review all published, peer-reviewed research on the Transtheoretical Model (TTM) and tobacco cessation and prevention by exploring the validity of its constructs, the evidence for use of interventions based on the TTM, the description of populations using TTM constructs, and the identification of areas for further research. The three research questions answered were: "How is the validity of the TTM as applied to tobacco supported by research?" "How does the TTM describe special populations regarding tobacco use?" "What is the nature of evidence supporting the use of stage-matched tobacco interventions?"
Computer Database search (PsychInfo, Medline, Current Contents, ERIC, CINAHL-Allied Health, and Pro-Quest Nursing) and manual journal search. INCLUSION/EXCLUSION CRITERIA: All English, original, research articles on the TTM as it relates to tobacco use published in peer-reviewed journals prior to March 1, 2001, were included. Commentaries, editorials, and books were not included.
Articles were categorized as TTM construct validation, population descriptions using TTM constructs, or intervention evaluation using TTM constructs. Summary tables including study design, research rating, purpose, methods, findings, and implications were created. Articles were further divided into groups according to their purpose. Considering both the findings and research quality of each, the three research questions were addressed.
The 148 articles reviewed included 54 validation studies, 73 population studies, and 37 interventions (some articles fit two categories). Overall, the evidence in support of the TTM as applied to tobacco use was strong, with supportive studies being more numerous and of a better design than nonsupportive studies. Using established criteria, we rated the construct validity of the entire body of literature as good; however, notable concerns exist about the staging construct. A majority of stage-matched intervention studies provided positive results and were of a better quality than those not supportive of stage-matched interventions; thus, we rated the body of literature using stage-matched tobacco interventions as acceptable and the body of literature using non-stage-matched interventions as suggestive. Population studies indicated that TTM constructs are applicable to a wide variety of general and special populations both in and outside of the United States, although a few exceptions exist.
Evidence for the validity of the TTM as it applies to tobacco use is strong and growing; however, it is not conclusive. Eight different staging mechanisms were identified, raising the question of which are most valid and reliable. Interventions tailored to a smoker's stage were successful more often than nontailored interventions in promoting forward stage movement. Stage distribution is well-documented for U.S. populations; however, more research is needed for non-U.S. populations, for special populations, and on other TTM constructs.
Smokers are insulin resistant, exhibit several aspects of the insulin resistance syndrome, and are at an increased risk for type 2 diabetes. Prospectively, the increased risk for diabetes in smoking men and women is around 50%. Many patients with type 1 and type 2 diabetes mellitus are at risk for micro- and macrovascular complications. Cigarette smoking increases this risk for diabetic nephropathy, retinopathy, and neuropathy, probably via its metabolic effects in combination with increased inflammation and endothelial dysfunction. This association is strongest in type 1 diabetic patients. The increased risk for macrovascular complications, coronary heart disease (CHD), stroke, and peripheral vascular disease, is most pronounced in type 2 diabetic patients. The development of type 2 diabetes is another possible consequence of cigarette smoking, besides the better-known increased risk for cardiovascular disease. In diabetes care, smoking cessation is of utmost importance to facilitate glycemic control and limit the development of diabetic complications.
Patients with type 2 diabetes and macroalbuminuria generally experience progressive glomerular filtration rate (GFR) decline despite angiotensin-converting enzyme inhibition (ACEI) and blood pressure (BP) control but this therapy generally stabilizes GFR in those without macroalbuminuria. Cigarette smoking exacerbates GFR decline in patients with type 2 diabetes and macroalbuminuria despite ACEI and BP control; whether this therapy prevents nephropathy progression in nonmacroalbuminuric type 2 diabetic smokers is unknown.
We determined the course of urine excretion of indices of renal injury that distinguished patients with type 2 diabetes with and without macroalbuminuria but with normal plasma creatinine who were prospectively followed 6 months while receiving ACEI and BP control. We compared this course in nonsmokers and smokers with normo-, micro-, and macroalbuminuria (n = 157) and in response to smoking cessation in a separate cohort (n = 80) with microalbuminuria.
Urine excretion of transforming growth factor beta-1 (UTGFbetaV) increased in macroalbuminuric but not in nonmacroalbuminuric nonsmokers and UTGFbetaV rate was higher in smokers than nonsmokers within each albuminuria group. In the separate microalbuminuric cohort, the rate of UTGFbetaV change for quitting smokers was not different from nonsmokers (0.093 versus -0.123 ng/g of creatine/week, P = not significant) but that for nonquitting smokers (0.970) was higher than nonsmokers (P = 0.017).
Patients with type 2 diabetes who are at high risk compared with low risk for nephropathy progression have progressive renal injury as measured by increasing UTGFbetaV. Cigarette smoking exacerbates renal injury in type 2 diabetes despite BP control and ACEI, but its cessation in those with microalbuminuria ameliorates the progressive renal injury caused by continued smoking.
To investigate awareness of pharmacotherapeutic aids to smoking cessation in diabetic cigarette smokers.
A structured questionnaire-based interview was held by a research nurse individually with consecutively attending cigarette smokers.
Of 597 diabetic patients attending a routine clinic, 100 (17%) were current cigarette smokers. Mean (+/-sd) age was 58+/-11 years, 58% were male, and 96% Type 2 diabetic patients. Mean daily cigarette consumption was 16/day, for a mean duration of 35 years. There were 34% who had never heard of nicotine replacement therapy (NRT), and of those who had, only 49% considered it safe with diabetes. Bupropion (Zyban) was unknown to 46%, and of those who knew of it, 39% thought it unsafe in diabetic patients. Only 31% of the group had been previously offered NRT, and 14% bupropion. The NHS Quitline was known of by 84%, but only 8% had used it.
Cigarette smokers with diabetes have poor uptake, awareness and knowledge of NRT and bupropion as aids to smoking cessation. They comprise a high-risk group, for large and small vessel disease, and these findings are therefore of concern. More active education and support for these patients by medical and nursing staff is needed.
The purpose of this study was to evaluate the impact of a tobacco cessation intervention using motivational interviewing on smoking cessation rates during diabetes self-management training (DSMT).
A randomized controlled trial was conducted with subjects recruited from an ongoing type 2 diabetes adult education program at a large diabetes center. A total of 114 subjects were randomized to intervention (n = 57; face-to-face motivational interviewing plus telephone counseling and offering of medication) or standard care (n = 57). Outcome measures included tobacco cessation rates, mean number of cigarettes smoked, A1C, weight, blood pressure, and lipids.
Intensive intervention using motivational interviewing integrated into a standard DSMT program resulted in a trend toward greater abstinence at 3 months of follow-up in those receiving the intervention. However, this same trend was not observed at 6 months. The addition of this structured smoking cessation intervention did not negatively affect either diabetes education or other measures of diabetes management, including A1C values.
Structured tobacco cessation efforts can be readily integrated into established diabetes education programs without a negative impact on diabetes care or delivery of diabetes education. However, an intervention of moderate intensity for smoking cessation was no more effective than usual care in assisting patients with tobacco cessation after 6-month follow-up. Whether a more intensive intervention, targeting patients expressing a readiness to discontinue tobacco use, and/or a longer duration or a more cumulative effect of treatment will be more effective must be evaluated.
To assess the value of systematic smoking cessation consultations for diabetic smokers admitted to hospital.
All diabetic smokers admitted to the Diabetes Department of Georges Pompidou European Hospital between February 2003 and February 2004 were systematically offered a consultation with a physician specialised in tobacco cessation. Follow-up visits at three, six and nine months were planned.
Of the 306 diabetic patients admitted, 38 (12.4%) were smokers. There were more men than women in the group of smokers and the diabetic smokers were younger than the non-smokers. The smokers had fewer micro-angiopathic complications than the non-smokers, but there was no difference in the frequency of macro-angiopathic complications. The level of nicotine physical dependence was moderate or high for 60% of the smokers. Although all the smokers agreed to the consultation, less than half agreed to drug-based treatments to help them to give up smoking and only 15% returned for the six-month visit. Only one patient had stopped smoking at the six-month visit.
This study demonstrates the difficulties in systematic interventions to help diabetic patients to stop smoking. Diabetic smokers probably constitute a specific population for which the barriers to giving up smoking should be explored.
We tested the hypothesis that continued cigarette smoking exacerbates and its cessation ameliorates progression of the early nephropathy of type 2 diabetes mellitus (DM2) from microalbuminuria to macroalbuminuria.
We recruited 91 DM2 subjects with microalbuminuria, 39 nonsmokers and 52 smokers. Smokers underwent smoking cessation intervention with 11 of the 52 smokers quitting, yielding 3 groups: nonsmokers (NS, n = 39), continued smokers (S, n = 41), and quitting smokers (Quit, n = 11), all on angiotensin converting enzyme inhibition (ACEI), treated toward recommended BP and glycemic targets, and followed prospectively for 5 years. Subjects had yearly measurements of estimated glomerular filtration rate (eGFR) and albumin (mg)-to-creatinine (g) ratios (alb/cr) in spot morning urines. Comparison of changes in characteristics was done using analysis of variance, with all pair wise multiple comparison procedure at alpha = 0.05.
Although average urine alb/cr was not different among groups at recruitment, 7 of the 41 S (17%) but none of the 50 NS or Quit progressed to macroalbuminuria (P < 0.003). eGFR decline rate was faster in S (-1.79 +/- 0.35 mL/min/yr) than in NS or Quit (-1.30 +/- 0.43 and -1.54 +/- 0.37 mL/min/yr, respectively, P < 0.001). Multivariate analysis revealed smoking to be the only measured baseline factor that influenced eGFR decline rate (P < 0.041).
Smoking exacerbates progression of early to advanced DM2 nephropathy and its cessation is an effective kidney-protective intervention in the early nephropathy of DM2.
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