Smoking and Diabetes: D H - J, R E. G, T L. T

Rev iews/ Com m en taries/ P osit ion Statem ents
T E C H N I C A L R E V I E W
Smoking and Diabetes

DEBRA HAIRE-JOSHU, PHD
RUSSELL E. GLASGOW, PHD tables and summarizing study content
TIFFANY L. TIBBS, MA and criteria, and summarizing these
studies and review articles. Articles
included were published in peer-
reviewed journals within the last 10 years
in English. In a few instances, articles of
The objective of this review is to summarize the literature on diabetes and smoking related particular merit within the past 15 years
to epidemiological risks, efficacy and cost-effectiveness of different cessation approaches, are presented. These procedures
and implications for clinical practice. Over 200 studies were reviewed, with special emphasis revealed a relatively small number of
placed on publications within the past 10 years. Intervention studies that included patients studies specific to diabetes and
with diabetes but did not report results separately by disease are included. Diabetes-specific smoking, especially on intervention
studies are highlighted. There are consistent results from both cross-sectional and
research. Therefore, in each section we
prospective studies showing enhanced risk for micro- and macrovascular disease, as well
as premature mortality from the combination of smoking and diabetes. The general present articles relevant to smoking in
cessation literature is extensive, generally well-designed, and encouraging regarding the general, focusing on studies of medical
impact of cost-effective practical office-based interventions. In particular, system-based patients (many of which include diabetic
approaches that make smoking a routine part of office contacts and provide multiple patients, but do not separate results for
prompts, advice, assistance, and follow-up support are effective. Although there is them vs. other patients), and then pres-
minimal information on the effectiveness of cessation interventions specifically for people ent the more limited literature
with diabetes, there is no reason to assume that cessation intervention would be more or less specifically related to diabetes and
effective in this population. There is a clear need to increase the frequency of smoking smoking. Together, these studies allow
cessation advice and counseling for patients with diabetes given the strong and consistent for the extrapolation of findings from the
data on smoking prevalence; combined risks of smoking and diabetes for morbidity,
general literature that are pertinent to
mortality, and several complications; and the proven efficacy and cost-effectiveness of
cessation strategies. people with diabetes.
PREVALENCE OF SMOKING
Diabetes Care 22:1887–1898, 1999
— This section presents factors
associated with smoking prevalence in
the general population and its impact on
health. The sociodemographic
characteristics associated with
prevalence are discussed. This is
he purpose of this review is to and medical office in promoting smoking followed by the more limited research
T
summarize tobacco control issues cessation and on the cost-effectiveness of on smoking prevalence among
across multiple levels: the patient, smoking cessation. We then review data individuals with diabetes.
the health that suggest the importance of care Cigarette smoking is the leading
care provider, the health care setting, settings in promoting optimal diabetes avoid- able cause of mortality in the U.S.,
and finally, policy implications. We first care as it relates to smoking cessation. account- ing for 434,000 deaths each
establish the health threat Finally, implications for health care year (1). Among cigarette smokers, 52%
associated with tobacco use in general policy and future research are discussed. of deaths for men and 43% of deaths for
and then summarize its heightened women were attributable to cigarette
impact on morbidity and mortality LITERATURE REVIEW AND smoking (2). In general, smoking
among people with diabetes. This ANALYSIS — A review of the prevalence has decreased over the past
includes a review of the patient literature on smoking in general and 10 years because of extensive public
perspectives associated with diabetes smoking relative to type 1 and type 2 health efforts (3,3a), including policy
care and management, which often diabetes was conducted. The changes and making the population
enhance the continuation of smoking literature was reviewed by establishing aware of the health hazards of active and
(e.g., absence of advice to quit, priority criteria for relevant studies, conducting passive smoking (environmental tobacco
given to other treatment objectives, computer searches, reviewing the exposure). Despite these figures,
weight concerns). We next consider the bibliographies of key articles, compiling 26–28% of American adults continue
types of interventions that have proven and reviewing full articles, to smoke (4), with variations reported by
most effective, focusing especially on constructing eth- nic group. For example, Royce et
the role of the health care provider al. (5) reported that African-Americans
typically
From the Department of Community Health (D.H.-J.), Saint Louis University School of Public Health; Community Health, Saint Louis University School
the of Public Health, 3663 Lindell Blvd., St. Louis,
Department of Psychology (T.L.T.), Washington University, St. Louis, Missouri; and the AMC MO 63108. E-mail: joshud@slu.edu.
Cancer This paper was peer-reviewed, modified, and
Research Center (R.E.G.), Denver, Colorado. approved by the Professional Practice
Address correspondence and reprint requests to Debra Haire-Joshu, PhD, Department of Committee, June 1999.
DIABETES CARE, VOLUME 22, NUMBER 11, NOVEMBER 1999 95
Abbreviations: AHCPR, Agency for Health Care Policy and Research; MRFIT, Multiple Risk Factor smoke ,25 cigarettes per day, but are
Inter- vention Trial. more likely to be nicotine dependent.
A table elsewhere in this issue shows conventional and Système International (SI) units and
conversion factors for many substances. Demo- graphic factors associated with
higher smoking prevalence include lower
socioeconomic status and lower
educational level. Those with less than a
high school education are more likely to
be current, ever, and heavy smokers and
the least likely to quit. In contrast, years
of education are associ-
96 DIABETES CARE, VOLUME 22, NUMBER 11, N OVEMBER 1999

Haire-Joshu, Glasgow, and
Tibbs
Technical Review: Smoking and
diabetes
ated with who (8). Among con- on the drug use difficulty of Health men who
never never people sidered, develop (11). breaking the Study, smoked
smoking smoked with especially ment of Various addiction 114,247 $25
and (48.1%) diabetes, in settings diabetes pharmacolo (13,14). In women cigarettes
increased were the where and its gical, addition, were fol- daily had a
cessation found in prevalence there is related biochemical, Parrott (15) lowed for 8 relative risk
rates (6). both pop- of smoking pressure complica and conducted a years and of diabetes
The ulations. decreased not to tions. psychologic series of 2,333 cases of 1.94 (95%
prevalence When as the report Nicot al processes studies that of type 2 CI 1.25–
of stratified duration of smoking ine is an interact in demonstrated diabetes 3.03) com-
smoking by age, disease (9,10). addictive nicotine the were pared with
among race, and increased However, substanc addiction importance confirmed. nonsmokers.
people with education (8). As in general, e related (12,13). of mood After After
diabetes , there reviewed these data to a Cig- arettes control as a controlling examining
appears to were later, this suggest highly are an ideal reason for for multiple the effects of
mirror that trends may in part diabetic controlle vehicle for smoking. risk factors, smoking on
of the toward a be due to individuals d or nicotine Evidence for the relative the 8-year
general higher the smoke at compulsi delivery, genetic risk of type incidence
population, prevalence increased rates ve taking only influences on 2 diabetes of type 2
at least at of mortality equiva- pattern 7 s for smoking and among diabetes on
younger smoking associated lent to the of drug nicotine to the impact of women 2,312
ages. In among with the general use. The reach the amount smoking Japanese
1988, 18- to combinatio population mood- brain via smoked on $25 men,
using 34-year- n of . altering inhalation. ability to cigarettes Kawakami et
results of olds, smoking effects Nicotine quit have per day al. (19) also
the African- and OVERVI function then triggers also been compared concluded
Behavioral Americans diabetes. EW OF as a euphoric reported with indi- that age of
Risk , and There EFFECT reinforce effects as (12). Twin viduals smoking
Factor those are some S OF ment to well as studies with who never initiation and
Surveillanc with specific SMOKI strengthe sedative or 4,960 twin smoked number of
e Sys- tem, lower limitations NG ON n anxi- olytic pairs was 1.42 cigarettes
a cross- education of these DIABETE behavior effects obtained (95% CI smoked were
sectional al levels. studies that S— and lead associated unadjusted 1.18–1.72), major risk
telephone These bear noting. Next, the to with heritability suggesting factors for
interview findings Several of characteris further neurohor- indices of a moderate developing
that are the studies tics of monal 53% for asso- diabetes. To
assessed consistent do not nicotine processes. smoking, ciation evaluate the
chronic with distinguish and its The with other between effects of
disease risk those of between effects on biological work sug- smoking cigarette
factors in the type 1 and the power of gesting that and the smoking on
individuals National type 2 general nicotine genetic subse- insulin sen-
across 37 Health diabetes. population makes contributions quent sitivity,
states, over Interview In are smoking are asso- developme Targher et
3,000 Survey, addition, addressed. patterns ciated with nt of al. (20)
people which many The resistant to the number diabetes studied 40
reporting found studies biologic change. At of cigarettes (17). Rimm patients with
diabetes self- also rely impact of the same smoked and et al. (18) type 2
were reported on self- nicotine time, the ability to quit reported diabetes and
compared smoking reported and other daily cir- smoking similar found
with . prevalenc versus metabolite cumstances, (16). findings insulin
52,000 e to be biochemica s, and the activities, Several from a resistance
without approxim l validation resulting and prospective study of was
diabetes ately of smoking addictive emotions to cohort 41,810 markedly
(7). Simi- equal status. This qualities which studies sug- men who aggravated
lar between is not are smoking is gest that were among those
percentage people necessarily described. conditioned smoking is followed who smoked.
s of with a critical This is tie this associated prospective Smoking
smokers (27.4%) flaw, but followed behavior to with the ly for 6 also appears
(26%), ex- and underreport by studies rituals of development years. After to be
smokers without ing of suggesting daily life, of diabetes. controlling associated
(25.9%), (25.9%) smoking the role of contributing In the for known with larger
and those diabetes must be smoking to the Nurses’ risk factors, upper body
fat resistance e Although interfere opment of Tibbs
distribution , raised multicenter this effect nce with complicati
—a marker plasma study with was small, insulin ons of
of insulin glucose 697 type 1 the results activity. diabetes.
concen- diabetic suggested Research Core
trations, subjects, that further informatio
and overt concluded smoking delineati n is
diabetes smoking blunts the ng the summarize
(21). was one of rise of metaboli d on the
The the HbA1c, c effects relation-
relationsh strongest which of ship
ip of predictors usually nicotine between
smoking of poor occurs in on complicati
to meta- metabolic nonsmoker diabetes on
bolic control in s. is developme
control addition to Smoking needed. nt and
has also age of was the Longitudi diabetes.
been onset, strongest nal Length
postulated blood independe studies considerati
(22). glucose nt factor with ons dic-
Chiodera monitoring, related to large tated
et al. (23) socioecono change in sample limiting
reported mic status, glycated sizes the
that and hemoglobi would number
hormonal knowledge. n. allow for and details
responses However, In further asso-
, Meigs et al. summary, determin ciated with
specifical (25) nicotine is a- tion of the noted
ly growth measured an the role studies.
hormone, the glycated addictive of The reader
arginine hemoglobi drug with smoking is referred
vasopressi n levels in use and to specific
n, and people supported cessation articles for
cortisol without by on additional
responses, diabetes individual, diabetes details
were from the personal, develop related to
significant original and ment and adjustment
ly higher cohort of social- manage s for
in type 1 the environme ment. poten-
diabetic Framingha ntal tially
versus m Heart circum- COMP confoundi
nondiabet Study and stances. LICATI ng
ic found that There is ONS sociodemo
smokers age and evidence OF graphic or
and BMI were of genetic DIABE psychosoci
conclude associated susceptibili TES al
d that with ty to AND variables.
smoking increases in smoking SMOK
might HbA1c over that may ING —
interfere the course affect ini- This
with the of tiation and section
tim- ing 4–6 years, cessation pro-
and while outcomes. vides an
optimizati smoking Initial overview
on of was studies of the
insulin associated suggest a relations
therapy. with a role for hip
Bott et al. decrease, nicotine between
(24), as even after in diabetes,
part of a controlling diabetes smoking,
large for age developme and the
prospectiv and BMI. nt and devel-
diabetes
Macro smoking impor tant (40) increased Micr When Tibbs reported by 42.8%, P ,
vascul was in th e conducted by 25%, ovasc compared Couper et 0.02). After
ar shown to Paris a which ular with al. (48), adjusting for
compli be a Prospectiv prospectiv was comp nonsmokers Corradi et effects of
cations significan e Study. e cohort never- licati and after al. (49), other
and t risk In study of theless ons controlling and Klein covariates,
mortal factor for addition, 372 men markedly of for glycated et al. (50). patients
ity death by the and 430 lower smoki hemoglo- Smokin smoking
Cigarette coronary combinatio women than ng bin, smokers g is also a $30 pack-
smoking is heart n of smok- with among and were at 2.2 documente years had
ass ociated disease ing and diabetes those diabe times greater d risk fac- more
with mor- in type 2 diabetes who were who had tes risk (95% CI tor for both neuropathy
bidity and diabetes appear to followed quit #9 Smoking is 1.2–3.8) for the than patients
premature in the heighten over 16 years ago. related to albuminuria. developme smoking less
death Multiple the years. This the Sawicki et nt and than this
among Risk developme Cigarette large- premature al. (46) also progres- amount with
non- Factor nt of smoking scale devel- found that sion of an adjusted
diabeti c Interventi macrovasc was found study opment of progression various odds ratio of
i ndi viduals on Trial ular to be an suggests multiple of types of 3.32 (95%
p rimari ly (MRFIT), complica- independe the complicatio nephropathy neuropathy CI 1.15–
due to the tions nt importan ns of dia- was (51,52). 9.58) (53).
cardio vasc Fi nnish (35,36). predictor ce of betes significantly Mitchell et A more
ular P rospecti Meigs et for stroke quitting (42,43). less common al. (53) recent
i llnes s (2). ve Study, al. (37) in these as early Nephropath (P , conducted prospective
People and the reported subjects. as y has been 0.001) a study by
with either P aris on 1,539 Finally, possible reported as among retrospec- Sands et al.
type 1 or Prosp ecti patients Chaturvedi in the common in nonsmokers tive case- (54) using a
type 2 ve Study with type 2 et al. (41), course of type 1 (11%) than control population-
diabetes (34). diabetes as part of diabetes diabetic smokers study of based cohort
exhibit Specificall and found, an (41). In patients (53%) or type 1 (n = followed
excess y, systolic in addition internation conclusi who smoke, those who 163) and 231 subjects
morbidity blood to other al cohort on, and had quit type 2 (n = who were
and pressure, factors study of smoking smoking smoking 166) free of distal
mortality to tal such as sex 4,427 increases increases (33%). Ikeda diabetic symmetric
due to ch olester and people the risk the risk for et al. (47) patients, neuropathy
circulatory ol , and hypertensi with of death microalbum conducted a using at baseline
and s moki ng on, former diabetes, and the inuria in cross- symptoms for an
cardiovasc were cigarette reported burden type 2 dia- sectional and average of
ular signif ica smokers mortality of betes study of 148 physical 4.7 years.
disease nt ly were 1.54 risks were morbidit (43,44). men with examinatio The adjusted
when associate times associated y from Several type 2 n to incidence
compared d wi th (95% CI with macrovas studies have diabetes, diagnose rate of
with i ncreased 1.49–1.58) history cular docu- concluding peripheral smokers was
people mortality more and complica mented the that the inci- neuropathy. 2.2 times
without in likely to duration tions in relationship dence of Type 1 dia- higher (95%
diabetes diabetic be of indi- of smoking micro- and betic CI 0.99–4.7)
(26–28). patients diagnosed smoking viduals to the macroalbum patients than for
Th e as with and with developmen inuria were who were nonsmokers.
evidence reported coronary quitting. diabetes. t of significantly current or Among those
from by artery When nephropathy higher in ex- diagnosed
studies of MRFIT disease. compared in type 1 current smokers with
individuals and the Similar with and 2 smokers were definitive
with Prospecti findings nonsmoke diabetes. (53%) significantl distal sym-
diabetes ve are rs, Chase et al. compared y more metric
sh ows the Finnish reported mortality (45) with ex- likely to neuropathy,
strong Study; by Dean et risk conducted a smokers have cigarette
influence smoking, al. (38) among lon- (33%) and neuropathy smoking
of smoking blood and individuals gitudinal nonsmokers than was
on pressure, Hanefield who had study of (20%). individuals associated
mortality and obe- et al. (39). quit $10 359 type 1 Similar who never with a 12-
(29–33). si ty were Tuomileht years ago diabetic findings smoked fold increase
Cigarette mo st o et al. was patients. have been (64.8 vs. (95% CI
2
diabetes with suggest s between of type stroke, and
. other that smoking, and lung
0 microvasc smoking retinopathy duration disease
– ular reduces , and of (57).
7 complicat retinal nephropat diabetes Smok- ing
1 ions of blood hy. and rates in
. diabetes. flow and In cessation the U.S.
5 As potentiates summary, on population
) reported the several complica have
by Klein hypoxic longitudin tions declined
( et al. environme al and develop from 40%
5 (50), nt of the cross- ment. In in 1965 to
4 most diabetic sectional particula the current
) epidemiol retina (55). studies r, level of
. ogical Reichard show research 26%. This
The research (56) found consistentl is needed reduction
relationship has not significant y that to further is
of cigarette found a rela- smoking establish attributabl
smoking to positive tionships has an the effect e to 30
retinopathy relationsh between impact on of years of
is less well ip smoking the devel- potentiall smoking
defined than between and the opment y cessation
that smoking pro- and confound research as
and gression of progressio ing well as
retinopath microvascu n of psycho- various
y, lar microalbu logical or public
although complicati min- uria social health and
there ons in and the factors on policy
have been 96 type 1 impairmen the actions
studies diabetic t of renal relations (3,3a,58).
that have patients, function in hip Most
suggested followed both type between cessation
such a over 1 and type diabetes, research
relationsh 5 years 2 diabetes. smoking, has not
ip. In the after being Other and focused
Wisconsi randomized studies are develop- on
n to conven- also ment of smoking
Epidemio tional or strongly complica in diabetic
- logical intensive suggestive tions. patients,
Study of therapy. of an but rather
Diabetic Progression association SMOKI on
Retinopat of with the NG smoking
hy, ciga- retinopathy developme CESSA in the gen-
rette was nt of neu- TION eral
smoking independen ropathy in INTER population
was not tly related both type VENTI or in other
found to to level of 1 and type ONS — disease
be related HbA1c and 2 diabetes There is groups
to the smoking and, less over-
incidence habits. As consistentl whelmin
or part of a y, g
prevalenc prospective retinopath evidence
e of multicenter y develop- that
proliferati study, ment. smoking
ve Muhlhause Additional cessation
retinopath r et al. (43) work is decreases
y, but also needed to the risk
was concluded clarify of
related to that there these cardiovas
mortality. were relationshi cular
Other significant ps, and disease,
data relationship the effect cancer,
Tibbs
diabetes
such as effectivene and 4) evidence of health and advice to Table 1,
cardiovasc ss stud- c were are care provider telephone quit content
ular or ies in published summariz significantly hotlines, smoking, found to be
h
lung which all between ed below. increase may increase taking ,3 most
a
disease patients in 1974 and Some of smoking cessation min to effective in
r 1995. As the 55 key rates relative conduct. increasing
patients a practice cessation
a presented studies to no Brief cessation
(many of are rates relative
c in these evaluating intervention. intervention rates
whom included to no inter-
have (using t clinical these vention. However, s involve included
diabetes). intent-to- e practice charac- There does self-help counseling aversive
The treat r guidelines teristics not appear formats were for at least smoking
following analyses), i (59), there are also to be any not as 3–10 min; techniques
section first not only s are core highlighte advantage to effective as however, (e.g., rapid
reviews the highly t treatment d in counseling interventions some smoking),
general motivated i characteris different (or with intensive intratreatme
evidence patients c - tics, or sections. intervention) providers intervention nt social
identifying (who are s dimensions It is delivered by (59). As s may last support
treatment typically The , that important a single type noted in $1 h and (direct
charac- recruited importance influence to note of Table 1, the involve contact
teristics for of success- that both professional. cessation multiple with health
associated clinical identifying ful the Rather, the rates for contacts. care
with trials successful smoking number data confirm individual As noted provider),
successful research). smoking cessation. of the and group in Table 1, and general
cessation, Second, cessation The randomiz importance counseling even problem-
with many interventio evidence ed trials of the were minimal solving
emphasis studies ns resulted from health and the smoking significantly contact (e.g., coping
on report on in the care methodol cessation higher than increases skills
interventio the convening settings and ogical message those for no cessation. training,
n in success of an expert interventio quality of being con- intervention Conclusion stress
medical rates panel by ns in the these sistently and or self-help. s from manage-
office engendere the Agency general studies repeatedly Thus, smok- these data ment,
settings. d by a for Health population, are delivered by ing cessation support a relapse
We then single Care which exemplary multi - ple interventions strong dose- prevention).
evaluate episode of Policy and includes and health care should response Aversive
the limited smoking Research but is not permitted providers include relationship techniques
evidence cessation (AHCPR) limited to the (57,60–64). either between have
on advice or to develop diabetic developm Format of individual or intensity of generally
smoking counselin smoking patients, ent of contact. group person-to- been
cessation g, despite cessation was evalu- evidence- There are counseling. person replaced by
interven- evidence clinical ated and based generally Intensity contact and nicotine
tions in that practice reported in guidelines three formats levels of cessation replacement
diabetes consis- guidelines the AHCPR derived for smoking intervention (59,66). therapies
care and tent and (59). These Smoking from cessation . This is Types of (59).
apply the repeated influential Cessation comprehe inter- defined as counseling Duration
general messages guidelines Guidelines nsive ventions: the amount . The and
literature reinforced were based , with key meta- self-help, of time a content of number of
to this over time on a review interven- analyses individual, health care smoking treatment
special yield the of studies tion (59). or group provider cessation sessions.
population. most that 1) were findings Type of counseling. spends with refers to Duration of
The successful randomized summarize health Curry (65) a smoker the type of an
cessation outcomes. controlled d in Table care concluded during a informa- intervention
rates trials of 1. Treat- provider. that self- clinical tion is defined
reported T intervention ment As noted help contact (e.g., conveyed by length of
here r s, 2) pro- characteris in materials, session in clinical treatment in
should be e vided a tics Table 1, defined as length). contacts weeks,
interpreted a minimum associated interventi videotapes Min- imal and the while
in light of t of 5 with ons or interventions specific number of
two points. m months of smoking delivered audiotapes, are defined behavior- treatment
First, the follow- up, cessation by any manuals or as consisting change sessions is
e
data 3) were and type booklets, of strong procedures defined by
n
generally peer- supported community and used. As number of
t by this personalized noted in contacts. In
come from reviewed, programs,
general, these cessation 1-year work of the use of Tibbs
findings intervention follow-up, Silagy et antidepress
revealed increases is more al. (70). ants
that the the longer effica- Informati (74,75),
longer the the dura- cious than on clonidine,
duration tion of control regarding and
of treatment interventio the use of anxiolytics
treatment, over a ns the newer is not
the higher period of regardless nasal conclusive
the ces- multiple of the nicotine (59).
sation sessions or intensity, sprays is However,
rates. person-to- and is more Hurt et al.
Specificall person more limited. (76) found
y, contacts efficacious Sutherlan in a
counselin (59). when used d et al. double-
g beyond Pharmacot in 4-mg (71) blind
8 weeks herapy and versus 2- conducte placebo-
achieved cessation. mg d a study controlled
cessation Various dosages with 227 trial of
rates of forms of (59). cigarette sustained
23.8% pharmacoth Transd smokers, release
(95% CI erapy, via ermal comparin form,
20.6– gum, nicotine, g nasal bupropion
27.1). patch, and or the nicotine yielded 1-
When sprays, nicotine spray to year
compared have been patch, is placebo cessation
with examined also spray. rates of
single for effec- effective Biochemic 12.4%
sessions, tiveness in and may al (placebo),
four to promoting be more verificatio 19.6%
seven smoking acceptable n of status (100 mg
sessions cessation. because of showed group),
were the Several greater people 22.9% (150
most meta- ease of using mg group),
effective analyses use. Fiore nasal and 23.1%
in concerning et al. (69) sprays (300 mg
achieving the use of conducted were group). In
cessation nicotine a meta- significan addition,
with an gum and analysis tly more bupropion
estimated patches of studies likely to subjects
cessation have been and achieve had
rate of published concluded 12-month reduced
22.6% (67–70), that the abstinenc weight
(95% CI concluding patch e (26%) gain,
19.9– that doubles compared making
25.3), nicotine the with a
followed gum likelihood placebo
by two to significantly of group
three improves abstinence (10%)—
sessions abstinence. at findings
with an The 6 months, supported
estimated AHCPR especially by
cessation report when used Tonnesen
rate of concluded in con- et al. (72)
18.8% that junction and
(95% CI nicotine with more Hjalmars
15.8– gum intensive on et al.
21.9). In improves behavioral (73).
sum- smoking formats— Finall
mary, the cessation findings y, the
efficacy of rates by supported data
a smoking 40–60% at by the regarding
diabetes
Table 1—Meta-analytic results examining smoking outcomes: estimated odds ratios and cessation rates by treatment characteristics
Estimated Estimated
Characteristics Number of arms odds ratio cessation rate
(95% CI) (95% CI)
Type of health care provider (n = 41
studies) No provider (reference group) 38 1.0 8.2
Multiple providers 14 3.8 (2.6–5.6) 25.5 (18.1–32.7)
Nonmedical health care provider (psychologist, social worker, 23 1.8 (1.5–2.2) 14.1 (12.0–16.3)
counselor)
Physician provider 36 1.5 (1.2–1.9) 12.0 (9.6–14.3)
Nonphysician medical health care provider (dentist, nurse, 20 1.4 (1.1–1.8) 11.5 (9.0–14.0)
health counselor)
Format of contact (n = 25 studies)
No intervention (reference 23 1.0 7.6
group)
Self-help 8 1.2 (1.0–1.6)* 9.3 (7.3–11.4)
Individual counseling 26 2.2 (1.9–2.4) 15.1 (13.6–16.5)
Group counseling 15 2.2 (1.6–3.0) 15.3 (11.4–19.2)
Intensity levels of person-to-person contact (n = 56
studies) No contact (reference group) 49 1.0 8.8
Minimal contact (#3 min) 14 1.2 (1.0–1.5)† 10.7 (8.9–12.5)
Brief counseling (.3 to #10 min) 26 1.4 (1.2–1.7) 12.1 (10.0–14.3)
Counseling (.10 min) 60 2.4 (2.1–2.7) 18.7 (16.8–20.6)
Types of content (n = 39
studies) No contact 25 1.0 8.8
(reference group)
Aversive smoking‡ 9 2.1 (1.0–4.2)§ 17.5 (7.6–27.2)
Intratreatment social supporti 21 1.8 (1.4–2.5) 15.2 (11.3–19.1)
General problem solving¶ 57 1.6 (1.2–2.2) 13.7 (10.3–17.1)
Quit day (specific quit date) 30 1.3 (0.9–2.0) 11.5 (7.4–15.7)
Extratreatment social support# 16 1.3 (0.8–2.0) 11.2 (7.0–15.5)
Motivation** 40 1.1 (0.9–1.5) 9.8 (7.5–12.2)
Weight, diet, or nutrition management 17 1.1 (0.8–1.6) 9.8 (6.6–13.0)
Exercise or fitness information or program 8 1.1 (0.6–1.0) 9.6 (4.8–14.3)
Contingency contract†† 13 1.0 (0.7–1.6) 9.1 (5.6–12.7)
Relaxation or breathing techniques 15 0.8 (0.5–1.3) 7.5 (4.3–10.7)
Cigarette fading‡‡ 18 0.7 (0.4–1.1) 6.4 (3.6–13.3)
Duration of treatment sessions (n = 55 studies)
,2 Weeks (reference group) 101 1.0 10.4
2 Weeks to ,4 weeks 14 1.6 (1.3–2.0) 15.6 (12.9–18.3)
4 Weeks to 8 weeks 12 1.6 (1.2–2.1) 16.1 (12.4–19.7)
.8 Weeks 15 2.7 (2.2–3.2) 23.8 (20.6–27.1)
Number of treatment sessions (n = 55 studies)
#1 Session (reference group) 96 1.0 10.4
2–3 Sessions 15 2.0 (1.6–2.4) 18.8 (15.8–21.9)
4–7 Sessions 25 2.5 (2.2–2.9) 22.6 (19.9–25.3)
.7 Sessions 12 1.7 (1.2–2.5) 16.7 (11.4–22.0)
Number of arms refers to the number of treatment groups included in the category. *Actual 95% lower confidence estimate equals 0.97; †actual 95% lower
confidence estimate equals 1.03; ‡techniques that involve smoking in an unpleasant or concentrated manner; §actual 95% lower confidence estimate equals 1.04;
iproviding support, help, or encouragement as part of the treatment; ¶training to identify and cope with events or problems that increase the likelihood of
smoking, including coping skill training, relapse prevention, and stress management; #techniques to help smokers increase social support outside of treatment;
**interventions designed to bolster patients’ resolve to quit; ††providing rewards for cigarette abstinence and incurring costs or unpleasant consequences for
smoking; ‡‡reducing the number of cigarettes smoked. Modified from Wetter et al. (144).
this a who are review Tibbs
particularly pregnant, establishin
promising is also g AHCPR
tool to recommen Smoking
assist ded if the Ces- sation
smokers in benefits of Guidelines
cessation quitting is that
(76a,76b). outweigh repeated
Based on the lim- interven-
the low ited risks tions,
risk for (77,78). provided
side effects, by
the use of Smoking multiple
phar- cessation health
macothera delivery care
py to systems professional
promote One of the s and
smoking most reinforced
cessation important over time,
is and are much
recommen consistent more
ded when findings effective
used in from the than single
conjunctio comprehen session rec-
n with sive ommendati
behavioral literature ons or
counseling brief
. Use in counseling
special (59). Such
population an
s, such as approach
those denotes the
importance
diabetes
of an absti- cessation services to n burden intervention limited to cigarettes
Tibbs studies, such
integrated nence advice to all patients on s in both people with decreased as those pre-
system of (81). diabetic (85), espe- clinical physician diabetes are in the viously cited,
care in Reinforce patients, cially staff office set- identified. behavior to include
systemat- ment of however because (88). For tings Ardron et therapy issues of
ically the 41% of performan example, (89,90) and al. (94) group particular
reducing decision diabetic ce-based there is mail-based conducted a when pertinence to
smoking to quit patients did quality of substanti intervention randomized compared diabetes care
rates. All and not receive care al s (91,92). study with with the (96–98). The
patients strategies any advice indicators evidence The use of 60 diabetic control limited
should be encouragi to quit (e.g., that multimedia smokers, group. number of
screened ng smoking. Health tailoring kiosks, contrasting However at studies
for use of relapse Barriers Plan or per- Internet brief advice the 6- focusing on
tobacco preventio commonly Employer sonalizin World Wide with month the need for
and have n promote reported Data g Web–based intensive follow-up, smoking
their status long-term by Informatio interventi applica- advice to overall quit cessation
documente abstinenc providers n Set on tions, and stop rates as interventions
d on a e. in [HEDIS], content small smoking. confirmed with diabetic
regular Only delivering National in a handheld The study by cotinine patients are
basis. about half cessation Committe mean- computers included a testing (a primarily
Screening of advice are e on ingful have shown follow-up metabolite descrip- tive
systems in smokers lack of time Quality way promise home visit. of in design
clinical seeing a and Assur- results in (93) but Half of the nicotine) (99) and
settings pri- mary reimburse ance [86], changes have not subjects was 10% report
increase the care ment for AHCPR of been used cited an and did not results on
probability physician smoking Smoking various to prevent attempt to differ small
of in the cessation Cessation lifestyle smoking quit significantl numbers of
consistent past year services, Guidelines behaviors initiation or resulting y by group. subjects
assess- reported actual or [59], and , to enhance from the There is (100).
ment and being perceived American enhances quitting intensive also little In
documenta asked lack of Diabetes outcomes success counseling. evidence conclusion,
tion of about knowledge Associatio relative among There was, regarding the minimal
tobacco their and skill in n Provider to usual smokers however, the effec- informa-
use smoking cessation Recognitio care with only one tiveness of tion
(79,80). (79), with counseling, n Program advice to diabetes verified smoking available
Follow-up a smaller and low measures quit, and specifically. quitter at the cessation specifically
assessment number expectation [87]) are has been end of 6 treatment on diabetic
of smoking being s regarding based on shown to Cessation months. characterist smokers
status and advised to the population be more systems Sawicki et al. ics or the suggests that
abstinence quit (82). efficacy of s rather effective for (95) impact of they may
should Malarcher such than than smokers conducted a adjunctive fare less
also be et al. (83) counseling individual stan- with prospective pharmacoth well than
con- examined (58,84). care dard diabetes random- erapy nondiabetic
ducted on a data from Additional guidelines. nonperso There is ized specific to smokers and
routine the provider More nalized minimal controlled smokers that inten-
basis at National training is recently, cognitive literature intervention with sive
regular Health needed in technologi - evaluating study with diabetes. strategies,
intervals Interview the AHCPR cal behavior treatment 89 diabetic The including
(59). Surveys Smoking advances al characteristi smokers that majority of nicotine
Additional from Cessation via cs or contrasted articles replace-
assessment 1974, Guidelines computer- delivery intensive about dia- ment
s within the 1985, emphasizin based systems behavior betes and therapy,
first and 1990 g the methodolo specific to therapy over smoking should be
2 weeks of and noted public gies have diabetes and 10 weeks have considered
quitting positive health provided smoking. To with focused on to optimize
have trends significanc innovative date, only 15 min of reviews of successful
proven to toward e of delivery two unstructured the current cessation. In
be effec- more achieving methods intervention outpatient literature addition,
tive in physi- small that have studies that physician and have
aiding cians changes by reduced address advice. extrapo-
patients to offering delivering the smoking Mean lated from
maintain smoking preventive interventio cessation number of other
studies
diabetesare smokers physician Even more and high-
needed to with counseling encouragin risk
identify diabetes to be as or g is the groups to
and under- and is more cost- fact that it conclude
stand strongly effective often costs that
factors recomme than other less than smoking
associated nded. routine $2,000 per cessation
with health care quality should be
diabetes C practices, adjusted extremel
man- os such as life year y cost-
agement t- treating saved. effective
(e.g., stress ef hypertensi Providing for
posed by fe on, screening diabetic
following cti screening and patients.
the dietary ve for counseling It is
regimen, ne cholesterol for high- more
medication ss , and other risk difficult
manage- of medical groups to
ment, etc.) ce practices. (e.g., those estimate
and how ss Eddy (102) with the cost-
these at identified coronary effectiven
factors io smoking heart dis- ess of
may n cessation ease, who public
influence co as the have health
the ability un “gold major risk measures
to achieve se standard” factors, or such as
successful li against who are no
cessation. ng which hospitalize smoking
In Smoking other d) are even policies
addition, cessation preventive more cost- and
these data is one of behaviors effective tax/price
strongly the few should be and may increases
suggest inter- evaluated. even be , but
that ventions Since these cost these
systems of that can early saving: a actions
care, safely articles, very rare may be
promoting and cost- virtually all finding in even
routine effec- subsequent the more
smoking tively be studies economic cost-
identificati recomme (103–107) literature effective
on and nded for and reviews (107–109). (108)
coun- all (103,108) Although and
seling need patients. have we are not should
to be a Cumming confirmed aware of be
priority of s et al. and even current
routine (101) strengthene data on
diabetes published d these the cost-
manageme an influ- findings. effectivene
nt. Further ential Most ss of
research early recent smoking
on delivery analysis studies cessation
systems via on the have esti- solely
system- cost- mated that among
wide clinic effective- smoking diabetic
or ness of cessation patients, it
technology counselin counseling is a logical
-based g costs extension
interventio smokers between from exist-
ns, has not to quit $1,000 and ing data
been that $3,000 per on medical
conducted demonstr year of life patients in
specific to ated saved. general
Tibbs
diabetes
included as smoking receive the addressed. on general, insulin weight gain o
part of a ranked priority it Survey weight gain treatment would o
societal 7th and deserves Weight (NHANE after and adversely d
tobacco was from either gain S) I cessation cessation affect The
control perceived patients Obesity is Study. may neg- with weight diabetes relationship
program. as less with a risk They atively affect gain. Haire- manageme between
One of the important diabetes or factor for found the desire Joshu et al. nt. smoking and
paradoxes than “not health care type 2 weight to quit (59), (118) However, depression
of the cost- eating providers. diabetes, gain with assessed much or dysphoric
effectivenes many while attributa attempts to beliefs of 64 more evi- mood has
s literature sweets” SPECIAL weight ble to prevent smokers dence is been
on smoking (2nd) or AND manageme smoking weight gain with type 1 needed to reviewed in
cessation is “drinking EMERGI nt is a cessation during ces- diabetes support numerous
that little or NG critical averaged sation about these population
although no ISSUES focus of 6–10 lb, potentially smoking and interpre- surveys and
intensive alcohol” — Several the with enhancing diabetes as tations. clinical
counseling (5th) factors of diabetes women the risk of part of a Research is studies
has been (110). particular care gaining relapse cross- also (119). Major
shown to In relevance regimen slightly (116). sectional needed on depres- sive
be one of summary, to people (111–113). more However, a descrip- tive ways to disorder is
the most studies of with Cig- weight review by study. help more than
cost- implemen diabetes arettes than Perkins Results providers twice as
effective ta- tion may be affect men. (117) cites suggesting more common
interventio of associated weight Major little direct concerns effectively among
ns ever diabetes with with weight evidence to about weight com- smokers as
studied guideline difficulty in smokers gain suggest that gain after municate among
(103,105,10 s and best achieving weighing (.25 lb) weight gain quitting were the risks of nonsmokers
7), only prac- long- term less than occurred after prevalent smoking in (6.6 vs.
5% of tices abstinence nonsmoker in ,10% cessation among light of 2.9%), and
patients are document from s. The of men interferes women, informatio smokers
will- ing to that smoking. mechanism and , with obese n related to with a
participate assessmen These fac- s by which 13% of motivation smokers, weight lifetime
in such t of tors smoking women. of smokers and those in gain after history of
multisessio smoking include decreases In to maintain poor cessation clinical
n coun- status and weight body abstinence. metabolic and the depression
seling. So, smoking gain weight Instead, he control importance are half as
even if cessation concerns include suggests (36%). of not likely to
offered, counselin and insulin developing Cigarettes smoking succeed in
patients g occurs depression. homeostas treatments were cited for diabetic smoking
often do less often Issues is, to enable by smokers patients. cessation as
not than associated lipoprotei ex-smokers as an smokers
perceive many with n lipase to accept appetite D without
cessation other smoking activity, what may suppressant e such a
as a key aspects of and and be (46%), and p history (14
treatment care. special preferences unavoidable many r vs. 28%).
priority. Despite population for food weight gain. smokers e These
For the s with con- Few were s findings
example, in demonstr diabetes, sumption studies have reluctant to s have been
a study of ated including (59,114). assessed the quit because i replicated in
patients’ efficacy adolescent Williamson role of of fear of o numerous
“personal and cost- and et al. (115) smoking weight gain studies
n
model” of effectiven hospitalize addressed and weight (49%). (120,121).
the ess and d patients, this in Diabetic Fant et al.
importance the will be relationshi individuals smokers a (122)
of various extensive summarize p using with appear to n reviewed
aspects of data d. Finally, data from diabetes, view d evidence
diabetes summariz factors the 1982– but it is of smoking as a and
self- ed above, associated 1984 concern strategy for l explanations
managemen smoking with National because of weight o for nicotine
t, it was cessa- refractory Health and the control and w addiction
found that tion does smokers Nutri- tion association expressed and
not not will be Examinati of both concern that concluded
m
that women Peopl n and smokers, male raising the may notTibbs
be
have a e with smoking. 70% were adolesce possibility a deterrent
higher diabetes Results regular nts of to
prevalence are at indicated smokers appear underre- initiation
of greater that the before age equally porting of of smoking
depression risk of number of 18. People likely to status. in
and thus depressio cigarettes who smoke Masson et
may be n smoked smoke at (2), with al. (131)
more prone compared was a an early the verified
to smoking with the significant age are highest smoking
relapse. This general predictor more rate status via
is supported adult of the level likely to (28%) urinary
by other populatio of depres- become found cotinine
reviews that n, with a sion nicotine among and found
concluded prevalenc among addicted high 31% of
that negative e esti- people and school diabetic
affect is mated at with develop seniors adolescents
related to 14% in diabetes serious (128). admitted
smoking the (126). comorbid Key smoking,
treatment diabetic Further health predictor while 48%
failure populatio studies conditions s of were
(120,121,12 n (range examining at younger smoking verified as
3). 8.5– the ages than initiation smokers.
27.3%) strength of their include In
versus 3– the nonsmokin age, addition,
4% in the relationship g living the
general of counterpar with a majority of
populatio depression ts. The tobacco smokers
n and younger user, and initiated
(124,125) smoking in one begins alcohol the habit
. diabetes, to smoke, use after their
However, and the the more (129). diagnosis
there is possible likely one Few of
minimal impact of is to be a studies diabetes, a
data depression current have finding
examinin on smoker as addressed also
g smoking an adult the reported
depressio initiation or (2). preva- by Shaw et
n and cessation, Overall, lence of al. (132).
smoking are needed. about one- smoking In
specific third of among addition,
to people A high adolesce Frey et al.
with d school– nts with (133) also
diabetes. o aged diabetes. found that
One l adolescent Often certain
cross- e s in the studies types of
sectional s U.S. rely on risky
survey c smoke or cross- behaviors,
examining e use sec- including
these two n smokeless tional smoking,
factors (chew or self- were
t
was spit) reported prevalent
conducted tobacco. informati among
with 183 s About on adolescent
diabetic m 16% of without s with
smokers o adolescent biochemi diabetes.
who k s in the cal In
complete e U.S. verificati summary,
d r smoke on of it appears
measures s (127). smoking that a
of Of current Currently, status diagnosis
depressio adult female and (130), of diabetes
diabetes
adolescents r cardiac counseling (119) cessation (119) whose Tibbs
smokers effective
. s disease , with the suggests interventio nicotine ran- domly ways
Adolescent In (135,136). remainder that ns has dependence assigned to (including
s with general, Stevens et citing lack those resulted in is asso- more harm
diabetes studies al. (136) of interest who a present ciated with traditional reduction
appear to suggest conducted or ill- ness continue day pool repeated cognitive- and other
initiate that a as reasons to smoke of relapse behavioral strategies) to
smoking at smoking randomize for not in the refractory (139). For interventio reach and
a rate cessation d trial of participati present smokers the sizeable ns. While work with
equiva- may be 1,110 ng. This day U.S. percentage not the first the high
lent to more hospitalize study are of smokers treatment percentage
nondiabetic likely d smokers, suggests highly currently not of choice, of patients
adolescents during or compar- that nicotine ready to such who may not
. subseque ing a usual diabetic dependen undertake therapies presently be
Prevalence nt to a care smokers, t, another might be ready to quit
of smoking patient’s treatment at the time overrepre attempt to considered and also
may be hospitaliz to a of - sent quit, it is for people who
higher than ation, bedside hospitaliza people of important to recalcitrant have
the data since counseling tion, may lower develop smokers comorbid
suggest there interventio be less socioecon alternative unwilling medical or
because of may be n tailored motivated omic strategies to repeat or psychologica
underreport an to the to status, designed to try other l conditions
ing by increased patient’s participate often decrease more and/or a
ado- sense of readiness in have smoking. established history of
lescents. vulnerabi to quit. smoking other For example, cessation unsuccessful
Systematic lity Overall, cessation drug there is methods. attempts to
methods of associate the counseling dependen empirical It is quit.
preventing d with relatively than some cies, and evidence to unclear
smoking the low other have suggest whether CONCLUS
and health intensity medical behavior reduced smokers IONS —
promoting risks and bedside population al or smoking, with dia- The
adolescent conseque interven- s. Future affective also referred betes are following
cessation nces of tion research is deficits to as more likely state- ments
through smoking increased needed to amenable controlled to present are drawn
diabetes (134). quitting replicate to smoking as recalci- from the
clinics or Studies odds by this study nicotine (140–142) trant evidence
other of 50% in the and to manage or harm smokers. presented
venues patients treatment determine ment. reduction, as However, above and
need to be with group. We reasons The a therapeutic given the apply to
developed serious were able for its nicotine option for data to individuals
and smoking- to find findings. dependen those suggest with either
evaluated. related only one ce smokers lower type 1 or
disease survey by R scores of unable or cessation type 2
H reported Haire- e America unwilling to rates and diabetes.
o esti- Joshu et al. f n quit (143). the addi-
s mates of (137) r smokers Glasgow et tional E
p cessation reporting a substanti al. (142) demands of p
i rates on c ally and Hughes diabetes i
t ranging cessation t exceed (143) found manageme d
from 20 counseling o those of smokers nt, smokers e
a
to 51% among r smokers randomized may be m
l
among hospitalize in other to such an more i
i y
patients d diabetic countries intervention dependent o
z (138).
with patients. In were no less and ben- l
e s Thus, it
pulmonar a study of likely, and efit from o
d m is
y disease 59 possi- bly additional g
and from smokers, o probable even more strategies y
s 22 to only 5 k that the likely, to quit to promote
m 62% agreed to e success smoking in cessation. a
o among participate r of many the long- Additional n
k those in s smok- term than research is d
e with cessation Pomerleau ing comparable needed on
h diabetes increase Smoking provider n should care, a AHCP
e insulin substanti s, using counse guide strategy R
a resist an ally individu ling in the that guidelin
l ce and heighten al or non- decision encoura es
t interfere s the risk group diabeti regardin ges should
h with for counseli c g use of provider assist
insulin neuropat ng, indivi nico- s to in
c action. hy and over duals. tine deliver over-
o Smoking nephrop time, Pharm replace smok- coming
n may athy. and acothe ment ing perceiv
s also be Data includin rapy therapy cessation ed
e associat suggest g appear and advice in barriers
q ed with that problem s to other a to
u develop- smoking -solving limit pharmac systemat cessati
e ment of is related or skills withdr ological ic way. on
n type 2 to the training awal aides Docume counsel
c diabetes, develop com- sympt for ntation ing and
e although ment of ponents oms cessatio of help
s the retinopat with and n. counseli both
evidence hy, social increas • ng and patient
o is although support. e Smokin follow- s and
f prelimin the Every abstine g up provid
ary. evidence effort nce. cessatio further ers
s • Smoking is less should To n assures give
m significa conclusi be made date, delivery successf smokin
o ntly ve. to there systems ul cessa- g
k enhances assure is no should tion and cessati
i the risk Smoking that eviden be a is on the
n for cessation diabetic ce of routine critical empha
g cardiova • Smoking smokers the compon to long- sis it
• The scular is a receive impact ent of term deserve
prevalence disease, complex cessatio of dia- success. s.
of contribu change- n advice pharm betes • •
smoking ting to resistant reflect- a- care, in Compute Smoki
among prematur behavior. ing cother accorda r-based ng
indi- e Several these apy nce technolo cessati
viduals morbidit treatmen treatme specifi with gies and on is
with y and t nt c to recom- other cost-
diabetes mortality character characte diabeti mendati methods effectiv
may be . istics ristics to c ons of of e.
equivalent have opti- smoke the personal Stoppi
to those been mize rs. The AHCPR izing ng
without identifie cessatio data Smokin informat smokin
diabetes. d by n rates. sugges g ion and g is
Only AHCPR • ting Cessatio counseli likely
about half meta- Nicotin the n ng one of
of people analyses e extensi Guideli strategie the
with and replace ve nes (59) s are
diabetes guidelin ment bene- for all promisin
are es as therapy fits of patients g
advised to critical enhance quittin . methods
quit to s g Smokin and
smoking achieve cessatio versus g status should
by their cessation n rates the should be
health . These when height be further
care include used as ened assessed explored
providers. cessation an risks for all .
• Smoking counseli adjunct of diabetic • Training
influences ng by to contin individu of health
several multiple smokin uing als as a care
factors health g to part of provider
that may care cessatio smoke routine s in the
Tibbs
diabetes
most effective medical actions that diabetic smokers is needed. 1992
can be taken with diabetic patients. Systematic introduction of 4. Centers for Disease Control:
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delivery of smoking cessation within-subject designs are rec- United States
services should be enacted. ommended given the small sample 1994. MMWR 45: 588–590, 1996
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Special issues and current concerns Hartwell T, Orlandi M: Smoking
• Additional research designed to cessation factors among African
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Smoking and Diabetes

96 DIABETES CARE, VOLUME 22, NUMBER 11, N OVEMBER 1999

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