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Smoking and Diabetes Care: Enhancing Patient Capacity for Cessation

Debra Haire-Joshu, PhD, RN

More than 400,000 people in this country die each year because they smoke cigarettes.^1-3 Smoking is the greatest source of preventable death in our society, accounting for about one of every seven deaths.^1-3 Smoking results in deaths from cancer, cardiovascular disease, and chronic obstructive lung diseases. In addition, thousands of smokers will experience a diminished quality of life because of diseases that result from the use of cigarettes and other tobacco products. Despite public awareness of morbidity associated with smoking initiation, 25% of all adults, 5 million teens (ages 12–17 years), and more than half a million youngsters (ages 8–11 years) smoke.^1-3

The negative sequelae of smoking are heightened among people with diabetes. The combined cardiovascular risks of smoking and diabetes are as high as 14 times those of either smoking or diabetes alone.^4-6 Diabetes has been found to increase the risk of hyperlipidemia and hypertension. The acceleration of macrovascular and microvascular atherosclerotic disease present in diabetes is heightened by the vasoconstrictive effects of smoking, increasing the risk of peripheral vascular disease and amputations.^7-9 Smoking is also associated with a heightened incidence of other diabetes complications, including retinopathy and neuropathy.^10-11

Despite the negative impact of smoking, the prevalence of smoking among people with diabetes remains equivalent to that in the general population. In fact, some studies report smoking prevalence among adults with diabetes to be even higher than that in the population at large.⁵ In addition, smoking cessation appears to be less frequent among people with diabetes than among members of the general population, who quit smoking at a rate of ~5% per year.^6-12

Enhancing patients’ capacity for optimal health is a major goal of diabetes care.^13-14 Preventing tobacco use and providing smoking cessation counseling must be incorporated into routine diabetes management. This requires translating information for patients about tobacco use and addiction in a systematic way that promotes their capacity to maintain healthful behaviors.

This paper will review the interaction of factors that promote nicotine addiction, discuss smoking cessation counseling as a priority of diabetes care, identify organizational components of a smoking cessation system, and describe a case study of smoking cessation counseling and ongoing diabetes management.

Factors of Nicotine Addiction
Multiple determinants influence an individual’s capacity to stop smoking. Current explanations assume that smoking is the result of an interplay of biological, psychological, and social processes. Nicotine is addictive, with cigarettes an ideal vehicle for nicotine delivery. It takes only 7 seconds for nicotine to reach the brain via inhalation from cigarettes.¹⁵ Within the brain, nicotine has euphoric effects, as well as sedative or anxiolytic effects associated with neurohormonal processes.

Rapid delivery makes nicotine an effective reinforcer of behavior, leading to continued inhalation to achieve the physical impacts of nicotine. The biological power of nicotine makes the learned behaviors that form smoking patterns stronger and more resistant to change.¹⁶

At the same time, cues in everyday life trigger the urge to smoke. These daily life patterns make breaking the addiction difficult. For example, cigarettes become the natural companion to a cup of coffee or the strategy used for dealing with anxiety-provoking situations. The pack-a-day smoker, over 20 years, will inhale cigarettes more than 1 million times in response to such cues, entrenching smoking as a routine occurrence. Coupled with the effects of advertising, an environment is created in which smoking is supported as a socially attractive behavior.^15-16 Thus, a smoker’s capacity for cessation must be enhanced by interventions that reflect an understanding of these multicorrelational factors.

Smoking Cessation Counseling
and Diabetes Care
It is clear that smoking has a significant negative impact on the health of patients with diabetes. Ironically, patients’ priorities about managing other aspects of the diabetes regimen (e.g., exercise, diet, and medication) and their capacity to do so may make them reluctant to quit smoking.

Smoking cessation counseling by health-care providers has been shown to have a significant impact on the reduction of smoking prevalence among patients with diabetes.^17-20 Five steps that can be implemented to ensure patients’ capacity for successful smoking cessation (the Five As) are: ask about smoking, advise to stop smoking, assess readiness to quit, aim interventions, and arrange follow-up.¹⁷ Each of these steps is described in Table 1 and in detail below.

1. Ask all patients about smoking at every opportunity. Address tobacco use at every visit. The message is not salient if said only once, infrequently repeated, or delivered amidst other complex messages about diabetes care. If patients have never or do not currently smoke, health-care providers should encourage continued abstinence, especially in adolescents. If patients currently smoke, providers should obtain a detailed history of tobacco use to gain information related to level of nicotine dependence. De-pendent smokers may benefit from pharmacological intervention.^15,20

2. Advise all patients who smoke to quit. Stress smoking cessation as a component of diabetes care. Health-care providers should communicate to patients an understanding of the difficulty of quitting, especially in the presence of chronic diseases. In addition, providers should explain the harmful physical consequences associated with smoking and diabetes, the addictive nature of nicotine, and advertising techniques that mask the health effects of smoking. Emphasize the importance of smoke-free environments to families and children.¹⁷

3. Assess smokers’ readiness to quit. Health-care visits are frequently limited by time constraints and the need to address multiple issues. Stages of Change theory provides a foundation for diagnosing a patient’s readiness to change and then focusing education to promote the individual’s capacity for cessation.^21-24 A basic assumption of this theory is that smoking cessation is a dynamic process occurring in several distinct stages: 1) pre-contemplation, the stage at which a person is unaware of the risks of smoking or aware but unwilling to consider quitting in the foreseeable future; 2) contemplation, the stage that begins when an individual is thinking about quitting smoking but is not taking active steps to change; 3) preparation or decision, the stage during which an individual is making definite plans to quit smoking; 4) action, the stage during which an individual initiates smoking cessation; 5) maintenance, the stage during which an individual is sustaining cessation and preventing relapse. Individuals may cycle through the stages several times before they maintain cessation.^21-24

Targeting the content and timing of cessation strategies according to patients’ stage of readiness to change facilitates their capacity for smoking cessation.^21-24 Those who are not considering quitting receive information designed to encourage quitting by raising risk awareness. Those ready to quit receive information devoted to a plan of action and strategies that would not be relevant to a patient in the pre-contemplation stage. Staging thus provides health-care providers with a means of optimizing limited time in the clinical visit by 1) diagnosing patient readiness to alter smoking patterns, 2) targeting information for optimal impact on cessation, 3) providing a systematic method for evaluating the effect of the educational treatment, and 4) individualizing future interventions based on patient outcomes.

4. Aim smoking cessation interventions based on readiness to quit. Behavioral and pharmacological assistance are available as means of promoting patients’ capacity for cessation. Multiple strategies delivered consistently over time have proven to be very beneficial in promoting cessation. Characteristics of several of these strategies include: self-monitoring of smoking patterns; temptation management, such as planning to avoid social situations where cigarettes are prevalent; contingency management, arranging a reward for not smoking over a specified period of time (e.g., buying oneself a gift); stimulus control, limiting contact with smoking reminders (e.g., removing all ash trays); stress management and relaxation techniques; positive thinking; developing exercise or activity strategies; and suggesting alterations in dietary patterns to accommodate cravings (e.g., snacking on vegetables or fruit).^17,20,25,26

While behavioral strategies are effective, more dependent smokers may also benefit from pharmacological intervention (i.e., nicotine replacement therapy). Smokers with diabetes may be more physically dependent on nicotine, as evidenced by the lower cessation rates among this group. Can-didates who most benefit from nicotine replacement therapy include smokers who have their first cigarette within 30 minutes of waking and those who smoke more than one pack per day.²⁷

Nicotine replacement allows patients to become accustomed to smoke-free living with diminished physical symptoms of nicotine withdrawal. These acute symptoms, which tend to be more intense during the first few weeks following cessation, include cravings, irritability, lethargy, difficulty concentrating, headaches, and changes in blood glucose level.

Nicotine replacement is an adjunct to patients’ efforts to quit smoking, the success of which is dependent on ongoing attention to and support for cessation efforts. Patient education should emphasize the use of nicotine replacement following cessation of all smoking. Smoking concurrent with patch use may cause an acute and dangerous rise in blood nicotine levels. All patients should be counseled to use the patch only when they have quit and to remove the patch if they resume smoking.²⁷

5. Arrange follow-up for all patients who smoke. Smoking cessation interventions should be followed by positive reinforcement after quitting occurs. Follow-up should assess the impact of cessation counseling, encourage precontemplators or contemplators to initiate cessation, determine the need for additional assistance for those ready to achieve cessation (preparation/decision stages), and promote relapse prevention strategies for those who have quit smoking (action and maintenance stages).^17-18

Patients who have stopped smoking should be provided support to prevent relapse. There are various causes of relapse, including environmental triggers (e.g., the urge for cigarette with morning newspaper and coffee) and social triggers (e.g., pressure from peers to smoke). Psychological triggers (e.g., stress about maintaining a diabetes care regimen) are also causes of relapse.

Many smokers in all populations cite the use of nicotine as an anxiety-reducing strategy or mood elevator. The higher prevalence of depression among smokers in general,^28-29 and those with diabetes in particular,^30-32 suggests the need for careful assessment of depression as a predisposing factor to smoking relapse. Counseling pa-tients to find alternative strategies for dealing with periods of emotional stress (e.g., walking or meditation) has the added benefit of promoting overall diabetes control.

Finally, weight gain may also accompany cessation.^4,33 Nicotine en-hances the metabolic rate, tending to reduce weight. In general, smokers weigh less than nonsmokers, and quitters gain an average of 5–10 pounds. In addition, smokers frequently use cigarettes as a substitute for eating, which lowers their caloric intake. These effects, and fear that quitting may cause weight gain, may discourage smokers with diabetes from quitting.

Such patients should be counseled that the risks of smoking far outweigh the risks of modest weight gain, even for those with diabetes.⁶ Health-care providers must emphasize that smoking cessation is a priority for optimal diabetes care and reassure patients that if post-cessation weight gain occurs, it may actually be a sign of return to normal (non-nicotine-altered) metabolic function.^6-16

Dealing with relapse. While health-care providers should emphasize total cigarette abstinence, a lapse does not signify a patient’s failure. Rather, the patient must understand that a lapse can serve as a learning experience to help in avoiding total relapse and promote eventual cessation. Assessment of the causes of the lapse (environmental, psychosocial, or physiological) may lead to additional strategies designed to prevent smoking resumption.¹⁷

Studies suggest that successful quitters average 2–3 attempts before success. This information is relevant to place the lapse in context. If a patient resumes regular smoking, the health-care provider should praise the quit attempt and offer the patient continued encouragement to learn from the lapse and to try again.

Organizing A Smoking Cessation System Across Settings of Care

The key to smoking cessation success is organization of the health-care environment to reflect the importance of smoking cessation, which further enhances support for patients’ capacity to eliminate tobacco-related risk behaviors. Clinic or office settings that wish to support smoking cessation counseling should:

• prepare all staff members for a role in smoking cessation interventions
• establish a smoke-free environ- ment policy
• conduct screenings of all patients for cigarette or tobacco use at every visit
• label all patient charts as either tobacco users or nonusers
• provide routine reminders to health-care providers to discuss cigarette use, document each dis- cussion, and communicate any plans made with patients
• identify a smoking cessation coor- dinator responsible as a resource for cessation activities
• arrange for the delivery of self- help booklets and other informa- tion to any patient interested in quitting smoking
• collaborate with and refer patients to community resources (e.g., the American Lung Association, the American Cancer Society, or the American Heart Association) that offer smoking- cessation classes and self-help programs
• establish a system for reinforcing the message to quit, including fol- low-up telephone calls after quit dates.^17,18

CASE STUDY: PACK-A-DAY
SMOKER WITH TYPE II DIABETES
R.B. is a 41-year-old African American woman diagnosed with type II diabetes of 18 months’ duration. She has a 3-year history of hypertension, for which she has been taking hydrochlorthiazide 50 mg/day and atenolol 50 mg/day. She denies symptomatic hyperglycemia and has undergone a 26-pound weight loss during the past 6 months, a result of following her prescribed meal plan.

R.B. is married and the mother of seven children, works part-time at the local school, and is active in her church. She has a family history of diabetes (her mother and one sister) and heart disease (her father).

She receives routine care from a local community health center. Physical examination reveals no evidence of hypertensive or diabetic retinopathy. Cardiac and lung examinations were normal.

Blood pressure: 142/94 mmHg
Fasting blood glucose: 150 mg/dl
Random blood glucose: 166 mg/dl
HbA1: 7.8 % (normal 4.5–6.5%)
Height: 64 inches
Weight: 240 pounds

On R.B.’s chart is a sticker stating that she is a smoker. Further assessment of smoking history reveals that R.B. has smoked a pack of cigarettes per day since the age of 15 years. Both of her parents smoked. Her father died at the age of 55 years of myocardial infarction, and her mother recently died of lung cancer at the age of 61 years.

R.B. indicates a desire to stop smoking for her own health and because she wants to be a role model for her children and those she meets through her school job. Her husband and children have encouraged her to stop smoking. She expresses that there is support through her church for maintaining smoking cessation as a means of maintaining health.

R.B. is very happy about her weight loss, stating that she has worked hard to lose weight and to achieve blood glucose control through meal planning. She indicates that it has been very difficult to maintain her weight because she has been depressed since the death of her mother.

The diabetes educator compliments R.B. on her maintenance of the regimen in the midst of multiple stressors and her continued motivation to maintain diabetes control. She then advises R.B. of the importance of smoking cessation as a priority for her diabetes management. The educator discusses R.B.’s family history of heart disease and cancer and R.B.’s own history of hypertension, as well as the enhanced risks of these factors in the presence of diabetes. The diabetes educator expresses her confidence in R.B.’s ability to quit, given her commitment to diabetes self-management.

When asked about her readiness to stop smoking, R.B. states that she tried to quit immediately following her mother’s death. Although her husband and children supported her attempt, she resumed smoking within 6 weeks. Assessment of the cause of the relapse revealed that R.B. was concerned that her 7-pound weight gain would result in being placed on insulin for diabetes control. She resumed smoking to control her appetite and to deal with her mother’s death.

The diabetes educator emphasizes that the quit attempt was an excellent indicator of future success, as most people learn from these attempts and achieve long-term cessation after several tries. She also states that planned coping strategies, including exercise regimens and dietary alterations, would assist with stress reduction, maintaining weight, and blood glucose control.

The educator informs R.B. that post-cessation weight gain, if it occurs, is typically 5-10 pounds, and that such gain is a return of the body to its nonnicotine-induced metabolic state. She assures R.B. that the risks of smoking, especially given her family history, are far more serious than the possible weight gain. In addition, the diabetes educator stresses that strategies commonly used in diabetes management are also helpful in achieving smoking cessation. These strategies, R.B.’s commitment to quitting for her health, the support of her family and diabetes health-care team, and the availability of community resources will enable R.B. to achieve long-term smoking abstinence.

R.B. states that she is thinking about quitting in the next month, and is willing to develop a plan to achieve this goal. The diabetes educator works with R.B. to set a quit date and to identify a plan to achieve cessation. She gives R.B. the American Lung Associa-tion’s guide to stopping smoking and information on methods for gaining support from family and friends.

An exercise prescription for a walking program is designed, and R.B. is scheduled to speak with a dietitian.

R.B. is a heavily dependent smoker, and thus a prescription for nicotine replacement therapy is provided by her physician. The physician emphasizes that the patch should be used only after complete cessation of smoking.

A follow-up telephone call from the diabetes educator is scheduled for one day before the quit date. Thorough documentation of smoking cessation counseling by each member of the diabetes team is noted in R.B.’s chart.

Conclusion
Patients with diabetes are active members of the health-care team, responsible for self-management activities. Since they are frequent consumers of health-care information, effective translation of this information is vital to optimizing health-care status.

Routine diabetes management provides an excellent means of promoting smoking cessation or abstinence as a priority of care. Enhancing an individual’s capacity to alter tobacco use as a risk behavior demands an understanding of the numerous interacting factors that promote tobacco use and effective counseling targeted to the patient’s self-assessment of capacity for change. A health-care environment that optimizes the effect of routine diabetes care by providing systematic counseling for smoking cessation will result in a reduction in cigarette use among this high-risk population.

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Debra Haire-Joshu, PhD, RN, is a research associate professor of medicine at the Center for Health Behavior Research of the Washington University School of Medicine, in St. Louis, Mo.

Note of Disclosure: Dr. Haire-Joshu is a member of the American Lung Association Board of Directors, which engages in activities designed to eliminate smoking and promote lung health. She is a past chair and a current member of that group’s committee on tobacco control.

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