Published in UAB Insight, Spring 2008
ABSTRACT: Although smoking rates in the United States are down, a surprising percentage of teens and young adults with diabetes and limited education smoke. Innovative smoking cessation programs are needed to reverse this alarming trend.
CME OBJECTIVE: The reader will understand the importance of using multiple methods to help people with diabetes and those at risk for diabetes stop smoking.
Monika M. Safford, MD, grants and research support NIH
Currently 23% of the adult population in Alabama smokes tobacco and 52% of these individuals are between the ages of 18 and 44 years. According to 2005 statistics from the Centers for Disease Control and Prevention, 8.6% of Alabamians have diabetes and 20.6% of these individuals smoke.
While smoking is universally recognized as a risk factor for cancers and respiratory and cardiovascular diseases, research has found an associative risk relationship with diabetes. A recent review and meta-analysis of 25 prospective cohort studies confirms active smoking is linked to an increased risk of type 2 diabetes (JAMA. 2007;298[22]:2654-2664).
An ongoing study, Translating Research Into Action for Diabetes (TRIAD), began in 2000 to examine the relationship between health behaviors and diabetes in managed care settings (Am J Public Health. 2007;97[8]:1-6). TRIAD’s six translational research centers interviewed more than 8000 participants aged ≥25 years with a physician-confirmed diagnosis of type 2 diabetes. Participants self-reported smoking behaviors and investigators used educational level as a socioeconomic indicator.
TRIAD study data indicate differing relationships among socioeconomic status and education and people with diabetes who smoke. “The smoking rate in people with diabetes aged 25 to 44 years with some high school education or less was 50% — an alarming rate when the overall US percentage of people who smoke is down to 20%,” says Monika M. Safford, MD, UAB associate professor of preventive medicine.
Safford, who coauthored the TRIAD study article, notes, “We expected to find that the health care system had done a better job educating these younger patients. The fact that 50% of younger diabetes patients with limited education — already at risk for stroke, heart attacks, and other cardiovascular outcomes — are smoking is quite startling.”
Diabetes in individuals who smoke increases the risk of microvascular and macrovascular disease along with other smoking-related diseases that compound with age. Diabetes in a young adult results in long-term exposure to the deleterious effects of chronic disease; the added effects of smoking-related risk factors necessitate urgent, cogent intervention for this population, Safford says.
Youth, Smoking, Low Health Literacy
The TRIAD report concluded that reduced educational status is linked to increased smoking prevalence in adults aged 25 to 44 years. These findings suggest that physicians should focus interventions toward this vulnerable group of people with the lowest levels of educational accomplishment. “Smoking cessation programs for teens have had modest success,” Safford says. “Yet this older at-risk population is no longer attending school, creating a need for more effective methods of targeted intervention.”
Literacy rates are an important barrier to causing changes in health behaviors. For example, diabetic patients who require educational intervention to improve self-management behaviors need advanced health literacy skills to attain optimal glycemic control.
Investigators evaluated a computer-based multimedia program, “Living Well With Diabetes,” during a trial of persons with diabetes and low health literacy. Investigators randomized participants to standard care or supplemental education with the multimedia program. Despite efforts to increase ease of use with touch-screen hardware and audiovisual media, computer use among the elderly and those with limited health literacy was low. However, the intervention did lead to significant improvement in hemoglobin A1c levels among people with low health literacy who had poor glycemic control (Diabetes Care. 2005;28[7]:1574-1580).
Targeted Interventions
“Health care professionals treating people with diabetes need to become more aware of the prevalence of smoking in this population and of strategies aimed at cessation,” Safford says. “By spending 5 minutes discussing smoking cessation methods with patients, physicians can double patients’ success rate.”
Adding formal counseling, text messaging, nicotine patches, antidepressants, and antianxiety medications to office-based intervention increases the baseline success rate of 5% to approximately 20%, Safford says. “Smoking cessation is advised by the American Diabetes Association treatment guidelines, and providers should consider redoubling interventional efforts to help young people with diabetes quit smoking.”
Helping smokers quit through the use of innovative methods has been a recent focus of smoking cessation research. Use of cell phone text messaging as a delivery medium for smoking cessation programs was evaluated during a randomized control trial of smokers 15 years and older. Investigators divided participants into control and treatment intervention groups. The intervention centered on delivering personalized messages based on participant preferences, their smoking history, and individual barriers to cessation (Tobacco Control. 2005;14:255-261).
Messages used participant nicknames, and content included information on symptoms associated with quitting, strategies to handle craving and avoid weight gain, instruction on breathing exercises, and sample success stories. Investigators also sent text messages to provide distraction from the urge to smoke. These contained general trivia, travel, sports, and fashion information unrelated to smoking. The control group received messages thanking them for their study participation and reminding them of study follow-up details.
Study investigators concluded that text messaging interventions approximately doubled quit rates at 6 weeks. They note the use of cell phone text messaging as a smoking cessation device has several advantages. It is an age-appropriate intervention for young adults, its cessation cues are easily personalized, and it is relatively inexpensive, highly marketable, and more accessible than computers for individuals in low socioeconomic groups.
Avatars as Cessation Counselors
Computers have been used to create a variety of smoking cessation materials, including personalized programs, Web sites, games, and electronic bulletin boards. However, none of these programs utilize an interactive approach allowing participants to engage in real-time communication with counselors or one another. A novel longitudinal study evaluating “Breathing Room,” a Web-based interactive program, let participants interact with a counselor and other teenaged smokers in real time in an Internet virtual world (Addictive Behaviors. 2007;32:1769-1786).
Breathing Room uses avatars, three-dimensional characters that users personalize by changing their gender, race, and clothing style. Avatars allow participants to see themselves and other participants in online role play. Using avatars encourages relationship development among players and counselors in an identity-free environment.
For the study of the avatar-based strategy, investigators randomized teenaged smokers to an intervention group that completed seven virtual world intervention sessions and surveys or to an observational group that completed surveys alone. The study found use of an Internet virtual world to deliver smoking cessation intervention reduced cigarette use in teens for up to a week. Participants did not maintain positive results after 4 to 12 months of follow-up. Adding virtual technology to traditional smoking cessation measures may increase its effectiveness. Notably, study investigators say results strongly support use of Internet communication as an age-appropriate tool to help young smokers reduce nicotine dependence or quit smoking.
Regardless of the potential methods, a sea change is needed to provide optimal cessation tools for the vulnerable subset of young people with diabetes who smoke. “In general, smoking rates are lower in diabetics than in the general population but not in younger adults with limited education. It is not clear what has led to this dichotomy,” Safford says.
Innovative cell phone and Web-based smoking cessation tools give physicians more options for younger patients with diabetes and hold potential to reduce smoking in this at-risk population, she says, adding that the effectiveness of brief counseling sessions during routine office visits should not be forgotten.
For more information:
Dr. Monika Safford
1.800.UAB.MIST
mist@uabmc.edu