Avoiding High-Risk Behaviors: Smoking Prevention and Cessation in Diabetes Care

Cigarette smoking causes more than 400,000 deaths annually, accounting for one of every five deaths in the United States.1 Among smokers, ∼43% of deaths for women and 52% of deaths for men are attributable to cigarette smoking.2 Smoking is the leading avoidable cause of mortality and is one of the most important modifiable causes of premature death.1 This loss of life due to smoking continues despite the decrease in smoking prevalence generally due to public health efforts and increased awareness regarding the health hazards of smoking.2–4 In addition to smoking, there are multiple high-risk behaviors, as demonstrated by the Behavioral Risk Factor Surveillance Survey, that have a powerful impact on health, including alcohol abuse, poor dietary practices, and sedentary lifestyles.5 

What causes individuals to begin or continue such a risky behavior? Smoking is a behavior that is maintained by physical addiction, psychological dependence, and habit. Nicotine, the addictive substance in cigarettes, has various mood-altering effects that contribute to and reinforce the highly controlled or compulsive pattern of drug use through smoking.6 The pharmacological and biochemical effects of nicotine are powerful, with mood-lifting pleasurable effects along with tension-reducing effects. In addition, through conditioning, smoking becomes associated with daily events, situations, activities, and emotions. Smoking becomes a ritualized means of coping, woven into daily life, with powerful and immediately reinforcing physical effects.7,8 Genetic factors have also been implicated in the initiation and cessation outcomes of smokers.9 In sum, powerful physical and psychological processes support compulsive nicotine use and make it difficult for smokers to quit.1 

Smoking bears similarities to other high-risk behaviors. Tobacco dependence and threat of physical withdrawal, for example, help to maintain smoking behaviors much like other substance abuse and dependence disorders. Smoking behavior is often conditioned and linked to activities of daily life and habits and is sometimes used as a way to cope with psychological stress, as are eating habits and dietary patterns. Many of the same methods used to address smoking have been used to prompt behavioral change, both addressing physical and psychological aspects of the high-risk behaviors while taking into account a patient’s readiness to change (e.g., using motivational interviewing).

Smoking has a substantial impact on the morbidity and mortality of patients with diabetes. Smoking complicates the health and quality of life of diabetic patients and, in many cases, causes premature death. The American Diabetes Association (ADA) technical review on smoking and diabetes summarized the many risks associated with smoking.1 

One of the greatest risks of smoking is the increased risk of death and morbidity from macrovascular complications in diabetic patients. Patients with either type 1 or type 2 diabetes, compared to patients without diabetes, are already at increased risk for morbidity and mortality related to circulatory and cardiovascular disease. Mortality due to cardiovascular disease is greatly increased among smokers with diabetes. The risk for cardiovascular disease among smokers with diabetes is up to 14 times higher than that for smoking or diabetes alone.

Smoking is also associated with many diabetes complications. Smokers with type 1 diabetes commonly experience nephropathy, and smoking increases the risk of microalbuminuria in type 2 diabetes. Smoking is related to the development of nephropathy in type 1 and type 2 diabetes. Smoking is also a documented risk factor for both the development and progression of various types of neuropathy, with in-creased risks ranging from 2.2- to 12-fold higher for smokers compared to nonsmokers. The relationship of cigarette smoking to retinopathy is less well defined than that with other microvascular complications of diabetes, but there are data to suggest that smoking reduces retinal blood flow and potentiates the hypoxic environment of the diabetic retina.

In addition to the negative impact smoking has on existing diabetic disease, nicotine may also play a role in the development of diabetes and interfere with insulin activity.1 

To reduce the high cost of smoking, health care professionals have a responsibility to help patients avoid or modify smoking behavior. Prevention of tobacco use and smoking cessation treatment is a cost-effective intervention that should be recommended for all patients with diabetes.1 

In the following sections, we discuss strategies for smoking prevention and cessation as a way to implement behavioral change into practice.10–12 The discussion will be focused on the research and practice of facilitating sustained abstinence rather than more controversial approaches such as harm reduction strategies, which focus on reducing smoking for those smokers who are unable or unwilling to quit completely. Additional research is needed on interventions to reach recalcitrant smokers.

What is the scope of the problem? Adolescence is a critical time with regard to initiating positive health habits and avoiding negative behaviors such as abusing alcohol or initiating smoking. For example, adolescents with diabetes begin smoking at a rate that is equal to nondiabetic individuals. The prevalence estimates of smoking among people with diabetes appear to be similar to those of the general population, at least at younger ages.5 

Despite the health risks associated with smoking, ∼26–28% of American adults continue to smoke, with variations reported for ethnic and sociodemographic groups. These figures mirror the prevalence of tobacco use among people with diabetes.13 Although research suggests that the prevalence of smoking among people with diabetes may decrease as the duration of the disease increases, this finding may be due in part to increased mortality associated with smoking and diabetes.13 Clearly, there is a need for prevention.

Prevention efforts need to begin early. Smoking is a behavior that often begins in adolescence; in fact, 70% of current adult smokers were regular smokers before age 18. Research suggests that the earlier one begins to smoke, the more likely that behavior persists into adulthood. Smokers who begin at an early age are more likely to become addicted to nicotine. Not surprisingly, these smokers also develop serious health conditions at younger ages compared to nonsmokers.2 Particularly concerning are reports that suggest a higher prevalence of smoking among 18- to 34-year-olds, African Americans, and those with lower educational levels.5 Increased prevention and intervention efforts are needed to reach these groups.

Little has been written on the knowledge and decisional process regarding smoking behavior in adolescents with diabetes; however, the prevalence estimates suggest that there are substantial numbers of young adults with diabetes who are smoking. What is more troubling is that the majority of these diabetic adolescents initiated the smoking habit subsequent to a diagnosis of diabetes.14,15 A specific area for exploration is the increasing problem of adolescent girls who initiate smoking to manage weight. Inaccurate or underreporting may be a problem in this population. One study of adolescents with diabetes reported that 31% of diabetic adolescents admitted smoking, but even more (48%) were verified via testing to be smokers.14 The diagnosis of diabetes is not sufficient to deter many adolescents from beginning a deadly habit, and adolescents may not be willing to discuss this with health care professionals. Given the devastating effect of smoking on people with diabetes, it is very important to talk openly with adolescent patients and prevent the initiation of smoking, as well as obesity and alcohol abuse, among young patients who already have a complex disease to manage.

What can health professionals do to help adolescent patients avoid high-risk behaviors? Using smoking as an example, at the individual level, diabetes professionals should ask all patients about tobacco use at every visit. If smoking were regarded as a “vital sign” to be checked at each medical contact, then smoking status would be consistently identified and documented in the chart.10,11 This screening system would serve as a reminder to professionals, and the attention given to smoking as a health behavior would communicate the value of preventing or quitting smoking to patients.

All health care providers should advise individuals with diabetes not to initiate smoking. This advice should be consistently repeated to prevent smoking and other tobacco use among children and adolescents with diabetes who are under the age of 21 years.10 Patients should be congratulated for abstinence from tobacco and reinforced with information about why avoiding smoking is particularly important for diabetic patients.

At the family level, diabetes professionals can talk with parents and family members about the importance of establishing behavioral standards, in this case a “no-smoking” standard, in the household. Parents should be educated about how parental smoking can affect their child’s general health and diabetes status. Parents can be powerful models regarding smoking behavior; they should be encouraged to quit smoking if they are current smokers. If they are nonsmokers, parents should talk with their children about their reasons for avoiding this high-risk behavior for the sake of their family’s health.

At an environmental level, diabetes professionals should ensure that the physical environment of the clinic or health care setting communicates the importance of health behaviors. With smoking as a focus, this can be accomplished by no-smoking policies, educational signs, and literature in the clinic. On a larger scale, professionals can support efforts to reduce accessibility of tobacco to young patients (increased cigarette costs, the enforcement of laws regarding cigarette sales to minors).

Given that many young adults may have already begun smoking, it is important to encourage honest reporting so that effective treatment can be offered. Although concerted efforts need to be made to prevent smoking, it is also important to address the established habit and promote cessation in individuals for whom this high-risk behavior is set (Table 1).

Although smoking is an extremely harmful behavior, the benefits of quitting smoking are quite remarkable. Behavioral change can result in substantial increases in a patient’s quality of life and health. Both short-term benefits (such as improvement in one’s ability to smell and taste clearly, increased energy, and nicotine and carbon monoxide reduction) and long-term benefits (such as decreased risk of disease, financial savings, and decreased smoking-related complications) are significant. Quitting smoking decreases the risk of cardiovascular disease, cancer, stroke, and lung disease.16 Given the increased risks of complications and mortality among diabetic smokers, it is imperative to educate diabetic patients and provide smoking cessation services. Evidence suggests the importance of quitting as early as possible in the course of diabetes, given the dramatic health benefits and reduced risk of mortality.3,17 

What can health professionals do to help patients make behavioral changes like quitting smoking? Smoking cessation must be a routine component of diabetes care.10 Research provides us with strong evidence about effective methods for smoking cessation.1 The behavioral strategies for smoking cessation have applications to other areas of intervention. For example, the general strategies may also be relevant for addressing eating habits, exercise habits, or screening for alcohol or drug abuse.

It should be noted, however, that for alcohol or drug abuse, patients should be referred to specific services to intensively treat substance abuse. Thus, it is important to know when to refer for more specialized treatment.

The following guidelines for making behavioral changes regarding smoking are based on the ADA position statement on smoking and diabetes10 and the Agency for Health Care Policy and Research (AHCPR) Clinical Practice Guidelines on Treating Tobacco Use and Dependence.1 

1. Ask every patient about smoking habits.

2. Advise every diabetic smoker to quit with personalized messages.

3. Assess willingness of diabetic smokers to quit at this time; success depends, in part, on patients’ readiness to change.

   If patients express unwillingness, have a brief discussion to enhance their motivation to quit. Address the 5 Rs: relevance, risks, rewards, roadblocks, and repetition. Discuss why quitting smoking is relevant for particular patients’ diabetes and health at this time. Emphasize the risks of continued smoking. Highlight the rewards of quitting smoking. Talk about roadblocks or barriers to quitting and how these might be addressed. Use repetition to emphasize that quitting smoking is one of the most important things patients can do for their health.

4. If patients express willingness and are motivated to quit, then assist them in quitting. Provide counseling, pharmacotherapy, and referrals as needed. There is a relationship between the intensity of smoking cessation counseling and its effectiveness. The most effective techniques involve counseling by multiple health care providers, using individual or group counseling, having multiple contacts over time, and learning problem-solving or skills with social support.

   In addition, there are effective pharmacological supplements used in combination with behavioral counseling. According to the recent AHCPR guidelines, five first-line pharmacotherapies have been identified as reliably increasing long-term smoking abstinence.1,10,11 These first-line medications include Bupropion SR, nicotine gum, nicotine inhaler, nicotine nasal spray, and nicotine patch. Two second-line pharmacotherapies that may be considered for use if first-line therapies are not effective include clonidine and nortriptyline. In the presence of special circumstances, such as certain diabetes complications or pregnancy, the risks of continued smoking need to be compared to the risks of nicotine replacement therapy or other pharmacological aids.

   In addition to provider’s advice during visits, referrals are also important to support patients’ behavioral change. For smoking, this may include referral to a smoking cessation group or a psychologist for individual sessions aimed at behavioral change.

5. Arrange for follow-up contact, preferably within 1 week of the quit date, to promote long-term abstinence. (See Table 2.)

Several special treatment considerations may make it challenging for patients with diabetes to make behavioral changes and more specifically to quit smoking. Managing diabetes on a daily basis requires much attention and energy. Devoting additional efforts to make behavioral changes such as smoking may be difficult. Patients with diabetes have a variety of health behaviors to maintain, and many patients place an important emphasis on managing their weight and dietary choices. Unfortunately, after quitting smoking, many individuals experience some weight gain. Average weight gain tends to be 6–10 lb, with women gaining slightly more weight than men.18 Fears about weight gain may prevent diabetic smokers from trying to quit smoking, particularly women, obese patients, and those in poor metabolic control.19 Including weight concerns as part of smoking cessation counseling has improved program outcomes20 and may be particularly useful in working with diabetic patients.

Finally, depression can be a barrier to successful behavior change. Depression is often comorbid, with negative health behaviors such as smoking, alcohol abuse, and eating disorders. In the case of smoking, research illustrates that depression is more common among smokers than nonsmokers21 and that depressive symptoms can interfere with successful smoking cessation efforts.22,23 Unfortunately, people with diabetes have a greater risk of depression compared to the general adult population.24,25 Thus, this may make quitting efforts more difficult for diabetic patients who are depressed. It is important to treat depressive symptoms through medication and/or psychotherapy so that attempts at behavioral change are more likely to be maintained successfully.

What can health care professionals do to ensure that their health care systems are structured to help patients avoid or modify high-risk behaviors? It is important to train staff to address high-risk behaviors at visits, to provide continued support to patients striving to make behavioral changes, and to ensure time and funding in the health care system to implement these strategies. The importance of intensive treatment and support by team members in diabetes care has been highlighted in recent studies.26,27 

Regarding smoking specifically, several strategies can be employed to help create and maintain effective systems for prevention and cessation. Research shows that the most effective smoking cessation interventions are repeated, provided by multiple health care professionals, and reinforced over time. First, all diabetes health care providers should be trained in the AHCPR guidelines regarding smoking cessation.11,12 If all diabetes care professionals are armed with smoking cessation training, then patients are more likely to receive the same strong message from various health care staff over many occasions. In addition to providing smoking cessation advice, diabetes care professionals should also be familiar with smoking cessation services and classes at local hospitals and in the community for effective referral.

Second, follow-up counseling to assess and reinforce quitting must be consistently implemented for all diabetic smokers. This is particularly important during the first 2 weeks after patients have tried to quit smoking because follow-up contacts have been shown to increase the likelihood of long-term cessation success. Contacts should focus on providing support and problem-solving.

Finally, health care providers should be reimbursed for treating tobacco dependence. Smoking cessation is cost-effective and clinically important.28 The cost of not treating smokers with diabetes, measured by loss of quality of life, complications, and mortality, is very high. Health care professionals should continue to lobby for reimbursement from insurers. When systems recognize and reimburse smoking cessation efforts, practitioners are able to provide effective treatment that results in better patient care and health.

Smoking is a high-risk behavior that results in devastating health consequences. The prevention and treatment of smoking should be a high priority for diabetes care providers. Behavior change, especially regarding a change-resistant behavior such as smoking, requires consistent attention over time from multiple providers. However, the benefits of quitting far outweigh the effort it takes to achieve such change.

Smoking is not the only behavioral issue that can be addressed for individuals with diabetes, and many of the same strategies to prevent and treat smoking behavior can be applied to other high-risk health behaviors. Diabetes practitioners have the opportunity to advise young patients to avoid developing negative behavior patterns and to offer assistance and referral to those patients who have developed problematic behaviors.