Excess risk of mortality and cardiovascular events associated with smoking among patients with diabetes: meta-analysis of observational prospective studies

Tobacco-enhanced biofilm formation by Porphyromonas gingivalis and other oral microbes

Microbial biofilms promote pathogenesis by disguising antigens, facilitating immune evasion, providing protection against antibiotics and other antimicrobials and, generally, fostering survival and persistence. Environmental fluxes are known to influence biofilm formation and composition, with recent data suggesting that tobacco and tobacco-derived stimuli are particularly important mediators of biofilm initiation and development in vitro and determinants of polymicrobial communities in vivo. The evidence for tobacco-augmented biofilm formation by oral bacteria, tobacco-induced oral dysbiosis, tobacco-resistance strategies, and bacterial physiology is summarized herein. A general overview is provided alongside specific insights gained through studies of the model and archetypal, anaerobic, Gram-negative oral pathobiont, Porphyromonas gingivalis.

Smoking, all-cause, and cause-specific mortality in individuals with diabetes in Mexico: an analysis of the Mexico city prospective study

OBJECTIVE

Evidence from low- and middle-income countries regarding the effect of smoking in people with diabetes is lacking. Here, we report the association of smoking with mortality in a large cohort of Mexican adults with diabetes.

METHODS

Participants with diabetes mellitus (self-reported diagnosis, use of antidiabetic medications or HbA1c ≥ 6.5%) aged 35-74 years when recruited into the Mexico City Prospective Study were included. Cox regression confounder-adjusted mortality rate ratios (RRs) associated with baseline smoking status were estimated.

RESULTS

Among 15,975 women and 8225 men aged 35-74 years with diabetes but no other comorbidities at recruitment, 2498 (16%) women and 2875 (35%) men reported former smoking and 2753 (17%) women, and 3796 (46%) men reported current smoking. During a median of 17 years of follow-up there were 5087 deaths at ages 35-74 years. Compared with never smoking, all-cause mortality RR was 1.08 (95%CI 1.01-1.17) for former smoking, 1.11 (95%CI 1.03-1.20) for current smoking, 1.09 (95%CI 0.99-1.20) for non-daily smoking, 1.06 (95%CI 0.96-1.16) for smoking < 10 cigarettes/day (median during follow-up 4 cigarettes/day), and 1.28 (95% CI 1.14-1.43) for smoking ≥ 10 cigarettes/day (median during follow-up 15 cigarettes/day). Mortality risk among daily smokers was greatest for COPD, lung cancer, cardiovascular diseases, and acute diabetic complications.

CONCLUSION

In this cohort of Mexican adults with diabetes, low-intensity daily smoking was associated with increased mortality, despite observing smoking patterns which are different from other populations, and over 5% of total deaths were associated with smoking.

Smoking and diabetes

Smoking increases insulin resistance via multiple mechanisms but is a poorly understood risk factor for onset of type-2 diabetes. It is also associated with impaired beta-cell function in humans, but again the mechanisms are poorly understood. Mechanistic studies of the impact of smoking on carbohydrate metabolism mainly evaluated nicotine as the causal agent, and more rarely other tobacco constituents, making it impossible to conclude that the risk of diabetes is linked to the effects of nicotine alone. Active smoking also has negative impact on glycemic control in both type-1 and type-2 diabetic patients. It increases the risk of all-cause mortality and worsens the chronic complications of diabetes. Impact on microangiopathic complications in type-2 diabetic patients, however, is more controversial. Data on pharmacological and behavioral strategies for smoking cessation used in the general population are more sparse in diabetic patients, despite opportunities with recent therapeutic trials involving varenicline and GLP-1 analogues. It is essential for diabetic patients to stop smoking, and diabetologists must get involved in smoking cessation as they have done for many years in therapeutic education, which can easily include measures to help patients stop smoking.

Metabolic Changes Following Smoking Cessation in Patients with Type 2 Diabetes Mellitus

BACKGROUND

Smoking cessation is crucial for reducing complications of type 2 diabetes mellitus (T2DM), but associated weight gain can worsen glycemic control, discouraging quitting attempts. Varenicline, a partial agonist of α4β2 nicotinic receptors, aids smoking cessation. This study examines the effects of varenicline on body weight and metabolic parameters in patients with T2DM and prediabetes.

METHODS

Fifty-three patients were enrolled, of which 32 successfully quit smoking after a three-month course of varenicline and were examined after an additional month with no medication. Measurements taken at baseline, 2.5 months, and 4 months included body weight, blood pressure, resting metabolic rate (RMR), glycated hemoglobin (HbA1c), fasting glucose, blood lipids, C-reactive protein (CRP), appetite-related hormones, and physical activity.

RESULTS

Post-treatment, there were no significant changes in body weight, blood pressure, RMR, or glycemic control. Total (CHOL) and low-density lipoprotein (LDL-C) cholesterol decreased significantly at 4 months of the study (from 168 to 156 mg/dL, p = 0.013, and from 96 to 83 mg/dL, p = 0.013, respectively). Leptin levels increased (from 11 to 13.8 ng/dL, p = 0.004), as did glucagon-like peptide-1 (GLP-1) levels (from 39.6 to 45.8 pM, p = 0.016) at 4 months of follow-up. The percentage of participants who reported moderate-intensity activity increased from 28% to 56%, while those reporting high-intensity activity increased from 19% to 22%, respectively (p = 0.039).

CONCLUSIONS

Our study showed that smoking cessation with varenicline in smokers with T2DM and prediabetes led to significant improvements in lipid profile, significant increase in plasma leptin and GLP-1 levels, and increased physical activity, without significant weight gain. Thus, smoking cessation without weight gain or deteriorated glycemic control is feasible for these smokers, with added benefits to lipid profiles, GLP-1 regulation, and physical activity.

Sex-specific predictive factors of smoking cessation in subjects at high cardiovascular risk

Smoking is a major risk factor for cardiovascular diseases (CVD), in particular in women, but smoking cessation (SC) reduces or even cancels the risk for both sexes. Using a nationwide SC services database, we aimed to determine the predictive factors of SC in men and women smokers with CV risk factors (CVRF) or CVD. A retrospective study from the French CDTnet database was conducted. Inclusion criteria were age ≥18years, and≥1 CVRF (Body Mass Index ≥25kg/m2, hypertension, diabetes, hypercholesterolemia) or CVD (myocardial infarction (MI) or angina pectoris, stroke, peripheral arterial disease [PAD]). Self-reported smoking abstinence (≥28 consecutive days) was confirmed by exhaled carbon monoxide<10ppm. Logistic regression analysis assessed the association between SC and sociodemographic, medical characteristics, and smoking profile. Among the 36,864 smokers at high CV risk, abstinence rate was slightly lower in women than in men, (52.6% [n=8,102] vs 55.0% [n=11,848], P<0.001). For both sexes, factors associated with the lowest abstinence rates were diabetes, respiratory and psychiatric diseases, anxiolytic/antidepressant use, and cannabis consumption. In women, the factors associated with smoking abstinence were suffering from MI or angina and taking contraceptive pill and the factors associated with persistent smoking were alcohol disorder and high cigarette consumption. In men, there was a positive relationship between overweight and abstinence while being dual users of cigarettes and electronic cigarettes at first visit, having tobacco-related diseases (cancer and PAD) and taking opioid substitution treatment were associated with persistent smoking. Finally, in both sexes, the factors associated with abstinence were: age≥65years, having a diploma, being employed, self-referred or encouraged by entourage, ≥1 previous quit attempt, ≤20 cigarettes per day consumption, benefiting from SC medication prescription and ≥4 follow-up visits. In conclusion, our results suggest the relevance of SC intensive management in smokers at high CV risk, based on sociodemographic, medical, and smoking behaviour characteristics, as well as a gender-specific SC approach.

The Association of Smoking Status with Diabetic Microvascular Complications in Korean Patients with Type 2 Diabetes

PURPOSE

Few studies have investigated the association between smoking and microvascular complications in the Asian population with type 2 diabetes mellitus (T2DM). We aimed to investigate the relationship between smoking status and microvascular complications in Korean patients with T2DM.

MATERIALS AND METHODS

From the Korean National Diabetes Program cohort, we included 2316 Korean male with T2DM who had baseline clinical information available, including their smoking status, and underwent diabetic complication studies.

RESULTS

Compared to non-smokers, current smokers had higher odds of any-microvascular complications [adjusted odds ratio (aOR) 1.45, 95% confidence interval (CI) 1.07-1.97, p=0.016]. The odds of neuropathy were significantly higher; however, the odds of retinopathy were significantly lower in current smokers than in nonsmokers (all p<0.05). Among those who underwent repeated complication tests after 3 years, the risk of newly developed retinopathy was significantly increased in ex-smokers [aOR 3.77 (95% CI 1.61-8.87), p=0.002]. Within ex-smokers, long smoking duration and smoking cessation within the recent 5 years were associated with an increased risk of newly developed retinopathy (all p<0.05).

CONCLUSION

Male smokers had higher odds of having overall diabetic microvascular complications, including neuropathy. However, the odds of having retinopathy were significantly lower among current smokers. More attention and research are needed regarding the increased risk of retinopathy development in ex-smokers who have recently stopped smoking after a long history of smoking.

Smoking cessation rate and predictors of successful quitting in Jordan: A cross-sectional study

Tobacco smoking in Jordan is the highest in the Middle East, with health consequences and economic burdens. Smoking cessation improves health and grows the economy. This study aimed to determine the prevalence of smoking cessation in Jordan and to identify the determinants of effective quitting. This cross-sectional study was conducted using an online survey directed towards the general population of Jordan. The questionnaire was formulated in Arabic and inquired about sociodemographic factors, health status, behaviors, smoking habits, previous quitting attempts, utilization of smoking cessation services, attitudes towards quitting, and barriers to quitting. Data were analyzed using Statistical Package for Social Science version 25. A total of 463 participants were included in this study. Twenty-one percent of them were ex-smokers (n = 97), 86% were male, 63.3% were from the middle governorates, and 29.2% were 24 years old or younger. The rate of sustained quitting for at least 3 months among participants was 13.6%. The factors associated with successful quitting included age > 50 years (P = .001), practicing regular physical activity (P = .003), using more than 1 tobacco product (P = .000), smoking waterpipes or e-cigarettes (P = .000 and .015, respectively), lower levels of nicotine dependence (P = .009), duration of smoking (P = .000), higher number of smoking cessation attempts (P = .000), having 1 or more chronic diseases (P = .049), and having DM (P = .003). More than half of the ex-smokers needed 2 to 5 attempts before successfully quitting smoking. There was a low rate of utilization of smoking cessation services and medications in both groups. On the other hand, there is a high rate of use of other smoking methods, particularly waterpipes and e-cigarettes, as an aid for quitting. Current smokers reported being in a stressful situation as a barrier to quitting significantly more often than did ex-smokers (P = .013). Both groups had moderately positive attitudes toward quitting. Ex-smokers had significantly better attitudes toward their ability to manage stress, weight gain, and increased appetite after quitting (P = .004, .004, and .007, respectively). This study provides valuable insights into the complex dynamics of smoking behavior, cessation attempts, and attitudes. These findings can inform the development of targeted smoking cessation programmes and policies.

Smoking and the Risk of Type 2 Diabetes: A Cross-sectional Analytical Study

Background

India is undergoing epidemiological transitions with the increase in noncommunicable disease (NCD) burden. Targeting the modifiable risk factors through lifestyle changes in the early years of life remains the most effective strategy for decreasing the prevalence of type 2 diabetes mellitus (T2DM). To determine the association between cigarette smoking and T2DM.

Materials and Methods

An analytical cross-sectional study was conducted among the patients attending the outpatient department of a tertiary care teaching hospital in Kolkata, West Bengal, India. Patients aged more than 35 years were enrolled, and details regarding sociodemography, clinical status, and NCD risk factors were collected using pretested semistructured questionnaires after obtaining IEC approval. Data collected were entered in MS Excel and analyzed using SPSS software. Simple logistic regression and multivariable logistic regression analysis were used to calculate the crude and adjusted odds ratio with 95% confidence interval.

Results

Out of 434 participants, 37.3% had diabetes mellitus, 51.6% were males, and 28.6% had alcohol consumption. Univariate logistic regression analysis revealed age, BMI, systolic BP, diastolic BP, and cigarette smoking were significantly associated with increased risk of T2DM. Multivariable logistic regression analysis revealed cigarette smoking, systolic BP, age, and female gender were significant risk factors for T2DM.

Conclusions

Our study reported cigarette smoking and systolic BP are modifiable risk factors associated with T2DM. Early identification of smoking through screening and appropriate control of hypertension in T2DM patients will decrease the morbidities and mortalities in T2DM cases.

Assessing the feasibility and acceptability of a diabetes-specific nurse-led multicomponent smoking cessation intervention in diabetes education: study protocol for an open-label pragmatic randomised controlled trial

INTRODUCTION

Smoking cessation is an essential, but often overlooked aspect of diabetes management. Despite the need for tailored smoking cessation support for individuals with diabetes, evidence of effective interventions for this cohort is limited. Additionally, individuals with diabetes do not easily adopt such interventions, resulting in low uptake and abstinence rates. This protocol describes a study that aims to assess the feasibility and acceptability of a unique smoking cessation intervention, based on the best evidence, theory and the needs of individuals with diabetes, among patients and service providers, the diabetes nurse educators.

METHODS AND ANALYSIS

This is an open-label pragmatic randomised controlled trial. Between 80 and 100 individuals with type 1 or type 2 diabetes who smoke will be recruited from the diabetes outpatients at the main acute public hospital in Malta, starting in August 2023. Participants will be randomly assigned (1:1 ratio) to the intervention or control arm for 12 weeks. The experimental intervention will consist of three to four smoking cessation behavioural support sessions based on the 5As (Ask, Advise, Assess, Assist and Arrange) algorithm, and a 6-week supply of nicotine replacement therapy. The control intervention will consist of an active referral to the Maltese National Health Service's one-to-one smoking cessation support service, which is based on motivational interviewing. The primary feasibility and acceptability outcomes include the recruitment and participation rates, resources used, problems identified by the nurses, the nurses' perceived challenges and facilitators to implementation and the nurses' and patients' acceptability of the study intervention. Data analyses will be descriptive, with quantitative feasibility and acceptability outcomes reported with 95% confidence intervals.

ETHICS AND DISSEMINATION

Ethical clearance was obtained from the Faculty of Health Sciences Research Ethics Committee, University of Malta. The study results will be disseminated through conference presentations and a publication in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

NCT05920096.

Influence of quitting smoking on diabetes-related complications: A scoping review with a systematic search strategy

INTRODUCTION

Smoking in people with diabetes markedly elevates their risk of developing complications and increases the likelihood of cardiovascular mortality. This review is the first to specifically provide evidence-based analysis about the influence of quitting smoking on diabetes-related complications in people with type 2 diabetes.

METHOD

The present review was carried out according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Extension for Scoping Reviews. All human clinical studies assessing the effects of stopping smoking cessation on diabetes-related complications were included. PubMed and Embase were screened until January 2024. References of primary studies and principal peer-reviewed scientific journals in the field were manually screened.

RESULTS

We identified a total of 1023 studies. Only 26 met the criteria for eligibility. In general quitting smoking is associated with decreased risks of myocardial infarction and ischemic stroke. Regarding microvascular complications, the strongest evidence for the beneficial effects of smoking cessation is observed in diabetic nephropathy. However, the relationship between smoking cessation and retinopathy, neuropathy, diabetic foot complications and diabetic-related erectile dysfunction, is poorly investigated.

CONCLUSION

Quitting smoking offers significant advantages in managing diabetes-related complications, significantly lowering the risks of myocardial infarction, ischemic stroke, and diabetic nephropathy. This underscores the importance of cessation. Providing evidence-based information on the benefits of stopping smoking for people with type 2 diabetes who smoke, can bolster smoking cessation efforts in the context of diabetes management.

The Experiences of People Who Smoke With Type 2 Diabetes: A Qualitative Interview Study Using the Capability, Opportunity, Motivation, and Behavior Model

ABSTRACT

Few interventions to support smoking cessation include content specifically about diabetes. This is problematic, as people with diabetes face unique challenges when they stop smoking. The purpose of this study was to understand patients' needs and challenges in relation to smoking with Type 2 diabetes and assess the acceptability of a text message intervention to support smoking cessation. People who smoke and have Type 2 diabetes in the United States and the United Kingdom were recruited to participate in semistructured interviews (n = 20), guided by the Capability, Opportunity, Motivation, and Behavior model. A combination of inductive and deductive approaches with framework analysis was used to analyze the data. Results indicated that the participants' experiences related to the constructs of the Capability, Opportunity, Motivation, and Behavior model and the categories of mental health and diabetes distress were also notable parts of their experiences. Results can be used to guide intervention development in this unique group.

A multicenter prospective randomized controlled trial investigating the effects of combustion-free nicotine alternatives on cardiovascular risk factors and metabolic parameters in individuals with type 2 diabetes who smoke: the DiaSmokeFree study protocol

Stopping smoking is crucial for public health and especially for individuals with diabetes. Combustion-free nicotine alternatives like e-cigarettes and heated tobacco products are increasingly being used as substitutes for conventional cigarettes, contributing to the decline in smoking prevalence. However, there is limited information about the long-term health impact of those products in patients with diabetes. This randomized controlled trial aims to investigate whether switching from conventional cigarettes to combustion-free nicotine alternatives will lead to a measurable improvement in cardiovascular risk factors and metabolic parameters over a period of 2 years in smokers with type 2 diabetes. The multicenter study will be conducted in seven sites across four countries. A total of 576 smokers with type 2 diabetes will be randomly assigned (1:2 ratio) to either standard of care with brief cessation advice (Control Arm) or combustion-free nicotine alternatives use (Intervention Arm). The primary end point is the change in the proportion of patients with metabolic syndrome between baseline and the 2-year follow-up. Additionally, the study will analyze the absolute change in the sum of the individual factors of metabolic syndrome at each study time point. Patient recruitment has started in September 2021 and enrollment is expected to be completed by December 2023. Results will be reported in 2026. This study may provide valuable insights into cardiovascular and metabolic health benefits or risks associated with using combustion-free nicotine alternatives for individuals with type 2 diabetes who are seeking alternatives to tobacco cigarette smoking. The study protocol, informed consent forms, and relevant documents were approved by seven ethical review boards. Study results will be disseminated through articles published in high-quality, peer-reviewed journals and presentations at conferences.

Smoking Behavior Change and the Risk of Heart Failure in Patients With Type 2 Diabetes: Nationwide Retrospective Cohort Study

BACKGROUND

Heart failure (HF) is one of the most common initial manifestations of cardiovascular disease in patients with type 2 diabetes. Although smoking is an independent risk factor for HF, there is a lack of data for the incidence of HF according to changes in smoking behaviors in patients with type 2 diabetes.

OBJECTIVE

We aimed to examine the association between interval changes in smoking behavior and the risk of HF among patients with type 2 diabetes.

METHODS

We conducted a retrospective cohort study using the National Health Insurance Service database. We identified 365,352 current smokers with type 2 diabetes who had 2 consecutive health screenings (2009-2012) and followed them until December 31, 2018, for the incident HF. Based on smoking behavior changes between 2 consecutive health screenings, participants were categorized into quitter, reducer I (≥50% reduction) and II (<50% reduction), sustainer (reference group), and increaser groups.

RESULTS

During a median follow-up of 5.1 (IQR 4.0-6.1) years, there were 13,879 HF cases (7.8 per 1000 person-years). Compared to sustainers, smoking cessation was associated with lower risks of HF (adjusted hazard ratio [aHR] 0.90, 95% CI0.86-0.95), whereas increasers showed higher risks of HF than sustainers; heavy smokers who increased their level of smoking had a higher risk of HF (aHR 1.13, 95% CI 1.04-1.24). In the case of reducers, the risk of HF was not reduced but rather increased slightly (reducer I: aHR 1.14, 95% CI 1.08-1.21; reducer II: aHR 1.03, 95% CI 0.98-1.09). Consistent results were noted for subgroup analyses including type 2 diabetes severity, age, and sex.

CONCLUSIONS

Smoking cessation was associated with a lower risk of HF among patients with type 2 diabetes, while increasing smoking amount was associated with a higher risk for HF than in those sustaining their smoking amount. There was no benefit from reduction in smoking amount.

Modifiable lifestyle, mental health status and diabetic retinopathy in U.S. adults aged 18-64 years with diabetes: a population-based cross-sectional study from NHANES 1999-2018

BACKGROUND

The relationship between integrated lifestyles, mental status and their impact on overall well-being has attracted considerable attention. This study aimed to evaluate the association between lifestyle factors, depression and diabetic retinopathy (DR) in adults aged 18-64 years.

METHODS

A cohort of 3482 participants diagnosed with diabetes was drawn from the National Health and Nutrition Examination Survey (NHANES) spanning the years 1999-2018. DR was defined based on self-reported diabetic retinopathy diagnoses by professional physicians, relying on Diabetes Interview Questionnaires. Subgroup analysis was employed to assess lifestyle and psychological factors between participants with DR and those without, both overall and stratified by diabetic duration. Continuous variables were analyzed using the student's t test, while weighted Rao-Scott χ2 test were employed for categorical variables to compare characteristics among the groups.

RESULTS

Of the 3482 participants, 767 were diagnosed with diabetic retinopathy, yielding a weighted DR prevalence of 20.8%. Patients with DR exhibited a higher prevalence of heavy drinking, depression, sleep deprivation, and insufficient physical activity compared to those without DR. Furthermore, multivariable logistic regression analysis revealed that sleeping less than 5 h (OR = 3.18, 95%CI: 2.04-4.95, p < 0.001) and depression (OR = 1.35, 95%CI:1.06-1.64, p = 0.025) were associated with a higher risk of DR, while moderate drinking (OR = 0.49, 95%CI: 0.32-0.75, p = 0.001) and greater physical activity (OR = 0.64, 95%CI: 0.35-0.92, p = 0.044) were identified as protective factors.

CONCLUSIONS

Adults aged 18-64 years with DR exhibited a higher prevalence of lifestyle-related risk factors and poorer mental health. These findings underscore the need for concerted efforts to promote healthy lifestyles and positive emotional well-being in this population.

The protective effects of curcumin against cigarette smoke-induced toxicity: A comprehensive review

Cigarette smoking (CS) is a crucial modifiable risk of developing several human diseases and cancers. It causes lung, bladder, breast, and esophageal cancers, respiratory disorders, as well as cardiovascular and metabolic diseases. Because of these adverse health effects, continual efforts to decrease the prevalence and toxicity of CS are imperative. Until the past decades, the impacts of natural compounds have been under investigation on the harmful effects of CS. Turmeric (Curcuma longa), a rhizomatous herbaceous perennial plant that belongs to the Zingiberaceae family, is the main source of curcumin. This review is an attempt to find out the current knowledge on CS's harmful effects and protective potential of curcumin in the pulmonary, liver, brain, gastrointestinal, and testis organs. According to the present review, simultaneous consumption of curcumin and CS can attenuate CS toxicities including chronic obstructive pulmonary disease, gastrointestinal toxicity, metabolic diseases, testis injury, and neurotoxicity. Moreover, curcumin suppresses carcinogenesis in the skin, liver, lungs, breast, colon, and stomach. Curcumin mediates these protective effects through antioxidant, anti-inflammatory, anti-apoptotic, and anti-carcinogenicity properties.

Changes in smoking status, amount of smoking and their relation to the risk of microvascular complications in men with diabetes mellitus

BACKGROUND

Smoking is a definite risk factor for macrovascular complications in diabetes mellitus (DM). However, the effect of smoking on microvascular complications is inconclusive.

METHOD

Study participants were 26,673 diabetic men who received health check-up both in 2003-2004 and 2009, excluding women. Assessing smoking status (never, quitting and current) at 2003-2004 and 2009, changes in smoking status were categorised into 7 groups (never - never, never - quitting, never - current, quitting-quitting, quitting-current, current-quitting and current-current). Smoking amount was categorised into never, light (0-10 pack years), moderate (10-20 pack years), and heavy smoking (>20 pack years) based on 2009 data. They were followed-up until 2013 to identify incident microvascular complications. We calculated the adjusted hazard ratios (HR) and 95% confidence interval (CI) (adjusted HR [95% CI]) for incident microvascular complications according to changes in smoking status and smoking amount.

RESULTS

Current-quitting (1.271 [1.050-1.538]), current-current (1.243 [1.070-1.444]) and heavy smoking (1.238 [1.078-1.422]) were associated with an increased risk of overall microvascular complications. The risk of nephropathy increased in current-current smoking (1.429 [1.098-1.860]) and heavy smoking (1.357 [1.061-1.734]). An increased risk of neuropathy was observed in current-quitting smoking (1.360 [1.076-1.719]), current-current smoking (1.237 [1.025-1.492]) and heavy smoking (1.246 [1.048-1.481]). However, we couldn't see the interpretable findings for the association between smoking and retinopathy.

CONCLUSIONS

Lasting and heavy smoking increases the risk of microvascular complications, including nephropathy and neuropathy. Quitting smoking and reducing smoking amount are imperative in preventing microvascular complications in DM patients.

Helping smokers with diabetes quit: A scoping review of the interventions utilised, and the challenges and barriers to smoking cessation

Tobacco smoking is recognised as a priority in diabetes management, yet many individuals with diabetes continue to smoke beyond diagnosis. This paper identifies the most promising smoking cessation strategies by reviewing the literature reporting interventions carried out amongst this study population, and the challenges and barriers to smoking cessation. Stand-alone smoking cessation interventions which included pharmacotherapy were found to be more successful in achieving abstinence than interventions which included smoking cessation as part of a broader intervention for improving diabetes management. Misconceptions about smoking and diabetes management were frequently reported, undervaluing smoking cessation. This emphasizes further the need to inform smokers with diabetes about the link between tobacco use and diabetes complications.

Smoking and diabetes: sex and gender aspects and their impact on vascular diseases

Smoking and diabetes mellitus (DM) have been identified as two major cardiovascular risk factors for many years. In the field of cardiovascular diseases, considering sex differences, or gender differences, or both has become an essential element in moving toward equitable and quality healthcare. We reviewed the impact of sex or gender on the link between smoking and DM. The risk of type 2 DM (T2DM) due to smoking has been established in both sexes at the same level. As is the case in the general population, the prevalence of smoking in those with DM is higher in men than in women, although the decrease in smoking observed in recent years is more pronounced in men than in women. Regarding chronic DM complications, smoking is an independent risk factor for all-cause mortality, as well as macrovascular and microvascular complications, in both sexes. Nevertheless, in T2DM, the burden of smoking appears to be greater in women than in men for coronary heart disease morbidity, women having a 50% higher risk of fatal coronary event. Women are more dependent to nicotine, cumulate psychosocial barriers to quitting smoking, and are more likely to gain weight, which might make it more difficult for them to quit smoking. Smoking cessation advice and treatments should take into account gender differences to improve the success and long-term maintenance of abstinence in people with and without DM. This might include interventions that address emotions and stress in women or designed to reach specific populations of men.

Effectiveness of intensive stand-alone smoking cessation interventions for individuals with diabetes: A systematic review and intervention component analysis

INTRODUCTION

Tobacco smoking poses a significant threat to the health of individuals living with diabetes. Intensive stand-alone smoking cessation interventions, such as multiple or long (>20 minutes) behavioral support sessions focused solely on smoking cessation, with or without the use of pharmacotherapy, increase abstinence when compared to brief advice or usual care in the general population. However, there is limited evidence so far for recommending the use of such interventions amongst individuals with diabetes. This study aimed to assess the effectiveness of intensive stand-alone smoking cessation interventions for individuals living with diabetes and to identify their critical features.

METHODS

A systematic review design with the addition of a pragmatic intervention component analysis using narrative methods was adopted. The key terms 'diabetes mellitus' and 'smoking cessation' and their synonyms were searched in 15 databases in May 2022. Randomized controlled trials which assessed the effectiveness of intensive stand-alone smoking cessation interventions by comparing them to controls, specifically amongst individuals with diabetes, were included.

RESULTS

A total of 15 articles met the inclusion criteria. Generally, the identified studies reported on the delivery of a multi-component behavioral support smoking cessation intervention for individuals with type I and type II diabetes, providing biochemically verified smoking abstinence rates at follow-up at six months. The overall risk-of-bias of most studies was judged to be of some concern. Despite observing inconsistent findings across the identified studies, interventions consisting of three to four sessions, lasting more than 20 min each, were found to be more likely to be associated with smoking cessation success. The additional use of visual aids depicting diabetes-related complications may also be useful.

CONCLUSIONS

This review provides evidence-based smoking cessation recommendations for use by individuals with diabetes. Nonetheless, given that the findings of some studies were found to be possibly at risk-of-bias, further research to establish the validity of the provided recommendations is suggested.

Prediabetes versus type 2 diabetes in patients with acute myocardial infarction and current smoking

BACKGROUND

Smoking is linked with increased risk of cardiovascular events among diabetic patients. Prediabetes is associated with increased risk for microvascular and macrovascular complications. We compared the 2-year clinical outcomes of current smoking between prediabetic and type 2 diabetes mellitus (T2DM) patients with acute myocardial infarction (AMI) after newer-generation drug-eluting stent (DES) implantation.

METHODS

A total of 5161 AMI patients who were currently smoking were classified into normoglycemia (group A: 1,416), prediabetes (group B: 1,740), and T2DM (group C: 2,005) groups. The primary endpoint was major adverse cardiac events (MACEs), defined as all-cause death, recurrent myocardial infarction and any repeat revascularization. The secondary endpoint was the occurrence of stent thrombosis (ST) and stroke.

RESULTS

The cumulative incidences of all primary and secondary endpoints including MACEs (adjusted hazard ratio [aHR]: 1.150; 95% confidence interval [CI]: 0.891-1.484; P = 0.284), ST, and stroke were similar between group B and group C. The cumulative incidences of MACEs (aHR: 1.385; 95% CI: 1.007-1.904; P = 0.045) and all-cause death or MI were significantly higher in group B than in group A. The cumulative incidences of MACEs (aHR: 1.572; 95% CI: 1.157-2.137; P = 0.004), all-cause death, Re-MI, and all-cause death or MI were significantly higher in group C than in group A.

CONCLUSIONS

Current smoking leads to worse clinical outcomes in patients with AMI and prediabetes, and thus, similarly to T2DM patients, more attention and more intensive treatment strategy including quitting smoking would be advantageous.

Smoking and diabetes interplay: A comprehensive review and joint statement

Evidence shows that smoking increases the risk of pre-diabetes and diabetes in the general population. Among persons with diabetes, smoking has been found to increase the risk of all-cause mortality and aggravate chronic diabetic complications and glycemic control. The current paper, which is a joint position statement by the French-Speaking Society on Tobacco (Société Francophone de Tabacologie) and the French-Speaking Society of Diabetes (Société Francophone du Diabète), summarizes the data available on the association between smoking and diabetes and on the impact of smoking and smoking cessation among individuals with type 1, type 2, and gestational diabetes mellitus. It also provides evidence-based information about the pharmacological and behavioral strategies for smoking cessation in these patients.

The Effect of Smoking Cessation on Body Weight and Other Metabolic Parameters with Focus on People with Type 2 Diabetes Mellitus

Smokers with diabetes mellitus substantially lower their risks of microvascular and macrovascular diabetic complications, in particular cardiovascular disease, by quitting smoking. However, subsequent post-smoking-cessation weight gain may attenuate some of the beneficial effects of smoking cessation and discourage attempts to quit. Weight gain can temporarily exacerbate diabetes and deteriorate glycemic control and metabolic profile. The molecular mechanisms by which quitting smoking leads to weight gain are largely associated with the removal of nicotine's effects on the central nervous system. This review addresses mechanisms of post-smoking-cessation weight gain, by reviewing the effects of nicotine on appetite, food intake, eating behaviour, energy expenditure, fat oxidation and appetite-regulating peptides. We also highlight correlations between post-cessation weight gain and risk of type 2 diabetes, consequences of weight gain in people with type 2 diabetes and the role of pharmacotherapies, which combine treatment of nicotine addiction and promotion of weight control.

Prevalence of Cardiovascular Risk Factors Among Patients With Diabetes Mellitus Type 2 at King Fahad University Hospital, Saudi Arabia

Background

Diabetes mellitus is considered a major risk factor for cardiovascular diseases. Patients with diabetes mellitus type 2 (DM-II) are at twice as high risk for the development of cardiovascular diseases than the general population. Thus, we aimed to assess the most prevalent cardiovascular risk (CVR) factors among DM-II patients in the Eastern province of Saudi Arabia.

Method

This is a cross-sectional, retrospective, and observational study conducted on DM-II patients at King Fahad University Hospital (KFUH) Al Khobar, Saudi Arabia, from January 2016 to December 2021. The total number of participants was 373 who were patients with DM-II. The patients' demographic information (age, sex, marital status, height, weight, body mass index (BMI), waist, hip circumference, and waist-hip ratio were calculated or obtained from hospital electronic records as were the CVR factors, age, gender, smoking habits, physical activity, BMI, haemodynamic measurements, glycosylated haemoglobin (HbA1C) levels and lipid profile.

The collected data were analyzed by using SPSS Statistics v.28 (IBM Corp., Armonk, NY). The descriptive statistics were reported using mean±SD for numerical data and relative frequencies (%) for categorical data. P < 0.05 were counted significant. Quantitative data were analyzed using the ANOVA test to compare the means of the three groups. Qualitative data were analyzed and compared using the chi-square test. Fisher’s exact test was also used to study the statistical significance of variables. Spearman rank correlation was used to study the relationship between HbA1C and other CV risk factors. 

Results

The mean age was 58 (± 13) years; females were 57% of the sample. Around 92% were smokers, 84% had a sedentary lifestyle, 72% had dyslipidemia, 58% were obese, 30% were overweight, 58% reported poorly control of their diabetes, 50% had hypertension and 32% had pre-hypertension. Furthermore, 89% of participants had two or more CVR factors other than DM-II. We found a significant association between high body mass index, dyslipidemia, high systolic blood pressure and pulse pressure (p<0.05) with HbA1C.

Conclusion

The majority of participants had two or more cardiovascular risk factors in addition to DM-II. Poor control of DM-II and cardiovascular risk factors cannot be ignored and primary to tertiary prevention must be the top priority when managing the diabetic population in order to prevent devastating outcomes and progression of reversible morbidity.

Efficacy and Safety of Varenicline for Smoking Cessation in Patients With Type 2 Diabetes: A Randomized Clinical Trial

Importance

Evidence of effective smoking cessation interventions in patients with diabetes is limited. The unique behavioral and metabolic characteristics of smokers with type 2 diabetes warrants a randomized clinical trial of the smoking cessation drug varenicline.

Objective

To evaluate the efficacy and safety of varenicline in patients with type 2 diabetes with an intention to quit smoking.

Design, Setting, and Participants

This multicenter, double-blind, placebo-controlled randomized clinical trial recruited patients from 6 outpatient clinics in 5 hospitals in Catania, Italy. Patients with type 2 diabetes, who were smoking at least 10 cigarettes a day, and who intended to quit smoking were screened for eligibility. Eligible patients were randomized to either varenicline or placebo treatment. The trial consisted of a 12-week treatment phase followed by a 40-week follow-up, nontreatment phase. Intention-to-treat data analysis was performed from December 2020 to April 2021.

Interventions

Varenicline, 1 mg, twice daily or matched placebo administered for 12 weeks. Patients in both treatment groups also received smoking cessation counseling.

Main Outcomes and Measures

The primary efficacy end point of the study was the continuous abstinence rate (CAR) at weeks 9 to 24. Secondary efficacy end points were the CAR at weeks 9 to 12 and weeks 9 to 52 as well as 7-day point prevalence of abstinence at weeks 12, 24, and 52.

Results

A total of 300 patients (mean [SD] age, 57.4 [0.8] years; 117 men [78.0%] in varenicline group and 119 men [79.3%] in placebo group) were randomized to receive varenicline (n = 150) or placebo (n = 150). The CAR at weeks 9 to 24 was significantly higher for the varenicline than placebo group (24.0% vs 6.0%; odds ratio [OR], 4.95; 95% CI, 2.29-10.70; P < .001). The CARs at weeks 9 to 12 (31.3% vs 7.3%; OR, 5.77; 95% CI, 2.85-11.66; P < .001) and weeks 9 to 52 (18.7% vs 5.3%; OR, 4.07; 95% CI, 1.79-9.27; P < .001) as well as the 7-day point prevalence of abstinence at weeks 12, 24, and 52 were also significantly higher for the varenicline vs placebo group. The most frequent adverse events occurring in the varenicline group compared with the placebo group were nausea (41 [27.3%] vs 17 [11.4%]), insomnia (29 [19.4%] vs 19 [12.7%]), abnormal dreams (19 [12.7%] vs 5 [3.4%]), anxiety (17 [11.4%] vs 11 [7.3%]), and irritability (14 [9.4%] vs 8 [5.4%]). Serious adverse events were infrequent in both groups and not treatment-related.

Conclusions and Relevance

Results of this trial showed that inclusion of varenicline in a smoking cessation program is efficacious in achieving long-term abstinence without serious adverse events. Varenicline should be routinely used in diabetes education programs to help patients with type 2 diabetes stop smoking.

Trial Registration

ClinicalTrials.gov Identifier: NCT01387425.

HbA1c, blood pressure and cholesterol control in adults with diabetes: A report card for Kuwait

Aim

To assess the level of glycemic, blood pressure, and cholesterol control (the ‘ABCs’) nationally amongst adults with diabetes living in Kuwait.

Materials and Methods

Using data from two national cross‐sectional surveys, the levels of risk factor control were assessed in 1,801 adults with diabetes, aged 18–82 years. Glycemic control was defined as HbA1c < 7%, blood pressure control as systolic and diastolic blood pressures of <140/90 mmHg, and non‐HDL cholesterol control as <3.4 mmol/L.

Results

The percentage of adults with diabetes achieving control was 39.2% (95% CI, 37.0–41.5) for glycemia, 58.4% (95% CI, 56.0–60.7) for blood pressure, and 28.3% (95% CI, 26.3–30.4) for non‐HDL cholesterol. The percentage of adults who were non‐smokers was 77.6% (95%, CI 75.6–79.4). The percentage of adults with diabetes achieving control on all three risk factors was 7.4% (95% CI, 6.3–8.8), and only 5.8% (95% CI, 4.8–7.0) achieved ABC control and were nonsmokers. ABC control was 30% higher in women compared with men. Non‐Kuwaitis were almost twice as likely to have uncontrolled ABC factors compared with Kuwaitis.

Conclusions

Only 1 in 13 people with diabetes in Kuwait achieved good control of glycemia, blood pressure, and cholesterol. Only 2 in 5 achieved glycemic control, 6 in 10 blood pressure control, and 2 in 7 cholesterol control. A national diabetes quality improvement program is urgently needed to improve the quality of care and to prevent long‐term complications.

Cardiovascular disease prediction model for Indonesian adult population with prediabetes and diabetes mellitus: The Bogor Cohort study of Noncommunicable Diseases Risk Factors

BACKGROUND AND AIMS

This study aims to develop a predictive model of cardiovascular events in dysglycemia among the Indonesian adult population.

METHODS

This is a retrospective cohort study conducted on subjects over 25 years in the "The Bogor Cohort Study of Noncommunicable Diseases Risk Factors" from 2011 to 2018. Data associated with age, gender, blood pressure, body mass index, waist circumference, blood glucose, cholesterol, smoking habits, family history of cardiovascular disease, and physical activity were obtained. Cardiovascular events in six years were observed; this included coronary heart disease, stroke, or all-cause cardiovascular mortality. Cox proportional hazards regression models were used to determine independent predictors of cardiovascular events.

RESULTS

A total of 1085 subjects with prediabetes and diabetes mellitus were included in this study, with 73.5% female. The cumulative incidence of cardiovascular events in six years was 9.7%. Predictors of cardiovascular events were age ≥45 years (HR = 2.737; 95% CI 1.565-4.787) and hypertension (HR = 2.580; 95% CI 1.619-4.112).

CONCLUSIONS

Age ≥45 years and hypertension were predictors of cardiovascular events in six years among the adult Indonesian population with prediabetes and diabetes, necessitating targeted intervention among these subjects.

A double blind randomized controlled trial investigating efficacy and safety of varenicline for smoking cessation in patients with type 2 diabetes: study protocol

Reducing exposure to cigarette smoke is an imperative for public health and for diabetic patients. Patients with diabetes who continue to smoke face challenges at quitting and the delivery of effective smoking cessation interventions is a major unmet need. The high-affinity α4β2 nicotinic acetylcholine receptor partial agonist varenicline in combination with counseling is effective for smoking cessation, but evidence in patients with diabetes is limited. A clinical trial of varenicline targeted specifically at smokers with T2DM is warranted. This randomized, double blind, placebo-controlled trial will be the first study to test efficacy and safety of varenicline in smokers with type 2 diabetes mellitus (T2DM) over the course of 52 weeks. We hypothesize that varenicline treatment (1 mg BID, administered for 12 weeks) would increase quit rates, maintain smoking abstinence up to 1 year after treatment, and be well-tolerated in T2DM smokers intending to quit. Efficacy end points will include carbon monoxide-confirmed continuous abstinence rate (CAR) and 7-day point prevalence of abstinence. The results of this RCT will help inform medical/health authorities and physicians worldwide whether an optimally varenicline-treated cohort of T2DM patients who smoke will experience significant success rates, without significant side effects.Trial registration NCT01387425 ( https://clinicaltrials.gov/ct2/show/NCT01387425 ).

Cigarette smoking and nicotine exposure contributes for aberrant insulin signaling and cardiometabolic disorders

Cigarette smoking- and nicotine-mediated dysregulation in insulin-signaling pathways are becoming leading health issues associated with morbidity and mortality worldwide. Many cardiometabolic disorders particularly insulin resistance, polycystic ovary syndrome (PCOS), central obesity and cardiovascular diseases are initiated from exposure of exogenous substances which augment by disturbances in insulin signaling cascade. Among these exogenous substances, nicotine and cigarette smoking are potential triggers for impairment of insulin-signaling pathways. Further, this aberrant insulin signaling is associated with many metabolic complications, which consequently give rise to initiation as well as progression of these metabolic syndromes. Hence, understanding the underlying molecular mechanisms responsible for cigarette smoking- and nicotine-induced altered insulin signaling pathways and subsequent participation in several health hazards are quite essential for prophylaxis and combating these complications. In this article, we have focused on the role of nicotine and cigarette smoking mediated pathological signaling; for instance, nicotine-mediated inhibition of nuclear factor erythroid 2-related factor 2 and oxidative damage, elevated cortisol that may promote central obesity, association PCOS and oxidative stress via diminished nitric oxide which may lead to endothelial dysfunction and vascular inflammation. Pathological underlying molecular mechanisms involved in mediating these metabolic syndromes via alteration of insulin signaling cascade and possible molecular mechanism responsible for these consequences on nicotine exposure have also been discussed.

International randomised controlled trial evaluating metabolic syndrome in type 2 diabetic cigarette smokers following switching to combustion-free nicotine delivery systems: the DIASMOKE protocol

INTRODUCTION

Reducing exposure to cigarette smoke is an imperative for public health and for patients with diabetes. Increasingly, combustion-free nicotine delivery systems (C-F NDS) such as e-cigarettes and heated tobacco products are substituting conventional cigarettes and accelerating the downward trends in smoking prevalence. However, there is limited information about the long-term health impact in patients with diabetes who use C-F NDS. This randomised trial of type 2 diabetic cigarette smokers will test the hypothesis that following a switch from conventional cigarettes to C-F NDS a measurable improvement in metabolic syndrome (MetS) factors will be shown over the course of 2 years.

METHODS AND ANALYSIS

The study is multicentre and thus will take place in five locations in four countries in an ambulatory setting. A total of 576 patients with diabetes will be randomised (1:2 ratio) to either a control arm (Study Arm A), in which they will be offered referral to smoking cessation programmes or to an intervention arm (Study Arm B) assigned to C-F NDS use. Participants will be at least 23 years old and of any gender. Patient recruitment will start in February 2021 and is expected to be completed by December 2021. Primary outcome measures include fasting plasma glucose, blood pressure, triglycerides, high-density lipoprotein and waist circumference, while secondary feature absolute change in the sum of the individual factors of MetS and change in each individual factor of MetS measured at each study time point.

ETHICS AND DISSEMINATION

The approval of research ethics committee (REC) regarding the trial protocol, informed consent forms and other relevant documents is required to commence the study. Substantial amendments to the study protocol cannot be implemented until the REC grants a favourable opinion. The results of the study are intended to be published as articles in high quality peer-reviewed journals and disseminated through conference papers.

TRIAL REGISTRATION NUMBER

NCT04231838. Pre-results stage.

Assessing Cardiovascular Risk in Patients with Diabetes: An Update

The globalization of the Western lifestyle has resulted in increase of diabetes mellitus, a complex, multifactorial disease. Diabetes mellitus is a condition often related to the disorders of the cardiovascular system. It is well established that three quarters of diabetics, aged over 40, will die from cardiovascular disease and are more likely than non-diabetics to die from their first cardiovascular event. Therefore, it is of paramount importance to individualize treatment via risk stratification. Conditions that increase cardiovascular risk in people with diabetes include age more than 40 years, male gender, history of relative suffering from premature CHD, blood pressure and high LDL levels, presence of microalbuminuria, obstructive sleepapnea, erectile dysfunction and other conditions.

Several models have been developed in order to assess cardiovascular risk in people with and without diabetes. Some of them have been proven to be inadequate while others are widely used for years. An emerging way of risk assessment in patients with diabetes mellitus is the use of biomarkers but a lot of research needs to be done in this field in order to have solid conclusions.

Joint effect of alcohol drinking and tobacco smoking on all-cause mortality and premature death in China: A cohort study

BACKGROUND

Tobacco smoking and alcohol drinking are associated with several diseases, and studies on the joint effects of smoking and drinking are rare.

OBJECTIVE

This study investigates the joint effects of tobacco smoking and alcohol drinking on all-cause and premature mortality in a contemporary cohort.

METHODS

The China Health and Retirement Longitudinal Study (CHARLS) is an ongoing nationally representative survey of subjects aged over 45 years in China that was performed every two years for a total of three waves from 2011 to 2015 in China. We used weighted logistic regression models to estimate the joint effects of tobacco smoking and alcohol drinking on all-cause and premature mortality.

RESULTS

After adjusting for prespecified confounders, the odds ratios (ORs) of all-cause mortality were 1.51 (95% CI: 1.09-2.10) and 1.47 (95% CI: 1.03-2.08) in smokers and smokers/drinkers, respectively. Compared with nonsmokers/nondrinkers, the OR of smokers/drinkers for premature death was 3.14 (95% CI: 1.56-6.34). In the female subgroup, there was an approximately 5-fold (OR = 4.95; 95% CI: 2.00-12.27) odds of premature mortality for smokers/drinkers compared to nonsmokers/nondrinkers.

CONCLUSION

This study found a joint effect of tobacco smoking and alcohol drinking on all-cause and premature mortality among a contemporary and nationally representative cohort in China. Our results suggested that the joint effects were more pronounced in women, but further research is needed.

Association of smoking cessation after new-onset type 2 diabetes with overall and cause-specific mortality among Korean men: a nationwide population-based cohort study

INTRODUCTION

This study aimed to examine the association between smoking cessation after new-onset type 2 diabetes and overall and cause-specific mortality risks among Korean men.

RESEARCH DESIGN AND METHODS

The Korean National Health Insurance Service-National Health Screening Cohort database was searched, and 13 377 Korean men aged ≥40 years diagnosed with new-onset type 2 diabetes between 2004 and 2007 were included and followed up until 2013. We defined smoking status changes by comparing participants' answers in the last survey before diagnosis to those in the first survey after diagnosis. We estimated the adjusted HR (AHR) and 95% CI for mortality risk using multivariable Cox proportional hazards regression models.

RESULTS

We identified 1014 all-cause mortality events (cancer, n=406 and cardiovascular disease (CVD), n=184) during an average follow-up duration of 7.2 years. After adjustment for all confounding factors, the reduced risk of all-cause mortality was more significant among short-term quitters (AHR 0.78; 95% CI 0.64 to 0.95), long-term quitters (AHR 0.68; 95% CI 0.54 to 0.85), and never smokers (AHR 0.66; 95% CI 0.56 to 0.78) compared with current smokers (p for trend <0.001). The lower risk of mortality from cancer was significant among the short-term quitters (AHR 0.60; 95% CI 0.44 to 0.83), long-term quitters (AHR 0.67; 95% CI 0.46 to 0.90), and never smokers (AHR 0.50; 95% CI 0.39 to 0.65) compared with current smokers (p for trend <0.001). There was no significant association between changes in smoking status and death from CVD. Smoking cessation after diagnosis in non-obese individuals (AHR 0.73; 95% CI 0.58 to 0.92) and exercisers (AHR 0.54; 95% CI 0.38 to 0.76) was significantly associated with reduced mortality risk than current smoking.

CONCLUSIONS

Smoking cessation after new-onset type 2 diabetes was associated with reduced mortality risk.

Does Type 2 Diabetes Mellitus Increase Postoperative Complications in Patients Submitted to Cardiovascular Surgeries?

Objective

To compare the incidence of postoperative complications (PC) between diabetic and nondiabetic patients undergoing cardiovascular surgeries (CS).

Methods

This is a retrospective cross-sectional study, based on the analysis of 288 medical records. Patients aged ≥ 18 years, admitted to the intensive care unit (ICU) between January 2012 and January 2013, and undergoing coronary artery bypass grafting (CABG) or vascular surgeries were included. The population was divided into those with and without type 2 diabetes mellitus (T2DM), and then it was evaluated the incidence of PC between the groups.

Results

The sample included 288 patients, most of them being elderly (67 [60-75] years old) male (64%) subjects. Regarding to surgical procedures, 60.4% of them were undergoing vascular surgeries and 39.6% were in the postoperative period of CABG. The incidence of T2DM in this population was 40% (115), just behind hypertension, with 72% (208). Other risk factors were also observed, such as smoking in 95 (33%) patients, dyslipidemias in 54 (19%) patients, and previous myocardial infarction in 55 (19%) patients. No significant difference in relation to PC (bleeding, atrial fibrillation, cardiorespiratory arrest, and respiratory complications) between the groups was observed (P>0.05).

Conclusion

T2DM has a high incidence rate in the population of critically ill patients submitted to CS, especially in the elderly. However, in this small retrospectively analyzed study, there was no significant increase in PC related to diabetes for patients undergoing CS.

Chronic Tobacco Exposure by Smoking Develops Insulin Resistance

BACKGROUND AND OBJECTIVES

The present review critically discusses the high occurrence rate, insulin resistance and type-2 diabetes in tobacco exposed individuals. Tobacco extracts and smoke contain a large number of toxic materials and a significant number of those are metabolic disintegrators.

DISCUSSION

Glucose and lipid homeostasis is severely impaired by this compound. Tobacco exposure contributes to adverse effects by impairing the physical, biochemical and molecular mechanisms in the tissues. The immunological components are damaged by tobacco with high production of proinflammatory cytokines (IL-6, TNF-∞) and augmentation of inflammatory responses. These events result in damages to cytoskeletal structures of different tissues. Degradation of matrix structure (by activation of different types of MMPs) results in the permanent damages to the tissues and their metabolic functions. Cellular antioxidant defense system mostly cannot or hardly nullify CS-induced ROS production that activates polymorphonuclear neutrophils (PMNs), which are a major source of cytokines and chemokines (TNFα, IL6, IL8, INFγ). Additive effects of these immediately promote the low energy-metabolism as well as inflammation. Oxidative stress, mitochondrial dysfunction, and inflammation contribute to the direct nicotine toxicity via nAChRs in diabetes. The investigator identified that skeletal muscle insulin-resistance occurs in smokers due to phosphorylation of insulin receptor substrate1 (IRS1) at Ser-636 position.

CONCLUSION

Tobacco exposure initiates free radical related immunological impairment, DNA damage, and inflammation. So, the present analysis is of importance to figure out the mechanistic layout of tobacco-induced tissue damage and its possible therapeutic interventions.

Life expectancy’s relationship with behavioral factors and polypharmacy in Western Balkan countries

Ageing is a multidisciplinary studied process characterized with a gradual increased time of homeostasis and decreased time of reaction and performance. Expected life expectancy is an important measure of a populations’ health status and healthcare system’s performance, which is characterized with a gradual increase in the modern world. This increasing trend changes between different countries and societies, while being affected by several internal, external and behavioral factors. This narrative review analyses and compares the countries of Western Balkans, all of whom classified as middle income countries. Increasing physical activity, avoiding smoking as well as decreasing overweight and obesity present reliable mechanisms to invest in terms of providing a better lifestyle and quality of life. Polypharmacy presents another integral player into this process, which affects and interacts with each and every other factor. Altogether should be taken in consideration in policy makings, healthcare approaches and intervention plans. Keywords: life expectancy, polypharmacy, western Balkan, overweight, obesity

The Effects of Smoking Cessation on Diabetes Mellitus Patients

BACKGROUND

Smoking is an established predictor of type 2 diabetes. However, the link between smoking cessation and diabetes progression remains a subject of scholarly investigation.

OBJECTIVE

The objective of this systematic review is to establish the link between smoking cessation and diabetes.

DATA SOURCES

The study utilized conference abstracts and peer-reviewed journals that reported randomized controlled trials smoking cessation interventions for diabetes patients.

RESULTS

Results from the review were inconclusive on the link between smoking cessation and diabetes. On one hand, several researchers have confirmed a positive correlation between smoking cessation and decreased risk of diabetes. On the other hand, some researchers have demonstrated that immediate withdrawal of nicotine resulted in increased risk of diabetes; however, this risk reduces with time.

CONCLUSION

The result of this review did not estblish a clear relationship between smoking cessation and diabates.

LIMITATIONS

Compared to other studies examining the implication of smoking on chronic diseases, this study identified a very small number of trials evaluating the effect of smoking cessation on diabetes. The small number of studies implies that the results may not be suitable for generalization.

IMPLICATION

Results from the review can help in the development of a tailored intervention for effective management of diabetes in smoking patients.

Health-related behaviours in a remote Indigenous population with Type 2 diabetes: a Central Australian primary care survey in the Telehealth Eye and Associated Medical Services Network [TEAMSnet] project

AIM

There is a wealth of data concerning the health behaviours of Indigenous Australians, but the health behaviours of Indigenous Australians with diabetes are not systematically documented. At the clinical level, understanding a person's health behaviours can help identify and address barriers to diabetes care and promote good clinical outcomes.

METHODS

We used a novel survey tool to systematically collect health behaviour data on Smoking, Nutrition, Alcohol consumption, Physical activity and Emotional well-being (SNAPE) from Indigenous Australians with Type 2 diabetes in a remote primary care setting in Alice Springs.

RESULTS

At least one of the five surveys in the SNAPE tool was completed by 210 participants: 30% male, mean age 52.6 years (range 22.9 - 87.4). Fifty per cent of men and 23% of women were current smokers (P < 0.001). None of the participants reported an adequate intake of vegetables. Only 9.6% reported an adequate fruit intake. Some 49% of men and 32% of women consumed alcohol in the past year (P = 0.022), and 46% of drinkers were considered high-risk or likely-dependent drinkers. On average, participants walked 10 min or more at a time 6.0 days a week and spent 4.8 h sitting on a weekday. Mean adapted Patient Health Questionnaire 9 score was 4.61, with 34% of participants having mild depressive symptoms and 11% having moderate-severe depressive symptoms.

CONCLUSIONS

Our SNAPE survey tool results present a high-risk, disadvantaged Indigenous population with Type 2 diabetes. More resources will be needed to sustainably implement interventions with the goal of improving health behaviours and subsequent long-term health.

Examining the effectiveness of general practitioner and nurse promotion of electronic cigarettes versus standard care for smoking reduction and abstinence in hardcore smokers with smoking-related chronic disease: protocol for a randomised controlled trial

Background

Despite the clear harm associated with smoking tobacco, many people with smoking-related chronic diseases or serious mental illnesses (SMI) are unwilling or unable to stop smoking. In many cases, these smokers have tried and exhausted all methods to stop smoking and yet clinicians are repeatedly mandated to offer them during routine consultations. Providing nicotine through electronic cigarettes (e-cigarettes) may reduce the adverse health consequences associated with tobacco smoking, but these are not currently offered. The aim of this study is to examine the feasibility, acceptability and effectiveness of general practitioners (GPs) and nurses delivering a brief advice intervention on e-cigarettes and offering an e-cigarette starter pack and patient support resources compared with standard care in smokers with smoking-related chronic diseases or SMI who are unwilling to stop smoking.

Methods/design

This is an individually randomised, blinded, two-arm trial. Smokers with a smoking-related chronic condition or SMI with no intention of stopping smoking will be recruited through primary care registers. Eligible participants will be randomised to one of two groups if they decline standard care for stopping smoking: a control group who will receive no additional support beyond standard care; or an intervention group who will receive GP or nurse-led brief advice about e-cigarettes, an e-cigarette starter pack with accompanying practical support booklet, and telephone support from experienced vapers and online video tutorials. The primary outcome measures will be smoking reduction, measured through changes in cigarettes per day and 7-day point-prevalence abstinence at 2 months. Secondary outcomes include smoking reduction, 7-day point-prevalence abstinence and prolonged abstinence at 8 months. Other outcomes include patient recruitment and follow-up, patient uptake and use of e-cigarettes, nicotine intake, contamination of randomisation and practitioner adherence to the delivery of the intervention. Qualitative interviews will be conducted in a subsample of practitioners, patients and the vape team to garner their reactions to the programme.

Discussion

This is the first randomised controlled trial to investigate whether e-cigarette provision alongside a brief intervention delivered by practitioners leads to reduced smoking and abstinence among smokers with smoking-related chronic diseases or SMI.

Trial registration

ISRCTN registry, ISRCTN59404712. Registered 28/11/17.

Smoking in men and women with type 2 diabetes: A qualitative gender-sensitive exploration of barriers to smoking cessation among people with type 2 diabetes

Objectives

Despite growing evidence of the impact of smoking on diabetes complications, people with type 2 diabetes still smoke at high rates and little is known about the specific barriers to quit smoking in this group. The purpose of this article is to explore the perception of smoking, and motivation and barriers to quit among smokers with type 2 diabetes. This exploratory study will help designing a smoking cessation intervention tailored to the needs of people with type 2 diabetes. We hypothesize both that living with diabetes and gender may raise additional difficulties to quit smoking.

Setting

The qualitative exploratory research included ten in-depth semi-structured individual interviews and five focus groups conducted in an Ambulatory Care University Hospital in Switzerland. The thematic analysis was conducted with a gender-sensitive focus.

Participants

Both current and former smokers recruited from the ambulatory clinic and the community took part in the qualitative interviews. We restricted the analysis to 21 current smokers only.

Results

The sample included 12 men and 9 women with type 2 diabetes, having a mean age of 59.4 years, who had diabetes for an average of 9 years with a mean HbA1c of 7.4%. We found that harmful effects of tobacco were superficially understood, and participants used several patterns of thinking to minimize the risks. The relation between tobacco and diabetes was poorly known. Readiness to change was related to personal self-image and meaningful engagement in life and social relationships. Barriers could be organized into three groups: dependence, psychological habits and social barriers. Barriers were markedly shaped by gender and living with diabetes.

Conclusions

Results suggest that “one -fits-all” smoking cessation interventions do not satisfy the needs of type 2 diabetic smokers. Personalized smoking cessation interventions should be preferred and should pursue positive psychological outcomes addressing contextual factors.

The global prevalence of tobacco use in type 2 diabetes mellitus patients: A systematic review and meta-analysis

BACKGROUND

A multi-layered association between tobacco use and type 2 diabetes mellitus (T2DM) is well established. However, global epidemiological patterns of tobacco use among T2DM patients are not well documented; this review thus aims to estimate the overall global burden of tobacco use in T2DM.

METHODS

A systematic review of studies published from Jan 1, 1990 to October 5, 2017 was undertaken, comprising: a comprehensive literature search on multiple electronic databases; quality assessment of studies; data extraction for the primary (prevalence of tobacco use in T2DM patients) and secondary outcomes (patterns of tobacco use in T2DM patients); and a meta-analysis. The review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement guidelines. A protocol for this review is available on PROSPERO (CRD42016038793).

FINDINGS

74 studies were included in the review, reporting data from 3.2 million participants across 33 countries. Global mean prevalence of tobacco use in T2DM was 20·81% (95% CI 18·93-22·76), and was higher in the WHO East Asia and Pacific and South Asia regions, compared to the Americas, Middle East and North Africa, Europe and Central Asia. In studies which compared prevalence of tobacco use in patients to non-patients, patients with T2DM were 26% less likely to use tobacco (pooled OR = 0·74 (CI 0·61-0·88).

INTERPRETATION

Tobacco is used by one in five T2DM patients globally, but usage is less likely in patients than in non-patients. Global patterns of use demonstrated by this review have implications for both prevention and The understanding of diabetes burden, and the success of tobacco cessation strategies.

Provider-Level Variation in Smoking Cessation Assistance Provided in the Cardiology Clinics: Insights From the NCDR PINNACLE Registry

Background Studies show suboptimal provision of smoking cessation assistance (counseling or pharmacotherapy) for current smokers attempting to quit. We aimed to identify smoking cessation assistance patterns in US cardiology practices. Methods and Results Among 328 749 current smokers seen between January 1, 2013, and March 31, 2016, in 348 NCDR (National Cardiovascular Data Registry) PINNACLE (Practice Innovation and Clinical Excellence)-affiliated cardiology practices, we measured the rates of cessation assistance. We used multivariable hierarchical logistic regression models to determine provider-, practice-, and patient-level predictors of cessation assistance. We measured provider variation in cessation assistance using median rate ratio (the likelihood that the same patient would receive the same assistance at by any given provider; >1.2 suggests significant variation). Smoking cessation assistance was documented in only 34% of encounters. Despite adjustment of provider, practice, and patient characteristics, there was large provider-level variation in cessation assistance (median rate ratio, 6 [95% CI , 5.76-6.32]). Practice location in the South region (odds ratio [OR], 0.48 [0.37-0.63] versus West region) and rural or suburban location (OR, 0.92 [0.88-0.95] for rural; OR, 0.94 [0.91-0.97] for suburban versus urban) were associated with lower rates of cessation assistance. Similarly, older age (OR, 0.88 [0.88-0.89] per 10-year increase), diabetes mellitus (OR, 0.84 [0.82-0.87]), and atrial fibrillation (OR, 0.93 [0.91-0.96]) were associated with lower odds of receiving cessation assistance. Conclusions In a large contemporary US registry, only 1 in 3 smokers presenting for a cardiology visit received smoking cessation assistance. Our findings suggest the presence of a large deficit and largely idiosyncratic provider-level variation in the provision of smoking cessation assistance.

Association of maternal arsenic exposure with birth size: A systematic review and meta-analysis

OBJECTIVES

Chronic exposure to arsenic during pregnancy or early life continues to be a major global health problem worldwide, affecting hundreds of millions of people. However, its effects on birth size are uncertain. The aim of this study is to summarized the association between maternal arsenic exposure and birth size.

METHODS

A comprehensive literature search was conducted on the maternal arsenic exposure and birth size (birth weight, birth length, head circumference and chest circumference) through databases (PubMed, Qvid Medline, Web of Science, Cochrane and EMBASE), the last search was in March 2019. Heterogeneity was testes by using the Q statistic and stratifying for epidemiological factors. The possibility of publication bias was assessed through Begg's test.

RESULTS

A total of 12 studies provided sufficient data were included. Meta-analysis revealed that maternal arsenic exposure was associated with the decrease of birth weight (β = -25.0 g; 95% CI: -41.0, -9.0) and head circumference (β = -0.12 cm; 95% CI: -0.24, -0.01) in random-effect model, birth length (β = -0.12 cm; 95% CI: -0.17, -0.07) in fixed-effect model, no significant reduction was suggested in chest circumference (β = -0.74 cm; 95% CI: -1.78, 0.3). In addition, we found that the birth weight decreased stronger in women living in the Americas, or appling the exposure marker of urine.

CONCLUSIONS

Maternal arsenic exposure is associated with the decrease of the birth weight, length and head circumference. Millions of people are still exposured to high-level arsenic, therefore, high quality epidemiologic studies that involve large samples are necessary to determine the precise relationships between maternal arsenic exposure with birth size. And that effective mitigation measures are also need to prevent arsenic exposure in women of reproductive age.

Quality indicators in type 2 diabetes patient care: analysis per care-complexity level

BACKGROUND

This study was developed to evaluate quality indicators in type 2 diabetes patient care at the Unified Public Health System's primary and tertiary health care centers within a local population.

METHODS

This was a retrospective cohort of 488 patients with type 2 diabetes (148 in each primary health care unit, ESF and UBS, and 192 at the tertiary health care unit) with a 1-year follow-up to evaluate the following care quality indicators: nephropathy, neuropathy and retinopathy tests, yearly lipid profile and nutritional assessments, and an inquiry about tobacco use. The presence of > 50% of the quality of care assessment measures was considered acceptable. Indicators were also evaluated in relation to patients without proper diabetes control (HbA1c > 8.5%).

RESULTS

In the results, a high percentage of patients were excluded specifically for not presenting the two HbA1c tests within a year (n = 208, 58.1% at ESF; n = 225, 58.4% at UBS; and n = 39, 16.9% at the tertiary health care unit). From the included patients, only 7 (4.7%) at ESF, 7 (4.7%) at UBS, and 52 (27.0%) at the tertiary health care unit showed > 50% of the quality criteria covered. When only patients without proper diabetes control were evaluated, none of them at any of the health care units showed all the quality criteria covered.

CONCLUSIONS

Our results show a low percentage of care assessment measures at each evaluated health care unit, pointing out the need to improve the protocols and care lines of diabetic patients.

The Importance and Role of Multiple Risk Factor Control in Type 2 Diabetes

PURPOSE OF REVIEW

The importance of composite risk factor control for reducing CVD risk in type 2 diabetes (T2DM) has gained increased attention and here we review the latest findings in the field.

RECENT FINDINGS

The Steno-2 study was the first to show that early intensive risk factor control could improve risk factor status and halve the CVD risk in patients with diabetes with lasting impact. A range of observational studies have added further insight to the importance of multiple risk factor control showing an incremental association between number of risk factors controlled and reduction in CVD risk. Noteworthy, a Swedish population-based study recently showed that optimal risk factor status in patients with T2DM was associated with a CVD risk similar to the general population. Early intensive intervention to achieve optimal risk factor control reduces CVD risk and should be of principal focus in T2DM management.

Association between full monitoring of biomedical and lifestyle target indicators and HbA1c level in primary type 2 diabetes care: an observational cohort study (ELZHA-cohort 1)

OBJECTIVE

Management of type 2 diabetes mellitus (T2DM) requires frequent monitoring of patients. Within a collective care group setting, doubts on the clinical effects of registration are a barrier for full adoption of T2DM registration in general practice. We explored whether full monitoring of biomedical and lifestyle-related target indicators within a care group approach is associated with lower HbA_1c levels.

DESIGN

Observational, real-life cohort study.

SETTING

Primary care data registry from the Hadoks (EerstelijnsZorggroepHaaglanden) care group.

EXPOSURE

The care group provides general practitioners collectively with organisational support to facilitate structured T2DM primary care. Patients are offered quarterly medical and lifestyle-related consultation.

MAIN OUTCOME MEASURE

Full monitoring of each target indicator in patients with T2DM which includes minimally one measure of HbA_1c level, systolic blood pressure, LDL, BMI, smoking behaviour and physical exercise between January and December 2014; otherwise, patients were defined as 'incompletely monitored'. HbA_1c levels of 8137 fully monitored and 3958 incompletely monitored patients were compared, adjusted for the confounders diabetes duration, age and gender. Since recommended HbA_1c values depend on age, medication use and diabetes duration, analyses were stratified into three HbA_1c profile groups. Linear multilevel analyses enabled adjustment for general practice.

RESULTS

Compared with incompletely monitored patients, fully monitored patients had significantly lower HbA_1c levels (95% CI) in the first (-2.03 [-2.53 to -1.52] mmol/mol) (-0.19% [-0.23% to -0.14%]), second (-3.36 [-5.28 to -1.43] mmol/mol) (-0.31% [-0.48% to -0.13%]) and third HbA_1c profile group (-1.89 [-3.76 to -0.01] mmol/mol) (-0.17% [-0.34% to 0.00%]).

CONCLUSIONS/INTERPRETATION

This study shows that in a care group setting, fully monitored patients had significantly lower HbA_1c levels compared with incompletely monitored patients. Since this difference might have considerable clinical impact in terms of T2DM-related risks, this might help general practices in care group settings to overcome barriers on adequate registration and thus improve structured T2DM primary care. From population health management perspective, we recommend a systematic approach to adjust the structured care protocol for incompletely monitored subgroups.

Cigarette smoking, type 2 diabetes mellitus, and glucagon-like peptide-1 receptor agonists as a potential treatment for smokers with diabetes: An integrative review

Tobacco use disorder (TUD), in particular cigarette smoking, contributes significantly to the macro- and micro-vascular complications of type 2 diabetes mellitus (DM). Persons with DM who regularly use tobacco products are twice as likely to experience mortality and negative health outcomes. Despite these risks, TUD remains prevalent in persons with DM. The objective of this integrative review is to summarize the relationship between TUD and DM based on epidemiological and preclinical biological evidence. We conclude with a review of the literature on the glucagon-like peptide-1 (GLP-1) as a potential treatment target for addressing comorbid TUD in smokers with DM.

Cardiovascular Disease in Type 2 Diabetes: A Review of Sex-Related Differences in Predisposition and Prevention

Type 2 diabetes mellitus is a major risk factor for cardiovascular disease. However, compiled data suggest that type 2 diabetes affects the risk of cardiovascular disease differentially according to sex. In recent years, large meta-analyses have confirmed that women with type 2 diabetes have a higher relative risk of incident coronary heart disease, fatal coronary heart disease, and stroke compared with their male counterparts. The reasons for these disparities are not completely elucidated. A greater burden of cardiometabolic risk in women was proposed as a partial explanation. Indeed, several studies suggest that women experience a larger deterioration in major cardiovascular risk factors and put on more weight than do men during their transition from normoglycemia to overt type 2 diabetes. This excess weight is associated with higher levels of biomarkers of endothelial dysfunction, inflammation, and procoagulant state. Moreover, sex differences in the prescription and use of some cardiovascular drugs may compound an "existing" disparity. We searched PubMed for articles published in English and French, by using the following terms: ("cardiovascular diseases") AND ("diabetes mellitus") AND ("sex disparity" OR "sex differences" OR "sex related differences" OR "sex-related differences" OR "sex disparities"). In this article, we review the available literature on the sex aspects of primary and secondary prevention of cardiovascular disease in people with type 2 diabetes, in the predisposition to cardiovascular disease in those people, and in the control of diabetes and associated cardiovascular risk factors.