Behaviour therapy versus doctor's anti-smoking advice in diabetic patients

A multicomponent smoking cessation program for adults with Type 2 Diabetes Mellitus (DiMe-SALUD2 project): A study protocol of a randomized controlled trial

Background

Tobacco use represents a significant public health burden, being especially harmful for smokers with Type 2 Diabetes Mellitus (T2DM). Effective smoking cessation interventions are required for this vulnerable population. The goal is to describe a study protocol of a randomized controlled trial (RCT) aimed at analyzing the effectiveness and efficiency of a multicomponent smoking cessation intervention for T2DM smokers, including a training protocol on healthy lifestyle habits and self-management of T2DM (DiMe-SALUD2 project).

Methods

This RCT will assign participants to: (1) Control Group (n = 30), including a brief psychoeducation advice about smoking cessation; (2) Cognitive-behavioral treatment (CBT) for smoking cessation (n = 30), based on a multicomponent program implemented in group-based sessions over an eight-week period; and (3) CBT plus DiMeSALUD2 protocol (n = 30), which will develop an additional psychoeducational protocol specifically designed to improve healthy lifestyle habits. Participants will be assessed at baseline, post-treatment and several follow-ups (1-, 6- and 12-months). Primary outcomes will include smoking abstinence (24-h point prevalence abstinence at post-treatment and 7-day point prevalence at follow-ups) and smoking continuous abstinence. Secondary outcomes will include treatment retention, changes in smoking patterns and nicotine dependence, as well as the impact on T2DM clinical variables, mental health, and quality of life.

Discussion

The DiMeSALUD2 program could assist T2DM smokers in quitting tobacco use and improving their overall quality of life. This project will help incorporating improvements in routine clinical practice with T2DM patients, offering a smoking cessation program adapted to their specific needs.

Trial registration

ClinicalTrials.gov. Identifier: NCT05885659. Date of registration: June 2nd, 2023.

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.

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.

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 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.

MIFuzzy Clustering for Incomplete Longitudinal Data in Smart Health

Missing data are common in longitudinal observational and randomized controlled trials in smart health studies. Multiple-imputation based fuzzy clustering is an emerging non-parametric soft computing method, used for either semi-supervised or unsupervised learning. Multiple imputation (MI) has been widely-used in missing data analyses, but has not yet been scrutinized for unsupervised learning methods, although they are important for explaining the heterogeneity of treatment effects. Built upon our previous work on MIfuzzy clustering, this paper introduces the MIFuzzy concepts and performance, theoretically, empirically and numerically demonstrate how MI-based approach can reduce the uncertainty of clustering accuracy in comparison to non- and single-imputation based clustering approach. This paper advances our understanding of the utility and strength of MIFuzzy clustering approach to processing incomplete longitudinal behavioral intervention data.

Brief intervention to promote smoking cessation and improve glycemic control in smokers with type 2 diabetes: a randomized controlled trial

The aim of the study was to examine the effects of a brief stage-matched smoking cessation intervention group compared with a control group (with usual care) in type 2 diabetes mellitus patients who smoked by randomized controlled trial. There were 557 patients, randomized either into the intervention group (n = 283) who received brief (20- minute) individualized face-to-face counseling by trained nurses and a diabetes mellitus-specific leaflet, or a control group (n = 274) who received standard care. Patient follow-ups were at 1 week, 1 month, 3 months, 6 months, and 12 months via telephone, and assessment of smoking status from 2012 to 2014. Patients smoked an average of 14 cigarettes per day for more than 37 years, and more than 70% were in the precontemplation stage of quitting. The primary outcome showed that both the intervention and control groups had similar 7-day point-prevalence smoking abstinence (9.2% vs. 13.9%; p = 0.08). The secondary outcome showed that HbA1c levels with 7.95% [63 mmol/mol] vs. 8.05% [64 mmol/mol], p = 0.49 at 12 months, respectively. There was no evidence for effectiveness in promoting the brief stage-matched smoking cessation or improving glycemic control in smokers with type 2 diabetes mellitus, particularly those in the pre-contemplation stage.

Group behaviour therapy programmes for smoking cessation

BACKGROUND

Group therapy offers individuals the opportunity to learn behavioural techniques for smoking cessation, and to provide each other with mutual support.

OBJECTIVES

To determine the effect of group-delivered behavioural interventions in achieving long-term smoking cessation.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Specialized Register, using the terms 'behavior therapy', 'cognitive therapy', 'psychotherapy' or 'group therapy', in May 2016.

SELECTION CRITERIA

Randomized trials that compared group therapy with self-help, individual counselling, another intervention or no intervention (including usual care or a waiting-list control). We also considered trials that compared more than one group programme. We included those trials with a minimum of two group meetings, and follow-up of smoking status at least six months after the start of the programme. We excluded trials in which group therapy was provided to both active therapy and placebo arms of trials of pharmacotherapies, unless they had a factorial design.

DATA COLLECTION AND ANALYSIS

Two review authors extracted data in duplicate on the participants, the interventions provided to the groups and the controls, including programme length, intensity and main components, the outcome measures, method of randomization, and completeness of follow-up. The main outcome measure was abstinence from smoking after at least six months follow-up in participants smoking at baseline. We used the most rigorous definition of abstinence in each trial, and biochemically-validated rates where available. We analysed participants lost to follow-up as continuing smokers. We expressed effects as a risk ratio for cessation. Where possible, we performed meta-analysis using a fixed-effect (Mantel-Haenszel) model. We assessed the quality of evidence within each study and comparison, using the Cochrane 'Risk of bias' tool and GRADE criteria.

MAIN RESULTS

Sixty-six trials met our inclusion criteria for one or more of the comparisons in the review. Thirteen trials compared a group programme with a self-help programme; there was an increase in cessation with the use of a group programme (N = 4395, risk ratio (RR) 1.88, 95% confidence interval (CI) 1.52 to 2.33, I2 = 0%). We judged the GRADE quality of evidence to be moderate, downgraded due to there being few studies at low risk of bias. Fourteen trials compared a group programme with brief support from a health care provider. There was a small increase in cessation (N = 7286, RR 1.22, 95% CI 1.03 to 1.43, I2 = 59%). We judged the GRADE quality of evidence to be low, downgraded due to inconsistency in addition to risk of bias. There was also low quality evidence of benefit of a group programme compared to no-intervention controls, (9 trials, N = 1098, RR 2.60, 95% CI 1.80 to 3.76 I2 = 55%). We did not detect evidence that group therapy was more effective than a similar intensity of individual counselling (6 trials, N = 980, RR 0.99, 95% CI 0.76 to 1.28, I2 = 9%). Programmes which included components for increasing cognitive and behavioural skills were not shown to be more effective than same-length or shorter programmes without these components.

AUTHORS' CONCLUSIONS

Group therapy is better for helping people stop smoking than self-help, and other less intensive interventions. There is not enough evidence to evaluate whether groups are more effective, or cost-effective, than intensive individual counselling. There is not enough evidence to support the use of particular psychological components in a programme beyond the support and skills training normally included.

Tobacco and diabetes: clinical relevance and approach to smoking cessation in diabetic smokers

Smoking is, together with diabetes mellitus, one of the main risk factors for cardiovascular disease. Diabetic patients have unique features and characteristics, some of which are not well known, that cause smoking to aggravate the effects of diabetes and impose difficulties in the smoking cessation process, for which a specificand more intensive approach with stricter controls is required. This review details all aspects with a known influence on the interaction between smoking and diabetes, both as regards the increased risk of macrovascular and microvascular complications of diabetes and the factors with an impact on the results of smoking cessation programs. The treatment guidelines for these smokers, including the algorithms and drug treatment patterns which have proved most useful based on scientific evidence, are also discussed.

Substance Use Disorders among Patients with Type 2 Diabetes: a Dangerous but Understudied Combination

PURPOSE OF REVIEW

This paper reviews research on substance use and disorders (SUDs) among adults with diabetes. It describes epidemiological data on SUDs in persons with type 2 diabetes, overviews effects of substance use on diabetes outcomes, and discusses treatments for SUDs in patients with diabetes.

RECENT FINDINGS

Rates of current smoking range from 10 to 26% and alcohol use disorders are 0-5%. Rates of illicit SUDs are 3-4%, but there are no population-based studies using nationally representative samples. Smoking increases the risk for long-term diabetes complications and premature death. Alcohol and illicit drug use can also impact long-term diabetes complications by impairing glucose homeostasis and adversely influencing self-management behaviors. There is mixed evidence about psychosocial smoking cessation interventions in adults with diabetes and little on alcohol and illicit SUD interventions. Limited data exist on pharmacotherapies for SUDs in this population, but a recent study suggests that varenicline is safe and effective for treating smoking in patients with diabetes. Substance use is an understudied problem in type 2 diabetes, and addressing substance use holds potential for improving outcomes. Additional large population-based epidemiological studies in those with type 2 diabetes are needed, particularly for alcohol and illicit SUDs. Longitudinal studies should be conducted to better understand the time course of diabetes onset and outcomes in relation to SUDs. Randomized controlled trials are needed to assess safety and efficacy of promising psychosocial and pharmacological interventions.

Integrated Tobacco Cessation Counseling in a Diabetes Self-management Training Program

Purpose

The purpose of this study was to evaluate the impact of a tobacco cessation intervention using motivational interviewing on smoking cessation rates during diabetes self-management training (DSMT).

Methods

A randomized controlled trial was conducted with subjects recruited from an ongoing type 2 diabetes adult education program at a large diabetes center. A total of 114 subjects were randomized to intervention (n = 57; face-to-face motivational interviewing plus telephone counseling and offering of medication) or standard care (n = 57). Outcome measures included tobacco cessation rates, mean number of cigarettes smoked, A1C, weight, blood pressure, and lipids.

Results

Intensive intervention using motivational interviewing integrated into a standard DSMT program resulted in a trend toward greater abstinence at 3 months of follow-up in those receiving the intervention. However, this same trend was not observed at 6 months. The addition of this structured smoking cessation intervention did not negatively affect either diabetes education or other measures of diabetes management, including A1C values.

Varenicline in smokers with diabetes: A pooled analysis of 15 randomized, placebo-controlled studies of varenicline

Aims/Introduction

Stopping smoking deserves high priority in preventing complications of diabetes; however, only sparse data are available regarding the efficacy of pharmacotherapy in smokers with diabetes. We assessed the efficacy and safety of varenicline in smokers with diabetes who participated in 15 double‐blind, randomized, placebo‐controlled studies.

Materials and Methods

This retrospective pooled analysis included data from smokers of ≥10 cigarettes per day with diabetes. Participants received varenicline 1 mg b.i.d. or placebo for 12 weeks. We examined carbon monoxide‐confirmed continuous abstinence rates (CARs) for weeks 9–12, 9–24 and 9–52, and compared safety in participants with and without diabetes.

Results

Of 6,771 participants, 323 had diabetes (varenicline n = 162; placebo n = 161). Week 9–12 CAR was higher with varenicline than placebo (43.8% vs 24.8%; odds ratio 2.36, 95% CI 1.47–3.79), as was week 9–24 CAR (27.5% vs 14.4%; odds ratio 2.25, 95% CI 1.27–4.00). Week 9–52 CAR was 18.4% for varenicline and 10.1% for placebo (odds ratio 2.00, 95% CI 0.90–4.49). The most commonly‐reported adverse events in participants with diabetes for varenicline vs placebo were: nausea (27.2% vs 8.1%); headache (9.3% vs 9.9%); and insomnia (8.6% vs 5.6%), incidences that were similar in participants without diabetes (29.6% vs 9.7%; 13.4% vs 10.9%; and 11.4% vs 7.1%, respectively). Weight gain in quitters with diabetes (1.7 kg) was similar to that of those without diabetes (2.1 kg).

Conclusions

Varenicline was an effective and well‐tolerated aid for smoking cessation in individuals with diabetes. Safety was comparable with participants without diabetes.

Multiple- vs Non- or Single-Imputation based Fuzzy Clustering for Incomplete Longitudinal Behavioral Intervention Data

Disentangling patients' behavioral variations is a critical step for better understanding an intervention's effects on individual outcomes. Missing data commonly exist in longitudinal behavioral intervention studies. Multiple imputation (MI) has been well studied for missing data analyses in the statistical field, however, has not yet been scrutinized for clustering or unsupervised learning, which are important techniques for explaining the heterogeneity of treatment effects. Built upon previous work on MI fuzzy clustering, this paper theoretically, empirically and numerically demonstrate how MI-based approach can reduce the uncertainty of clustering accuracy in comparison to non-and single-imputation based clustering approach. This paper advances our understanding of the utility and strength of multiple-imputation (MI) based fuzzy clustering approach to processing incomplete longitudinal behavioral intervention data.

Effects of cigarette smoking on rhinologic diseases: Korean National Health and Nutrition Examination Survey 2008-2011

BACKGROUND

Several studies have shown a relationship between cigarette smoking and general diseases of the nose in a large Asian population. The current study was conducted to better understand the effect of cigarette smoke exposure on rhinologic diseases in Koreans.

METHODS

Data were obtained from the 2008-2011 Korea National Health and Nutrition Examination Survey, a cross-sectional survey of the noninstitutionalized population in Korea. Of the 37,753 people surveyed, 11,589 adult participants had completed questionnaires on rhinologic symptoms and smoking behaviors, had undergone nasal endoscopy, and had provided urine collection were enrolled. Rhinologic diseases investigated in this study included subjective olfactory dysfunction, rhinitis symptoms, chronic rhinosinusitis (CRS), and nasal septal deviation with obstructive symptoms. The relationship between disease and cigarette smoking was evaluated using multivariate regression analyses.

RESULTS

In South Korea, the weighted prevalence of subjective olfactory dysfunction, rhinitis symptoms, CRS, and nasal septal deviation with obstructive symptoms was 4.6%, 27.2%, 6.2%, and 4.0%, respectively. The only disease significantly associated with active smoking was CRS in participants 40 years of age and older after adjusting for age, sex, residency, house income, education, and occupation (adjusted odds ratio = 1.427, 95% confidence interval = 1.050 to 1.938). For each year of active smoking, CRS prevalence increased by 1.5%. None of the rhinologic diseases examined were associated with passive smoking.

CONCLUSION

Our study showed that CRS seems to be associated with active smoking in older participants. Considering the relatively high prevalence of CRS in Korea, further longitudinal researches for their association and prevention are required.

Smoking cessation in adults with diabetes: a systematic review and meta-analysis of data from randomised controlled trials

OBJECTIVES

To evaluate the effects of more intensive smoking cessation interventions compared to less intensive interventions on smoking cessation in people with type 1 or type 2 diabetes.

DESIGN

A systematic review and meta-analysis of randomised trials of smoking cessation interventions was conducted. Electronic searches were carried out on the following databases: MEDLINE, EMBASE, CINAHL and PsycINFO to September 2013. Searches were supplemented by review of trial registries and references from identified trials. Citations and full-text articles were screened by two reviewers. A random-effect Mantel-Haenszel model was used to pool data.

SETTING

Primary, secondary and tertiary care.

PARTICIPANTS

Adults with type 1 or type 2 diabetes.

INTERVENTIONS

Smoking cessation interventions or medication (more intensive interventions) compared to usual care, counselling or optional medication (less intensive interventions).

OUTCOME MEASURES

Biochemically verified smoking cessation was the primary outcome. Secondary outcomes were adverse events and effects on glycaemic control. We also carried out a pooled analysis of self-reported smoking cessation outcomes.

RESULTS

We screened 1783 citations and reviewed seven articles reporting eight trials in 872 participants. All trials were of 6 months duration. Three trials included pharmacotherapy for smoking cessation. The risk ratio of biochemically verified smoking cessation was 1.32 (95% CI 0.23 to 7.43) for the more intensive interventions compared to less intensive interventions with significant heterogeneity (I(2)=76%). Only one trial reported measures of glycaemic control.

CONCLUSIONS

There is an absence of evidence of efficacy for more intensive smoking cessation interventions in people with diabetes. The more intensive strategies tested in trials to date include interventions used in the general population, adding in diabetes-specific education about increased risk. Future research should focus on multicomponent smoking cessation interventions carried out over a period of at least 1 year, and also assess impact on glycaemic control.

Results of the application of the American Diabetes Association guidelines regarding tobacco dependency in subjects with diabetes mellitus

The objective of the study was to evaluate the stages of change for cessation in smoking after the application of American Diabetes Association recommendations in diabetic patients who smoke. This longitudinal descriptive study involved smokers with diabetes mellitus (DM) who were attended for their DM between September 2003 and December 2006. Intervention used was dependent on the stage of change for cessation (according to Prochaska and Di Clemente). For precontemplation subjects, a brief session was carried out where information regarding the risks of smoking in conjunction with DM was given. Patients at the contemplation stage of smoking cessation were offered the chance to participate in a cessation program. Later evaluation was carried out after a follow-up of more than 6 months. Seven hundred thirty-three subjects with DM were evaluated, including 156 smokers (21.28%): 103 (66.02%) in the precontemplation stage, 25 (16.02%) in the contemplation stage, 12 (7.69%) in the preparation stage, 12 (7.69%) in the action stage, and 4 (2.56%) in the maintenance stage. By the last follow-up, 65 (41.6%) subjects had quit smoking (36 ex-smokers), of whom 20 (30.77%) had subsequently relapsed. The use of the American Diabetes Association recommendations for the treatment of tobacco dependence in diabetes treatment results in an increased change of smoking cessation stages in subjects with DM as well as a higher overall percentage in abstinence.

Cigarette smoking, smoking cessation, and diabetes

There is evidence for increased risk of developing type 2 diabetes among cigarette smokers. In addition, smoking-associated health risks can exacerbate major conditions that precede or accompany diabetes, such as cardiovascular and kidney diseases. Smoking cessation can result in weight gain and a short-term worsening of some diabetic symptoms that may deter smokers with diabetes from attempting to quit. Additionally, there is limited evidence regarding the efficacy/safety of smoking cessation pharmacotherapies in this population and the general effects of smoking cessation, particularly for type 1 diabetes. Smoking cessation in diabetes therefore remains a highly relevant subject for further research.

Reducing risks in diabetes self-management: a systematic review of the literature

OBJECTIVE

The purpose of this systematic review was to review published literature on risk-reducing interventions as part of diabetes self-management.

DATA SOURCES

Medline (1990-2007), CINAHL (1990-2007), and Cochrane Central Register of Controlled Trials (first quarter 2007) databases were searched. Reference lists from included studies were reviewed to identify additional studies.

STUDY SELECTION

Intervention studies that addressed reducing risks to help prevent or minimize diabetes complications were included.

DATA EXTRACTION

Study design, sample characteristics, interventions, and outcomes were extracted.

DATA SYNTHESIS

Thirty-three studies, represented by 39 articles, met the criteria for inclusion and were classified as smoking cessation (n = 3), eye examination (n = 2), foot care (n = 10), oral health (n = 2), vaccination (n = 1), cardiovascular risk reduction (n = 9), and comprehensive risk reduction (n = 6). Only 46.3% of the 283 outcomes measured in the 33 studies were significantly improved.

CONCLUSIONS

Reducing risks involves implementing effective risk reduction behaviors to prevent or slow the progression of diabetes complications. Recognizing risk factors for complications and what constitutes optimal preventive care is an important part of managing diabetes. Intervention studies are lacking in some areas of reducing risks. Further studies are needed to test specific interventions to reduce the risks of diabetes complications.

Difficulties of smoking cessation in diabetic inpatients benefiting from a systematic consultation to help them to give up smoking

AIM

To assess the value of systematic smoking cessation consultations for diabetic smokers admitted to hospital.

METHODS

All diabetic smokers admitted to the Diabetes Department of Georges Pompidou European Hospital between February 2003 and February 2004 were systematically offered a consultation with a physician specialised in tobacco cessation. Follow-up visits at three, six and nine months were planned.

RESULTS

Of the 306 diabetic patients admitted, 38 (12.4%) were smokers. There were more men than women in the group of smokers and the diabetic smokers were younger than the non-smokers. The smokers had fewer micro-angiopathic complications than the non-smokers, but there was no difference in the frequency of macro-angiopathic complications. The level of nicotine physical dependence was moderate or high for 60% of the smokers. Although all the smokers agreed to the consultation, less than half agreed to drug-based treatments to help them to give up smoking and only 15% returned for the six-month visit. Only one patient had stopped smoking at the six-month visit.

CONCLUSION

This study demonstrates the difficulties in systematic interventions to help diabetic patients to stop smoking. Diabetic smokers probably constitute a specific population for which the barriers to giving up smoking should be explored.

Smoking cessation in patients with diabetes mellitus: results from a controlled study of an intervention programme in primary healthcare in Sweden

OBJECTIVE

To evaluate an intervention programme on smoking cessation in patients with diabetes mellitus in primary healthcare.

DESIGN

Regional controlled intervention study.

SETTING

Seventeen primary healthcare centres in Sweden.

INTERVENTION

In the intervention centres, nurses with education in diabetes were given one half-day of training in motivational interviewing and smoking cessation. An invitation to participate in a smoking cessation group was mailed to patients from the intervention centres followed by a telephone call from the patient's diabetes nurse. The nurses who intervened were specially educated in smoking cessation. The control group received a letter containing advice to stop smoking and information about a one-year follow-up.

PATIENTS

Daily smokers with diabetes mellitus, 30-75 years of age. In the intervention centres 241 patients fulfilled the criteria and in the control centres 171 patients.

MAIN OUTCOME MEASURES

Self-reported smoking habits after one year.

RESULTS

In total, 21% of the smokers accepted group treatment. After 12 months, 20% (42/211) in the intervention centres reported that they had stopped smoking and 7% (10/140) in the control centres; 40% (19/47) of the smokers who had participated in group treatment reported that they had stopped smoking.

CONCLUSION

A computerized record system for patients in primary healthcare was used to identify diabetic patients who were smokers. The selected group was invited to a stop smoking programme. At a one-year follow-up significantly more patients in the intervention centres had stopped smoking compared with patients in the control centres.

Group behaviour therapy programmes for smoking cessation

BACKGROUND

Group therapy offers individuals the opportunity to learn behavioural techniques for smoking cessation, and to provide each other with mutual support.

OBJECTIVES

We aimed to determine the effects of smoking cessation programmes delivered in a group format compared to self-help materials, or to no intervention; to compare the effectiveness of group therapy and individual counselling; and to determine the effect of adding group therapy to advice from a health professional or to nicotine replacement. We also aimed to determine whether specific components increased the effectiveness of group therapy. We aimed to determine the rate at which offers of group therapy are taken up.

SEARCH STRATEGY

We searched the Cochrane Tobacco Addiction Group Trials Register, with additional searches of MEDLINE and PsycINFO, including the terms behavior therapy, cognitive therapy, psychotherapy or group therapy, in January 2005.

SELECTION CRITERIA

We considered randomized trials that compared group therapy with self help, individual counselling, another intervention or no intervention (including usual care or a waiting list control). We also considered trials that compared more than one group programme. We included those trials with a minimum of two group meetings, and follow up of smoking status at least six months after the start of the programme. We excluded trials in which group therapy was provided to both active therapy and placebo arms of trials of pharmacotherapies, unless they had a factorial design.

DATA COLLECTION AND ANALYSIS

We extracted data in duplicate on the participants, the interventions provided to the groups and the controls, including programme length, intensity and main components, the outcome measures, method of randomization, and completeness of follow up. The main outcome measure was abstinence from smoking after at least six months follow up in patients smoking at baseline. We used the most rigorous definition of abstinence in each trial, and biochemically validated rates where available. Subjects lost to follow up were analyzed as continuing smokers. Where possible, we performed meta-analysis using a fixed-effects (Mantel-Haenszel) model.

MAIN RESULTS

A total of 55 trials met inclusion criteria for one or more of the comparisons in the review. Sixteen studies compared a group programme with a self-help programme. There was an increase in cessation with the use of a group programme (N = 4395, odds ratio (OR) 2.04, 95% confidence interval (CI) 1.60 to 2.60). Group programmes were more effective than no intervention controls (seven trials, N = 815, OR 2.17, 95% CI 1.37 to 3.45). There was no evidence that group therapy was more effective than a similar intensity of individual counselling. There was limited evidence that the addition of group therapy to other forms of treatment, such as advice from a health professional or nicotine replacement, produced extra benefit. There was variation in the extent to which those offered group therapy accepted the treatment. There was limited evidence that programmes which included components for increasing cognitive and behavioural skills and avoiding relapse were more effective than same length or shorter programmes without these components. This analysis was sensitive to the way in which one study with multiple conditions was included. We did not find an effect of manipulating the social interactions between participants in a group programme on outcome.

AUTHORS' CONCLUSIONS

Group therapy is better for helping people stop smoking than self help, and other less intensive interventions. There is not enough evidence to evaluate whether groups are more effective, or cost-effective, than intensive individual counselling. There is not enough evidence to support the use of particular psychological components in a programme beyond the support and skills training normally included.

Race disparities in psychiatric rates in emergency departments

Psychiatric diagnoses based on the International Classification of Diseases--Ninth Revision were examined in the medical discharge records of 33,000 emergency department (ED) patients to determine if (a) psychiatric disorders were underdiagnosed, (b) there were race and gender disparities in psychiatric rates, and (c) psychiatric rates varied as a function of type of injury (e.g., self vs. other-inflicted injuries) and medical diagnosis. The observed psychiatric rate of 5.27% was far below the national prevalence rate of 20%-28%. Both race groups were underdiagnosed, but the underdiagnosis was larger for African Americans. Younger patients had fewer psychiatric diagnoses than older patients. Men had more psychiatric diagnoses overall, whereas women had more mood and anxiety diagnoses. Self-injury patients had much higher psychiatric rates than the other injury groups. This psychiatric underdiagnosis contributes to needless emotional suffering, especially for minorities and the poor who rely on EDs for most of their health care.

Smoking is associated with increased HbA1c values and microalbuminuria in patients with diabetes--data from the National Diabetes Register in Sweden

OBJECTIVES

The aim was to examine trends in the proportion of smoking in diabetes patients, and to study associations between smoking, glycaemic control, and microalbuminuria.

METHODS

Smoking habits were reported to the Swedish National Diabetes Register (NDR), with data from hospitals and primary health care. Patient characteristics included were age, gender, type of treatment, diabetes duration, HbA1c, BMI, blood pressure, antihypertensive and lipid-lowering drugs, and microalbuminuria.

RESULTS

The proportion of smokers in type 1 diabetes was 12-15% during 1996-2001, it was high in females<30 years (12-16%), and was higher in the age group 30-59 years (13-17%) than in older (6-9%) patients. The corresponding proportion of smoking in type 2 diabetes was 10-12%, higher in those less than 60 years of age (17-22%) than in older (7-9%) patients. Smoking type 1 and type 2 patients in 2001 had higher mean HbA1c but lower mean BMI values than non-smokers. Smokers also had higher frequencies of microalbuminuria, in both type 1 (18 vs 14%) and type 2 (20% vs 13%) diabetes. Multiple logistic regression analyses disclosed that smoking was independently associated with elevated HbA1c levels (p<0.001) and microalbuminuria (p<0.001), but negatively with BMI (p<0.001), in both type 1 and type 2 diabetes.

CONCLUSIONS

Smoking in patients with diabetes was widespread, especially in young female type 1, and in middle-aged type 1 and type 2 diabetes patients, and should be the target for smoking cessation campaigns. Smoking was associated with both poor glycaemic control and microalbuminuria, independently of other study characteristics.

Meta-analysis of randomized educational and behavioral interventions in type 2 diabetes

PURPOSE

This meta-analysis was conducted to assess the effect of educational and behavioral interventions on body weight and glycemic control in type 2 diabetes.

METHODS

Studies selected for analysis were published randomized controlled trials that evaluated educational and behavioral interventions (no drug interventions) in type 2 diabetes (sample size > or = 10). These criteria were applied to searches of electronic databases and relevant bibliographies. Data were independently abstracted by 2 reviewers and adjudicated by consensus.

RESULTS

Of the 63 articles that met the inclusion criteria, 18 provided enough information for pooled estimates of glycohemoglobin (total Ghb, HbA1, or HbA1C). These 18 studies yielded 2720 participants (sample sizes of 18 to 749). Interventions ranged from 1 to 19 months; follow-up ranged from 1 to 26 months. Glycohemoglobin was reduced by a mean of 0.43%. When results were stratified by quality score, glycohemoglobin was -0.50% and -0.38% for studies with high and low quality scores, respectively. When weighting studies by sample size, fasting blood glucose was reduced by 24 mg/dL and weight by 3 lbs.

CONCLUSIONS

Previous educational and behavioral interventions in type 2 diabetes have produced modest improvements in glycemic control. Future research should refine such interventions and improve methodology.

Group behaviour therapy programmes for smoking cessation

BACKGROUND

Group therapy offers individuals the opportunity to learn behavioural techniques for smoking cessation, and to provide each other with mutual support.

OBJECTIVES

We aimed to determine the effects of smoking cessation programmes delivered in a group format compared to self-help materials, or to no intervention; to compare the effectiveness of group therapy and individual counselling; and to determine the effect of adding group therapy to advice from a health professional or nicotine replacement. We also aimed to determine whether specific components increased the effectiveness of group therapy. We aimed to determine the rate at which offers of group therapy are taken up.

SEARCH STRATEGY

We searched the Cochrane Tobacco Addiction Group trials register, with additional searches of PsycInfo and MEDLINE, including the terms behavior therapy, cognitive therapy, psychotherapy or group therapy, in December 2001.

SELECTION CRITERIA

We considered randomised trials that compared group therapy with self-help, individual counselling, another intervention or no intervention (including usual care or a waiting list control). We also considered trials that compared more than one group programmes. We included those trials with a minimum of two group meetings, and follow-up of smoking status at least six months after the start of the programme. We excluded trials in which group therapy was provided to both active therapy and placebo arms of trials of pharmacotherapies, unless they had a factorial design.

DATA COLLECTION AND ANALYSIS

We extracted data in duplicate on the people recruited, the interventions provided to the groups and the controls, including programme length, intensity and main components, the outcome measures, method of randomisation, and completeness of follow-up. The main outcome measure was abstinence from smoking after at least six months follow-up in patients smoking at baseline. We used the most rigorous definition of abstinence in each trial, and biochemically validated rates where available. Subjects lost to follow-up were counted as smokers. Where possible, we performed meta-analysis using a fixed effects (Peto) model.

MAIN RESULTS

A total of fifty two trials met inclusion criteria for one or more of the comparisons in the review. Sixteen studies compared a group programme with a self-help programme. There was an increase in cessation with the use of a group programme (N=4,395, odds ratio 1.97, 95% confidence interval 1.57 to 2.48). Group programmes were more effective than no intervention controls (six trials, N=775, odds ratio 2.19, 95% confidence interval 1.42 to 3.37). There was no evidence that group therapy was more effective than a similar intensity of individual counselling. There was limited evidence that the addition of group therapy to other forms of treatment, such as advice from a health professional or nicotine replacement produced extra benefit. There was variation in the extent to which those offered group therapy accepted the treatment. There was limited evidence that programmes which included components for increasing cognitive and behavioural skills and avoiding relapse were more effective than same length or shorter programmes without these components. This analysis was sensitive to the way in which one study with multiple conditions was included. There was no evidence that manipulating the social interactions between participants in a group programme had an effect on outcome.

REVIEWER'S CONCLUSIONS

Groups are better than self-help, and other less intensive interventions. There is not enough evidence on their effectiveness, or cost-effectiveness, compared to intensive individual counselling. The inclusion of skills training to help smokers avoid relapse appears to be useful although the evidence is limited. There is not enough evidence to support the use of particular components in a programme beyond the support and skills training normally included.

Quality improvement in primary health care using computerised journal, exemplified by a smoking cessation programme for diabetic patients

OBJECTIVE

To study the possibility of using the computerised journal for quality improvement in diabetes care.

DESIGN

The computerised journal was used to reach all diabetic smokers aged 30-75 years and to invite them to a structured smoking cessation programme. The follow-up time was 18 months.

SETTING

Habo, a Swedish community with 9600 inhabitants, with one primary health care centre.

SUBJECTS

147 subjects, aged 30-75 years, were registered with the diagnosis of diabetes mellitus in the computerised journal at the primary health care centre. Altogetber 25 of these patients were registered as smokers in the journal. All of them were invited to a smoking cessation group.

RESULTS

Information about smoking habits in the journal was available for all but 11%. After 18 months' follow-up, 9 of the 14 patients (64%) who started in the smoking cessation group had become non-smokers. Of those 11 subjects who did not attend the group, 6 had stopped smoking during the follow-up time in spite of not participating in the structured programme.

CONCLUSION

The computerised journal is a useful tool for quality improvement, giving the opportunity for directed preventive efforts on selected patient groups.

Pharmacological treatment of diabetic patients with cardiovascular complications

Cardiovascular complications are frequently present in insulin-dependent (IDDM) and non-insulin dependent diabetes mellitus (NIDDM) patients and confer a very poor prognosis. In this overview we critically analyse the current literature with regard to the benefits and also the possible harms of the available pharmacological treatment strategies in these patients. To date, insulin is the only hypoglycaemic agent which has been proven both effective and safe in NIDDM patients with cardiovascular complications. Also, several trials indicate that treatment with oral hypoglycaemic agents may confer a substantial risk in such patients. Conventional antihypertensive treatment, including betablockers and diuretics, has been convincingly shown to reduce mortality and morbidity in diabetic nephropathy and in NIDDM patients. However, this may not be the case with newer antihypertensive agents, such as angiotensin-converting enzyme (ACE) inhibitors and calcium channel blockers. Likewise, convincing evidence is lacking that these newer antihypertensive agents provide meaningful clinical benefit when compared to the conventional treatment regarding slower progression of diabetic nephropathy or their impact on lipid and glucose metabolism. Cholesterol lowering therapy with statins and aspirin treatment have also been repeatedly shown to improve the prognosis of diabetic patients with coronary heart disease.

Smoking-related beliefs and behaviour of South Australians with diabetes

Data cumulated from three representative population surveys (n = 9402) in South Australia were used to determine smoking prevalence of those aged 15 years or over with and without self-reported medically confirmed diabetes. Overall, smoking prevalence in the two groups did not differ. However, among those aged under 40 years with self-reported diabetes, smoking prevalence approached 55 per cent, which was significantly higher than in young respondents without diabetes (32 per cent). Diabetic smokers were no more likely than were nondiabetic smokers to have tried to quit or to be ready to quit; one-quarter of diabetic smokers had no thought of quitting or of modifying their habit. Smokers with diabetes were significantly more likely to be heavy smokers (43.5 per cent) than were nondiabetic smokers (23.4 per cent). Fewer smokers with diabetes tended to believe that smoking causes or aggravates heart disease or circulatory problems than did other smokers, although these differences did not reach statistical significance. Additional effort is required to find methods to assist people with diabetes to refrain from smoking.

Cigarette smoking and diabetes: an update

The article provides an overview of recent scientific information on the role of cigarette smoking in the prognosis of diabetes. Data sources included an English-language MEDLINE search for 1989 through 6/1993, supplemented by manual search of bibliographies of pertinent articles. Only studies of humans were considered. Cigarette smoking is related to the development and progression of diabetic nephropathy. Therefore, smoking status has to be taken into account in clinical studies on the course of nephropathy. The association between smoking and retinopathy is less consistent. Evidence is accumulating that cigarette smoking influences insulin action. Several large prospective cohort studies have shown that the relative risk for all-cause mortality is about twice as high for smoking compared to non-smoking diabetic patients. Strong associations are consistently found between cigarette-pack years and complications. It has been calculated that the theoretical benefit of stopping smoking is the most (cost-)effective risk factor intervention for diabetic patients. However, available programmes to help diabetic patients to stop smoking are unsuccessful.