Help your patients kick the habit for good
Smoking piles on risk of diabetic complications
There’s the bad news that most everyone knows: Smoking is terrible for your health. Some even say it is "suicide" for a patient with diabetes to smoke.
Then there’s the good news: Stopping smoking, even briefly, can reverse the destructive effects of tobacco use.
To the clinician in the field, there is no question that one of the most difficult tasks in diabetes care is to find a way to help patients give up nicotine. In addition to all the risk factors associated with tobacco use in a nondiabetic population, smoking has a host of disease-specific risks for diabetics. According to publications of the Canadian Diabetes Association, smoking impairs tissue oxygenation and reduces retinal blood flow. It also limits insulin action, mainly by reducing peripheral glucose uptake. Furthermore, nicotine impairs insulin action in the liver, adipose tissue, and muscle.
"I tell my patients smoking increases insulin resistance, which makes their diabetes worse. It’s a pretty simple message," says Janet Swift, RN, patient education coordinator at Memorial Hospital in Sheridan, WY.
Diabetics out-smoke the general population, 27.3% to 25.9%, according to National Health Interview Survey results published a decade ago, the latest statistics available. Neither the duration of diabetes nor the presence of complications seemed to deter resolute diabetics who smoke.
Diabetes educators and providers who need to convince patients about the dangers of smoking have help, however. They can arm themselves with these numbers:
• The Framingham Multiple Risk Factor Inter-vention shows smoking is a major risk factor for mortality and morbidity in those with diabetes. One analysis shows the relative risks of myocardial infarction in diabetic smokers is more than three times that of nonsmoking diabetics and the Colorado Integrated Dialysis Data Management Registry Follow-up Survey reported morbidity in smokers was 10 times that in nonsmoking Type 1 diabetics. (For more on Framingham, see cover story.)
• A German study found 53% of the Type 1 diabetics who smoked progressed to nephropathy, compared to 11% of the nonsmoking diabetics.
• Smoking also is correlated to retinopathy, peripheral neuropathy, and periodontal disease in patients with diabetes.
Here’s another fact to bolster clinicians’ determination to help their patients get off the nicotine merry-go-round. Patients who received just three minutes of smoking cessation advice from their physicians are more likely to quit than those who receive no counseling at all, according to the Agency for Health Care Policy and Research.
Fannie Harton, RT, RCP, a therapist at St. Joseph’s Hospital in Atlanta has tragic personal experience with the lethal combination of diabetes and smoking. Her niece died in January of a cerebral aneurysm at the age of 27 — the victim of uncontrolled diabetes, heavy smoking, and radical weight fluctuations.
"I tell [patients] smoking increases their risk of cardiovascular disease by 100-fold," says Harton. "By smoking, they cancel everything good they do in terms of diet, exercise, and medication. We all have health choices. It’s taking on a whole load of responsibility; it’s true, but life is about good choices."
Dire predictions of future events may jar some out of their smoke-surrounded reverie, but for others it simply increases the stress of managing their disease and juggling dramatic lifestyle changes required by a diagnosis of diabetes.
"I can explain the facts; I can tell them if they want to get better, they better not smoke," says Swift. "But I also know they need to see it for themselves." She suggests patients find out for themselves the effects of smoking. She asks them to test their glucose levels at least twice on a day when they are smoking their normal amount, then try testing their glucose level in the morning and again after half a day without smoking.
"They are usually amazed at the difference they get without the cigarette," she says. In fact, she recalls one patient who was able to cut his insulin requirement in half simply by stopping smoking and making no other lifestyle changes.
Diabetics tell clinicians there are a variety of reasons why they smoke: to reduce stress, to manage weight, to regulate nicotine levels, and to stabilize mood swings. Good diabetes management focuses on weight control, dietary adherence, blood glucose monitoring, and compliance with medications, as well as number of preventive health practices. A perception of failure in any of those areas often leads to feelings of guilt and inadequacy and increases stress. Those feelings then lead to a vicious cycle where the patient justifies smoking to combat the feelings and reduce appetite and diminish weight gain.
"Stress is certainly an issue," says Harton, who is an ex-smoker. "Many people think smoking helps reduce stress, and it definitely is a pleasurable and relaxing sensation. They look at the suggestion to quit smoking as a lose-lose situation. But I tell them there are many healthier ways of stress relief."
Her diabetes management program includes a module on stress reduction and an exercise program encourages participation in gentle, relaxing forms of exercise, such as Tai Chi and yoga.
"Everybody wants to cope better with the stress in their lives, and the first way to cope with it is to recognize when it occurs," she adds.
Suggest substitutes
If it’s a hand-to-mouth fixation that makes it hard for a patient to stop smoking, Harton has a few suggestions for substitutes:
• cinnamon bark sticks;
• straws;
• toothpicks;
• sugar-free lollipops.
Many smokers are trapped in a mental pattern that associates certain types of activities with having a cigarette, says Sharon Sweeting, MS, RD, CDE, coordinator of patient-family education at Jackson Memorial Hospital at the University of Miami Medical Center in Miami.
"I ask them to list their three favorite cigarettes of the day," she says. For most people, the trigger times are when they first wake up, with morning coffee, and after dinner.
Sweeting’s behavior modification plan calls for using constructive behavior diversions to avoid being trapped by those triggers. "Going for a walk is one of the most common ones, but sometimes people resist that." She suggests a variety of nonfood rewards for making it past the temptation: a 10-minute phone call to a friend or a bubble bath after dinner. Other rewards could be moving away from the table to help kids with homework, spending a few minutes curled up with a book, or watching a favorite television show.
Her strongest trigger breaker: a rubber band worn around the wrist. "Whenever they want a cigarette, they snap the rubber band. It’s a wake-up call, a sensory stimulator that helps break thought patterns, and it has the advantage of being simple, inexpensive, and unobtrusive," says Sweeting.
She also suggests that patients trying to kick the habit put away all ashtrays in their homes, break any cigarettes they have before they dispose of them, and avoid being around other people who are smoking.
One innovative patient came up with what Sweeting describes as a "brilliant" idea. He carried a bottle of fabric deodorizer around with him and whenever he felt the urge for a cigarette or he got a whiff of cigarette smoke, he simply misted the air around him.
"It immediately changes the odor, which eliminates the smoke smell and perhaps neutralizes the trigger, too," she says.
Ending decades of smoking will undoubtedly be difficult for most patients, says Swift.
Sometimes advice to stop smoking becomes the straw that broke the camel’s back, especially for a person newly diagnosed with diabetes.
Patients are asked to monitor sugars, change life-long eating habits, start exercising when they don’t feel well, and take medications, perhaps even inject themselves with insulin.
"I have a lot of angry people," says Swift, suggesting that smoking cessation might better be left to a time when a patient has achieved some degree of control in his newly-prescribed lifestyle. She emphasizes that recommendations to stop smoking are less likely to be well received by the patient if there’s also a recommendation to lose weight. Too many demands may lead to diabetic overwhelm, Swift says.
Some need counseling beyond what most diabetes care team members feel capable of providing. "I really worry about the ones who are so ticked off about what has happened to them," she says. "Sometimes I’ll open the door to talk about their anger by just saying, Gee, you really seemed upset today.’ Nobody thinks diabetes is their only problem, and sometimes they need to talk it all out."
Harton also suggests that clinicians may find themselves confronted with their own feeling of failure when a patient who smokes succumbs to diabetes-related complications, as her niece did.
"She was a diabetic in denial with an unhealthy lifestyle who never was able to stop smoking," says Harton.
"I’ve looked at everything. I did everything I could, but it wasn’t enough. A part of me knows her vascular system has suffered over the years," she says. "It’s not a mystery to me that a vessel could rupture at any moment. Yet, as her aunt and someone who knows so much about these risks, I keep thinking there must have been something else I could have done."
[For more information, contact Janet Swift at (307) 672-1193, Fannie Harton at (404) 851-7179, and Sharon Sweeting at (305) 585-8168.]
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