Tobacco Use and It’s Impact on Diabetes

1. Tobacco Use and It’s Impact on Diabetes Peggy Bourgeois, APRN, MN, CNS, CDE PBB Associates, LLC

2. Diabetes MellitusScope of Problem • Affects 20.8 million Americans • Affects many areas of the body • New therapies can prevent and/or delay complications

3. Diabetes Prevalence

4. LOUISIANA DIABETES STATISTICS • Approximately 274,000 adults or seven percent of adults in Louisiana have been diagnosed with diabetes (BRFSS, 2004) • African Americans have the highest prevalence of diabetes, with a 10.9% diagnosis rate, compared to 7.9% of Hispanics and 7% of the white population (BRFSS, 2004) • As of 1996, Louisiana had the highest death rate due to diabetes (32.5 per 100,00) of all the other U.S. states. The national death rate due to diabetes is 18.5 per 100,000 • In 2002, diabetes was the cause of 3,190 deaths, approximately 830 (26%) listed cardiovascular disease as an underlying cause • In 2001, the total cost of hospital discharges for people with diabetes in Louisiana was approximately $1.5 billion dollars (LAHIDD, 2001)

5. DiabetesDefinition • A chronic illness in which the body lacks insulin or is resistant to insulin • Multiple hormones play a role in glucose regulation

6. Classifications Diabetes Mellitus • Type 1 (absolute insulin deficiency) • Idiopathic • Immune-Mediated • Type 2 (insulin resistance) • Relative insulin deficiency • Deficient insulin secretion • Impaired Fasting Glucose (IFG) • Impaired Glucose Tolerance (IGT) • Gestational Diabetes (GDM)

7. Diagnostic Criteria Diabetes • FPG >126 mg/dl on 2 occasions • Casual glucose >200 mg/dl with symptoms • IFG: Fasting >100 and < 126 mg/dl (Pre – diabetes) • IGT: 2 hr PG >140 and < 200 mg/dl

8. Normal MetabolismInsulin • Secreted by beta cells of pancreas • Allows glucose to enter cells • Allows glucose to enter liver • Prevents release of liver glycogen • Prevents fat breakdown • Stores excess calories as fat

9. Normal Insulin ReleaseNon-diabetic never stops making insulin Insulin bolus occurs in the first 10 minutes after eating Basal insulin is released every 12 minutes Meal Meal Meal

10. Problems in type 1 Diabetes • Generally less than 40 years • No insulin, must be given by injection • No amylin (must be given by injection) • Ketone prone • Autoimmune disease

11. Metabolic Syndrome or Pre Diabetes AKA Syndrome X hyperlipidemia hyperglycemia

12. Progression of type 2 Diabetes Impaired Glucose Tolerance Frank Diabetes Normal Insulin Resistance Hepatic Glucose Production Insulin Production (-cell failure) Hyperinsulin production Postprandial Blood Glucose Fasting Blood Glucose Years to Decades Typical Diagnosis of type 2 Diabetes Time

13. Diabetes Screening – Type 2 • ADA recommends screening for diabetes & pre diabetes • High risk, asymptomatic adults • > 45 years • BMI > 25 • Younger if there are other risk factors • Fasting or 2-h OGTT (75 gm carb) • Fasting less expensive, shows pre-diabetes • OGTT shows IGT • If normal repeat every 3 years

14. Diabetes Screening Children Test FPG at age 10 or puberty w/ these criteria: • BMI > 85th percentile • for age & sex • weight for height or • weight > 120% ideal for height • Plus 2 additional risk factors • family history type 2 • Race/ethnicity • Signs of insulin resistance • Repeat every 2 years

15. Complications of DM Retinopathy: 14-40% Stroke: >200% ESRD- new cases:32% Heart Disease: >400% Foot/Leg Amputations: 50%

16. American Diabetes Association • Tobacco has many bad health effects, particularly for people with diabetes • No matter how long you've smoked, your health will improve after you quit • Nicotine is one of the most addictive substances known • Physical addiction • Become psychologically hooked on cigarettes • Kicking the habit is hard - but worth the work

17. Smoking Hurts Your Health • Smoking is best-known for causing cancer aggravates heart and blood vessel disease in people with diabetes • Decrease the amount of oxygen to tissues leading to heart attack, stroke, miscarriage, or stillbirth • Increases cholesterol levels and the levels of other fats increasing the risk of heart attack • Smoking increases blood pressure • Damages and constricts the blood vessels. This damage can worsen foot ulcers and lead to blood vessel disease and leg and foot infections American Diabetes Association; “Smoking”, www.diabetes.org

18. Smoking • Smokers with diabetes are more likely to get nerve damage and kidney disease • Smokers get colds and respiratory infections easier • Smoking increases risk for limited joint mobility • Smoking can cause cancer of the mouth, throat, lung, and bladder • People with diabetes who smoke are three times as likely to die of cardiovascular disease as are other people with diabetes • Smoking raises blood sugar level, making it harder to control • Smoking can cause impotence American Diabetes Association; “Smoking”, www.diabetes.org

19. Position Statement Health care professionals should emphasize smoking cessation as a priority of state-of-the-art care for all diabetic smokers

20. LOUISIANA TOBACCO STATISTICS • Tobacco use is the single most preventable cause of death and disability causing more deaths every year that AIDS, alcohol, car crashes, murders, suicides, and illegal drugs combined. • Cigarette smoking was the leading risk factor for disease, responsible for an estimated 6,427 deaths and 96,085 years of potential years of life lost in 1999. • Cigarette smoking is responsible for one in four deaths due to cardiovascular disease and contributes to illness and death due to cancers, respiratory diseases, premature and low birth weight infants, sudden infant death syndrome, and burns. • More than 750,000 adults (24.6%), 79,000 high school, and 28,000 (17.1%) middle school aged children in Louisiana currently smoke cigarettes. Louisiana Youth Tobacco Survey, Tobacco Control Program, 2002

21. LOUISIANA TOBACCO STATISTICS • Nine out of ten current smokers started before they were 18 years of age. • 15.7% of the adult population in Louisiana has used smokeless tobacco products such as chewing tobacco, dip, or snuff at some point in their lives. • Individuals: • in the 18-44 year age group • With an annual household income less than $25,000 • Individuals with less than a high school education • African Americans were more likely to report that they are being exposed to second-hand smoke at their place of work. • The total cost during 1999 for Louisiana that was attributable to cigarette smoking was estimated at $2.81 billion. • Smokers not only put their own lives at risk, but also affect the lives of people around them.

22. Public Health Service (PHS) Clinical Practice Guideline for Teaching Tobacco Use and Dependence • Established the “5 A’s” of intervention • Ask • Advise • Assess • Assist • Arrange

23. ASK • History of tobacco use • Adolescent and Adult with diabetes • Pregnancy – use multiple choice questions • Which of the following best describes your tobacco use? • I use tobacco regularly now, about the same as before becoming pregnant • I use tobacco regularly now, but have cut down since I found out I was pregnant • I use tobacco every once in a while • I have quit using tobacco since finding out I was pregnant • I have never used tobacco. • Psychologically, fear of harming the baby • Former tobacco users should be offered short term relapse prevention intervention

24. ADVISE • Advise to quit should be clear, strong and personalized to the individual’s own situation. • Prevention of diabetes complications • Effects of second hand smoke on the family • Monetary cost of smoking

25. ASSESS • “Are you willing to try to quit at this time?” • What if they are not willing to stop? • No desire to stop • Fear they will be unable to stop • Fear withdrawals • Fear weight gain • Offer the “5 R’s”

26. ASSIST • The patient is willing to quit: HOW to quit. • Set a quit date - within two weeks is best. • Tell family and friends. • Social support helps! • Review past quit attempt experiences. • What worked? • What didn’t?

27. ASSIST • Anticipate challenges. Symptoms: • Irritability • cravings • Insomnia • coughing may occur for 2-3 weeks after quitting • Encourage adult patients attempting to quit to utilize effective pharmacotherapies for tobacco dependence treatment i.e., >10 / day, other medical constraints, pregnant/breastfeeding, adolescents except in special circumstances • Refer to an intensive counseling service

28. ARRANGE • Schedule follow-up in person or on the phone • Should occur within the first week after the quit date • Provide with relapse prevention information • If already relapsed: • Consistent with the chronic nature of tobacco dependence • Not a sign of personal failure • Set a new quit date and revise his/her quit plan

29. THE “5 R’s” • RELEVANCE: • Why quitting is important to their own personal situation • RISKS: • Outline the risks of continued tobacco use • REWARDS: • Outline the Benefits of quitting

30. THE “5 R’s” • ROADBLOCKS: • What are the barriers preventing this person from quitting? • What are some solutions to these barriers? • REPETITION: • Repeat this discussion frequently, until the person is ready to quit.

31. Why is Quitting So Hard? • People smoke for two reasons. • Nicotine is highly addictive. • Withdrawal • Symptoms include: irritable, sweating, headaches, diarrhea, or constipation, feeling restless, tired, or dizzy. • Is usually worst on the second day and gradually lessens with time.

32. “But it’s so hard to quit!” • Second, • Many become psychologically tied to smoking. • Part of daily ritual • Helps them wake up in the morning • Comforts them when they are upset, and • Rewards them for a job well done • Smoking also has pleasurable physical effects • It relaxes people and perks them up.

33. Stress • Stress can alter blood glucose levels • May not take care of themselves • Increase smoking, alcohol consumption, less exercise • Stress hormones may also alter blood glucose levels • In type 1 diabetes response is more mixed • While most people's glucose levels go up with mental stress, others' glucose levels go down. • In people with type 2 diabetes, mental stress often raises blood glucose levels • Physical stress, illness or injury, causes higher blood glucose levels in people with either type of diabetes.

34. Stress • Stress blocks the body from releasing insulin in people with type 2 diabetes • People with type 2 diabetes may also be more sensitive to some of the stress hormones • Stress reduction doesn't have this effect in type 1 diabetes

35. Preparing to Quit • Study your own smoking habits • What events or activities make you light up? • How often do you smoke? • Look for replacements for smoking • Learn and practice another way to relax • Deep breathing and relaxation exercises • Stand and stretch exercises • Walk - Exercise makes you more alert • Set a date to quit

36. Barriers to Cessation • Prevalence of smoking not much different as that of the population at large. • Minimal information available for diabetic smokers. • Suggests the patients don’t do well • Weight gain • Perceived as less important than avoiding sweets, limiting alcohol consumption and several other health behaviors • Low priority

37. Guidelines for Reducing Barriers • Ensure intensive counseling • Stress the specific role of tobacco in diabetes complications • Plan for and limit weight gain • Look for and treat depression. • Find safe, tobacco-free coping methods to deal with diabetes related stressors

38. Learning to Relax • Breathing exercises. Sit or lie down, uncross legs and arms. Take in a deep breath. Push out as much air as you can. Breathe in and out again, this time relax muscles on purpose while breathing out. Keep breathing and relaxing for 5 to 20 minutes at a time. Do the breathing exercises at least once a day. • Progressive relaxation therapy. In this technique, you learn in a clinic or from an audio tape, to tense and relax muscles • Exercise. Relax your body by moving through a wide range of motion. Three ways to loosen up through movement are circling, stretching, and shaking parts of body. To make this exercise more fun, move with music.

39. Learning to Relax • Replace bad thoughts with good ones. Each time you notice a bad thought, purposefully think of something that makes you happy or proud. Or memorize a poem, prayer, or quote and use it to replace a bad thought. • Whatever method you choose to relax, practice it. Just as it takes weeks or months of practice to learn a new sport, it takes practice to learn relaxation.

40. Tobacco Use and Diabetes Complications • Tobacco raises blood glucose • Nicotine and other products in tobacco smoke inhibit the action of insulin. • Chewing tobacco is high in sugar • Increases retinopathy • Greater chance of developing gum disease and tooth loss. • Increases nerve damage - nephropathy

41. Tobacco Use and Diabetes Complications • Erectile dysfunction • More likely to have a heart attack and 3x’s more likely to die of a heart disease • Smoking triples the chance of developing kidney disease in people without diabetes • Below the knee amputations common in smokers.

42. Weight Gain • Nicotine increases metabolism • Causes body tension • Accelerates heart rate • Increase blood pressure • Physical agitation • Quitters gain 3-5 #’s due to water retention during the first week after quitting • Tobacco reduces the ability to smell, food is more appealing when they quit smoking • Hands to face habit – increased eating • Cravings for cigarettes or chewing confused as hunger

43. Healthy Ways to Minimize Weight Gain • Increase physical activity • Gradually improve eating habits • Replace smoking with healthy activities • Drink fluids, especially water – avoid caffeinated beverages • Get enough sleep • Lifetime history of clinical depression are about half as likely to succeed • People with diabetes are at greater risk for depression

44. Medications to Help Quit Smoking

45. STOP SMOKING PROGRAMS • The Great American Smokeout • American Cancer Society • Food and Fitness • The American Lung Association • Positive Thinking • Why Quit? • You Can Quit Smoking • Helpful Tips to Kick the Smoking Habit

46. LA REPORT CARD - 2006 • Grades:    • Smokefree Air A • Youth Access F • Tobacco Prevention & Control Spending F • Cigarette Tax F

47. PHS Guideline • “Smokers with comorbid psychiatric conditions should be provided smoking cessation treatments identified as effective … although psychiatric comorbidity places smokers at increased risk from relapse, such smokers can be helped by smoking cessation treatments.”

48. Helping Patients with Diabetes Quit Using Tobacco • Guideline for Treating Tobacco Use and Dependence • November 2003

49. Thank You peggyboo1@cox.net