Diabetic Patients Who Smoke: Are They Different?

The Solberg et al. article on diabetic smokers is important for both its public health, and its clinical implications. Given the health consequences, smoking should be considered as a priority comorbid condition, and it is refreshing to see smoking get the attention that it deserves in diabetes. For too long, the focus, at least in the diabetes management research literature, has been almost exclusively on glycemic control. There has of course been a recent focus on CVD risk factors among diabetes patients, especially hypertension, and this article extends this focus to behavioral risk factors.

This paper also raises a challenge that faces clinicians who treat diabetes and other complex chronic illnesses: namely prioritizing intervention goal setting when the patient has many competing risk factors and areas in need of attention (e.g., the article convincingly documents that diabetic smokers have higher rates of depressed mood, lower levels of diabetes self-management, and physical activity). They propose a ‘stage- matched intervention’ approach to help smokers.

I would agree that use of a patient-centered, evidence-based approach that involves collaborative goal setting is helpful for both smoking and diabetes self-management issues. However, I would place greater emphasis on the USPSTF (Whitlock et al,. 2002) and AHRQ recommended multi-level “5 A’s approach” noted by the authors, than a stages of change orientation. My experience is that greatest attention should be focused on rearranging the office environment, involving all staff in supporting patient self- management and smoking modification efforts, and providing follow-up support. Such a social ecological approach is likely to be more feasible to implement and integrate into practice than a full blown Transtheoretical Model intervention, and also should work across other self-management areas and for other chronic illnesses (Glasgow et al., 2003).

Russ Glasgow, Ph.D. Senior Scientist Kaiser Permanente Colorado

Glasgow RE, Davis CL, Funnell MM, Beck A. (2003). Implementing practical interventions to support chronic illness self-management in health care settings: Lessons learned and recommendations. Joint Commission Journal on Quality and Safety, 29, 563-574.

Whitlock EP, Orleans CT, Pender N, Allan J. (2002). Evaluating primary care behavioral counseling interventions: An evidence-based approach. American Journal of Preventive Medicine, 22, 267-284.

Competing interests:   None declared

I would like to thank Dr. Solberg, et. al. for re-emphasizing the importance of smoking cessation in the overall therapeutic approach for diabetes in their recent article “Diabetic Patients Who Smoke: Are They Different?” Too often in clinical practice the treatment of diabetes becomes a synonym for the treatment of hyperglycemia, and important risk factors such as smoking are easily overlooked. A simple chase for progressively lower A1Cs, or more frequent A1CS, undermines the importance of tailoring therapy for the individual. In practice, risk factors are clustered. The best approach to an individual is not easily determined by evaluating performance on a set of diabetes quality improvement measures. Although it may be easier to persist in lowering blood sugars to continually lower levels than to intervene in smoking as a behavior, it is not necessarily the most appropriate treatment for the individual. Dr. Solberg’s article further reminds us that our effectiveness as physicians is compromised by our lack of knowledge and our lack of infrastructure to support and motivate our patients to live healthier lifestyles.

Competing interests:   None declared