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Promoting health in diabetes: smoking cessation

Debbie Duncan
RGN RM BSc in Nursing PNCert
Nurse Practitioner
Greenwich
E:malcolm@j3-16.com

Working in primary care I have met a lot of clients who have diabetes and who smoke. I have often felt unable to spend quality time with them discussing their need to stop smoking. Although brief interventions of health promotion are of benefit to clients, they are not always successful. Perhaps the client needs more specific health promotion or a longer period of time to respond. Recently there has been a great deal of discussion and debate on empowering people to change their lifestyle and take responsibility for their own health. Diabetes is a chronic disease, the effects of which can be reduced or controlled by lifestyle change. To enable people to feel empowered to change one important lifestyle condition, smoking, I have looked at the literature surrounding this area and have put together a health promotion plan to be used in general practice. We are hoping to implement this in the practice where I work at the end of this year. One idea is to run it along side our new coronary heart disease clinic.
Tones and Tilford show that one of the functions of health education is the actual process of empowering and supporting individual choice, classifying empowerment as an "educational model" of health promotion.(1) This is different from the traditional medical model in which people have an illness and the medical team provide the answer. In the latter model, those who do not do what the medical professional suggests are in some way penalised. The traditional medical model assumes that the whole aspect of choice is not an issue with which the patient should be concerned.
The Ottawa charter defines health promotion as "the process of enabling people to take control over, and to improve their health".(2) That aspiration is somehow addressed in the self-empowerment model, which seeks to facilitate choice. It does so not only by providing understanding and enabling the practice of decision-making skills, but also by attempting to empower the individual. It is worth noting that empowerment is also the third standard of the National Service Framework for diabetes,(3) which discussed the need for clients to be empowered so that they have better control of the day-to-day management of their disease, with part of this process being the development of behavioural change programmes.
Empowerment is the process whereby a person or community acquires power or the ability to control others or resources. Self-empowerment focuses on an ­individual's ability to control their own life. In health promotion, this means recognising a person's needs and enabling them to meet those needs by themselves, wherever possible. In this way, individuals can move from a state of perceived powerlessness to having a greater sense of control.
The model used for this programme is the "cycle of change" model, based on the "stages of change" theory devised by Prochaska and DiClemente specifically for looking at behavioural change within a group of clients who have an addiction.(4) The model is individual in nature and when used in this setting can help empower people to change a lifestyle behaviour that affects their optimal level of health and wellbeing.

Self-efficacy
Bandura expanded on the self-empowerment model with the self-efficacy theory, derived from social learning. It is concerned with an individual's perception of personal efficacy or how they feel they can carry out an action. From Bandura's work and others, Prochaska and DiClemente developed the "transtheoretical stages of change model".(4) Their objective was to examine a wide range of existing perspectives on behavioural change in smokers and to develop a working model which would address these issues. In a study of 872 smokers they found that the perceived self-efficacy ratings were related to stages in the cycle of efforts to stop smoking. As people progressed from thinking about stopping smoking to actually stopping, their self-efficacy increased. Bandura has questioned whether individuals go through these stages at all and argues that self-efficacy increases with a reduction in stress, experience, verbal persuasion and accomplishment.(5)
What is not considered by Bandura is that low self-esteem and a perceived external locus can impact on genuine free choice. Also, while attitudes cannot always help us predict behaviour, they can help us when trying to assess the likelihood of behavioural change, which in turn helps us assess readiness for change.
Kanebo makes the valid point that the outcomes of smoking cessation are poor and that this can have negative effects on the patient in the future.(6) The conclusion of this study was that there is no single ideal method and one should use multiple cessation methods because people and their smoking habits are so different. Using the cycle of change model, however, can individualise the education that an individual is receiving because it identifies the different stages they may have reached. Despite a paucity of strong supportive evidence for the cycle of change model, it pragmatically appears to be the best model to use at this time.(7) The cycle of change model also helps us to have a better understanding of behaviour and it shows us where people encounter problems, such as in the area of decision-making.
The cycle of change model is individualistic and enables the facilitator to identify those individuals with problems. It shows the process by which addictive ­behaviour can change. For these reasons, the cycle of change model was chosen as a suitable model for running a smoking cessation group for clients with diabetes.

The cycle of change model
Stopping smoking is not a single event but a series of relatively self-explanatory stages. These are:

  1. Precontemplation.
  2. Contemplation.
  3. Preparation.
  4. Action.
  5. Maintenance.
  6. Relapse.

A person may pass through these stages more than once. For a health promotion programme to be effective, it needs to be tailored to the smoker's readiness to stop, which may change from week to week. It is therefore important to have a period of assessment at the start of each session and to provide factual information and support. For that reason the sessions consisted of a formal teaching time before discussion each week and a time of "catching up" on progress during the ­preceding 7-day period

Why smoking and diabetes?
One of the most important public health problems in the UK today is thought to be cigarette smoking.(8) One in every two long-term smokers die from a smoking-related disease and it costs the NHS approximately £1.7b a year to treat smoking-related illnesses. A recent study showed that 70% of smokers want to stop.(8)
Smoking is also the most important modifiable risk factor for coronary heart disease.(9) Smoking has been identified as a causative factor in the development of diabetes in a large American study.(10) The number of people with diabetes who smoke is quite significant, at 27%.(11)
Smoking has a huge effect on clients who already have diabetes as it causes a raise in blood glucose levels and can impair insulin sensitivity. This is due to the vascular changes that can occur when one smokes and the reduction in blood flow. The nicotine, carbon monoxide and other chemicals found in cigarette smoke have a toxic effect on the pancreas and beta cell function.(12) There has also been a link between insulin sensitivity with smoking and dyslipidaemia.(13) A client who has diabetes and smokes will have higher blood glucose levels, increased insulin resistance and an abnormal blood lipid profile. It can also lead to the development of neuropathy and retinopathy.(11) The St Vincent Declaration of 1995 laid down specific targets in relation to diabetes, such as reducing lower limb amputation by 50% and reducing both renal damage and retinopathy. To achieve these targets it was suggested that smoking cessation initiatives should be developed.
Research also suggests that smokers are more receptive to advice on smoking cessation when they have an existing medical condition like diabetes. This is ­accentuated if their visits to the surgery can be linked to smoking cessation.(14) Spencer reviewed the cases of clients with diabetes who smoked and concluded that a smoking cessation programme was needed.(11) She used the stages of change model.

The health promotion plan
Aims and objectives
The aim of the course is to provide clients who have diabetes with the information and skills needed to stop smoking. The objectives are as follows:

  • The client would decide a stop date within the first 2 weeks of the course.
  • They would move to at least the next step of the stages of change model.

Those attending
Those attending would be clients from the contact group and their significant others.

The facilitator
The facilitator would be a trained nurse who had undergone the relevant training.

The environment
The course would be held at the local practice in the conference room.

Teaching aids
Handouts would be compiled to be distributed each week. The facilitator would have a variety of books, articles and other resources to use. A video produced by the RCN containing personal testimonies from reformed smokers would also be available.

The course
The course would consist of six sessions running over six concurrent weeks. At the end of the course two follow-up sessions in 1 month and 6 months would be arranged between facilitator and client. There would be some traditional teaching at the start, developing into a more contemporary type of education. There would be time for discussion and some one-to-one intervention. Before the course started there would be a precourse assessment. There would also be an evaluation at the end.
The course would be held at a mutually agreed time decided upon after the precourse interview. The ­information given would be as follows:

  • Week 1 - The effects of smoking on the general population and those complications specific to diabetes.
  • Week 2 - Addiction and nicotine replacement therapy.
  • Week 3 - Individual plans.
  • Week 4 - Behavioural change.
  • Week 5 - Coping with stress.
  • Week 6 - Coping with stress.

Execution of the plan
The contact group

The computerised patient medical notes will be used to identify those to be targeted. Before the course an audit will be carried out on the database to identify those clients who have diabetes and smoke. A letter will be sent to those patients that fit both criteria, providing them with information about the impending course and asking if they are interested. This is also a tool to stimulate those in the precontemplating stage of quitting.(15) Posters displaying information about the course will be put up in surgeries and shops, as not all clients are honest about their addictions.
The clients will be allowed to bring along someone to support them, as it has been shown that positive support from those close to the client will influence the client's attitudes towards ­smoking cessation.(16)

The facilitator
The facilitator will need to be someone with a special interest in diabetes and smoking cessation. Clients will expect the facilitator to be knowledgeable in both areas. Within our practice I am hoping to implement this programme with one of my colleagues working beside me.

Others involved
The doctor will also be on hand for additional advice and support. Both the practice nurse and the doctor know that they need to be sensitive to the needs of the group, thus enabling trust, clarity, acceptance and facilitating the development of a positive caring ­environment, as promoted by Carl Rogers.(17)

The environment
There is some debate as to the suitability of doctors' surgeries for such a course,(18) but because of accessibility for those attending, it was decided that this would be the best place for this particular course. The room which will be used is not too small yet not too large to be intimidating.

The content of the course
The local PCT has recommended the areas to be covered. Added to this material is information relevant to diabetes. The correct information covered in the discussions will be reinforced not only by the facilitator, but also by the materials handed out. These will be adapted for each member of the group, as specific information has been shown to be more effective than general information.(18)

The teaching session
The teaching session is an example of contemporary education. The information given will be relevant to those attending, delivered in a group session in a discursive manner. It will not all be delivered in a one-way form because face-to-face behavioural support has a better success rate than one-way information sharing or brief interventions. Brief interventions have a success rate of 5% compared with 7% with this form of teaching.(18) One may question how effective it is with such small numbers but for those with diabetes who stop smoking it will halve their chances of having a significant event that affects their lifespan. For the NHS this represents a considerable amount of money.
There will be an opportunity within the first week to decide on a stop date, as abstinence is the goal of this course. One of the sessions looks at nicotine replacement therapy and the client will be assessed and the best type to use recommended to them.(17)

Precourse interview
There will be a precourse interview because different people have different precontemplating plans.(19) They may want to stop in 6 months, so one should provide them with some initial information and recommend they return to the clinic on a regular basis to talk about their plans. They may just want to cut down or they may not be at the stage of wanting to change their behaviour at all.
The cycle of change model does not allow for a precourse interview so including it in the initial stages will be advantageous. This interview will enable us to assess a person's attitudes to smoking, and their readiness to change. Using this knowledge the facilitator can plan the educational programme accordingly.

Evaluation
Any health promotion plan needs to be evaluated to identify whether it has achieved its aims and objectives. This will be an ongoing process particularly within the stages of change framework, as clients may relapse or not progress to the next stage within the 6-week period. It is therefore important to have regular contact with the group even 6 months later. The Department of Health's guidelines recommend a 4-week follow-up with carbon monoxide validation for an optimal cessation service.(20)
Any information gained through this process can be used to improve nursing care in the future. Learmouth and Mackie investigated whether "it is possible to systematically review evaluations of health promotion activity in order to generate guidelines for good practice''.(21) They proposed using the theory of change approach to evaluation.

Conclusion
This course may produce changes in peoples' knowledge base and their attitudes and beliefs. It will enable people to acquire new skills and hopefully will result in lifestyle changes. Tones and Tilford consider this to be effective health education.(2) If this is the result then it will lead to an improvement in health and a reduction in the risk of cardiac events. The model used is appropriate as there are some people who will not stop smoking but are somewhere in that cycle of change.

References

  1. Tones K, Tilford S. Health education. 2nd ed. London: Chapman Hall; 1994.
  2. Edleman CL, Mandle CL. Health promotion. St Louis: Mosby; 1991.
  3. Department of Health. National Service Frameworks for diabetes. London: Department of Health; 2001.
  4. Prochaska J, DiClemente CC. Stages of change in the modification of problem behaviours. In: Herson M, Eilser RM, Miller PM, editors. Progress in behaviour modification. Newbury Park: Sage; 1994.
  5. Kendall S, editor. Health and ­empowerment. London: Arnold; 1990.
  6. Kanebo M. A methodological inquiry into the evaluation of smoking ­cessation programmes. Health Educ Res 1999;14:433-41.
  7. Whitelaw S, Baldwin S, Bunton R, Flynn D. The status of evidence and outcomes in stages of change research. Health Educ Res 2000;15:707-18.
  8. Roberts J. Smoking cessation: a role for every practitioner. Br J Comm Nurs 2002; 7:182-8.
  9. Scriven A, Orme J. Health promotion. 2nd ed. Basingstoke: Palgrave; 2001.
  10. Manson JE, Ajani UA, Liu S, Nathan D, Hennekens CH. A ­prospective study of cigarette smoking and the incidence of diabetes mellitus among US male ­physicians. Am J Med 2000;109:538-42.
  11. Spencer J. The smoker with diabetes: implications for nursing ­practice. J Diabetes Nurs 1997;1(3):76-84.
  12. Madsbad S, McNair P, Christensen MS. Influence of smoking on insulin requirement and metabolic status in diabetes mellitus. Diabetes Care 1980;3:41-3.
  13. Facchini FS, Hollenbeck CB, Jeppesen J. Insulin resistance and ­cigarette smoking. Lancet 1992;339:1128-30.
  14. Butler CC, Pill R, Stott NC. Qualitative study of patients' perceptions of doctors advice to quit smoking : implications for opportunistic health promotion. BMJ 1998;316:1878-81.
  15. Dijkstra A, De Vries H. Subtypes of precontemplating smokers defined by different long term plans to change their smoking behaviour. Health Educ Res 2000;15:423-34.
  16. Haire-Joshu D, Heady S, Thomas L, Schichman K, Fisher E. Beliefs about smoking and diabetes care. Diabetes Educ 1994;20:410-15.
  17. Rogers C. The characteristics of a helping relationship. In: Kirschbaum H, Henderson V, editors. The Carl Rogers reader. London: Constable Press; 1990.
  18. West R, NcNeill A, Raw M. Smoking cessation guidelines for health professional: an update. Thorax 2000;55:987-99.
  19. Crittenden KS, Manfredi C, Lacey L, Warnecke R, Parsons J. Measuring readiness and motivation to quit ­smoking among women in public health clinics. Addict Behav 1998;23:181-200.
  20. Department of Health. NHS ­smoking cessation services. Service and monitoring guidance 2001/2002. London: DoH; 2001.
  21. Learmouth A, Mackie P. Evaluating effectiveness in health promotion: a case of re-inventing the millstone? Health Educ J 2000;59:267-80.

Resources
RCN. Smoking cessation training programme. A guide for health professionals. London:RCN; 2001
W:www.rcn.org.uk

Quit
A charity for people wanting to stop smoking
W:www.quit.org.uk

NHS smoking website
W:www.giving upsmoking.co.uk

Department of Health tobacco
website
W:www.doh.gov.uk/tobacco