Assessing the feasibility and acceptability of a diabetes-specific nurse-led multicomponent smoking cessation intervention in diabetes education: study protocol for an open-label pragmatic randomised controlled trial.

INTRODUCTION: Smoking cessation is an essential, but often overlooked aspect of diabetes management. Despite the need for tailored smoking cessation support for individuals with diabetes, evidence of effective interventions for this cohort is limited. Additionally, individuals with diabetes do not easily adopt such interventions, resulting in low uptake and abstinence rates. This protocol describes a study that aims to assess the feasibility and acceptability of a unique smoking cessation intervention, based on the best evidence, theory and the needs of individuals with diabetes, among patients and service providers, the diabetes nurse educators. METHODS AND ANALYSIS: This is an open-label pragmatic randomised controlled trial. Between 80 and 100 individuals with type 1 or type 2 diabetes who smoke will be recruited from the diabetes outpatients at the main acute public hospital in Malta, starting in August 2023. Participants will be randomly assigned (1:1 ratio) to the intervention or control arm for 12 weeks. The experimental intervention will consist of three to four smoking cessation behavioural support sessions based on the 5As (Ask, Advise, Assess, Assist and Arrange) algorithm, and a 6-week supply of nicotine replacement therapy. The control intervention will consist of an active referral to the Maltese National Health Service's one-to-one smoking cessation support service, which is based on motivational interviewing. The primary feasibility and acceptability outcomes include the recruitment and participation rates, resources used, problems identified by the nurses, the nurses' perceived challenges and facilitators to implementation and the nurses' and patients' acceptability of the study intervention. Data analyses will be descriptive, with quantitative feasibility and acceptability outcomes reported with 95% confidence intervals. ETHICS AND DISSEMINATION: Ethical clearance was obtained from the Faculty of Health Sciences Research Ethics Committee, University of Malta. The study results will be disseminated through conference presentations and a publication in a peer-reviewed journal. TRIAL REGISTRATION NUMBER: NCT05920096.

Influence of quitting smoking on diabetes-related complications: A scoping review with a systematic search strategy.

INTRODUCTION: Smoking in people with diabetes markedly elevates their risk of developing complications and increases the likelihood of cardiovascular mortality. This review is the first to specifically provide evidence-based analysis about the influence of quitting smoking on diabetes-related complications in people with type 2 diabetes. METHOD: The present review was carried out according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Extension for Scoping Reviews. All human clinical studies assessing the effects of stopping smoking cessation on diabetes-related complications were included. PubMed and Embase were screened until January 2024. References of primary studies and principal peer-reviewed scientific journals in the field were manually screened. RESULTS: We identified a total of 1023 studies. Only 26 met the criteria for eligibility. In general quitting smoking is associated with decreased risks of myocardial infarction and ischemic stroke. Regarding microvascular complications, the strongest evidence for the beneficial effects of smoking cessation is observed in diabetic nephropathy. However, the relationship between smoking cessation and retinopathy, neuropathy, diabetic foot complications and diabetic-related erectile dysfunction, is poorly investigated. CONCLUSION: Quitting smoking offers significant advantages in managing diabetes-related complications, significantly lowering the risks of myocardial infarction, ischemic stroke, and diabetic nephropathy. This underscores the importance of cessation. Providing evidence-based information on the benefits of stopping smoking for people with type 2 diabetes who smoke, can bolster smoking cessation efforts in the context of diabetes management.

Behavioral Therapy for People With Diabetes Who Smoke: A Scoping Review.

BACKGROUND: Tobacco smoking exacerbates diabetes-related complications; its prevalence is notwithstanding substantial. Persons with diabetes face a number of barriers and challenges to quitting such as multiple lifestyle restrictions; tailored interventions are required for smoking cessation. OBJECTIVE: To identify research on behavioral interventions for smoking cessation in diabetes. METHODS: Studies had to be randomized controlled trials, quasiexperimental or systematic reviews. The behavioral interventions included were: the 5As, Cognitive-Behavioral Therapy, Motivational Interviewing, Contingency Management, Health Coaching and Counselling, as compared to standard care. The outcomes were self-reported and/or biochemically verified smoking cessation. CINAHL Complete, MEDLINE Complete, the Cochrane databases of systematic reviews and randomized controlled trials, PsychInfo and PubMed Central were searched until July, 2023. Keywords used included diabetes, smoking cessation and each of the behavioral interventions included. RESULTS: 1615 papers were identified. Three studies on the 5As/brief advice, 4 on Motivational Intervention and 1 on counseling were retained. The results on the 5As and Motivational Interviewing were conflicting. More intensive interventions appear to be more successful in achieving smoking cessation in smokers with diabetes. CONCLUSIONS: Future research should focus on the continued development and evaluation of structured smoking cessation interventions based on the 5As, Motivational interviewing and Cognitive Behavioral Therapy.

Acceptability measures for evaluating smoking cessation interventions among individuals with diabetes.

Background: The literature indicates that individuals with diabetes do not easily adopt smoking cessation interventions. Given that the success of such interventions depends on patient involvement and attitudes, assessing intervention acceptability, including patient satisfaction and perceived usefulness, is crucial before implementing a smoking cessation intervention. This paper reports the preliminary validation of the satisfaction and perceived usefulness questionnaires for evaluating smoking cessation interventions among individuals with diabetes. Study design: Validity study. Methods: The satisfaction questionnaire contained eight statements while the perceived usefulness questionnaire had fourteen; both rated on a 5-point Likert scale. Content validation involved five tobacco cessation facilitators rating item relevance using a 4-point ordinal rating scale, suggesting improvements. The questionnaires were also translated into Maltese for local use and assessed for translation validity using a similar scale. Unanimous agreement among experts was required for item relevance and equivalence. Thirty-four individuals with type 1 or type 2 diabetes, attending a diabetes-specific smoking cessation intervention, received either the Maltese or English versions of the questionnaires. Internal consistency was measured using Cronbach's alpha. Results: After two rounds of content validation, the experts unanimously agreed on item relevance and conceptual equivalence. Fifteen and sixteen participants completed the Maltese and English versions of the questionnaires, respectively. Both questionnaires' versions were found to have a high internal consistency (>0.8). Conclusions: These findings provide the initial validation of these instruments for assessing the acceptability of smoking cessation interventions among individuals with diabetes. Further validation in different settings using a larger sample is suggested.

Exploring the smoking cessation needs of individuals with diabetes using the Information-Motivation-Behavior Skills model.

INTRODUCTION: Smoking cessation is an important aspect of diabetes management. Despite the increased risk for diabetes complications when smoking, evidence suggests that people living with type 1 and type 2 diabetes are less likely to quit smoking when compared to those without diabetes. Guided by the Information-Motivation-Behavioral Skills model, this study aimed to identify the needs of individuals living with type 1 and type 2 diabetes to quit smoking. METHODS: A qualitative descriptive design was adopted. Semi-structured telephone interviews were held between April and June 2021, with 20 former and current Maltese smokers living with type 1 or type 2 diabetes, recruited from the diabetic clinics within the two main acute public hospitals. The interview transcriptions were analyzed using applied thematic analysis. RESULTS: Individuals with diabetes need more information on the effects of smoking on diabetes to encourage cessation. Preventing diabetic complications was reported as a motivator to quit smoking. However, having diabetes was identified as a challenge to quitting. Participants welcomed the provision of health professional support for quitting smoking, identifying the need to provide smoking cessation support within diabetic clinics. The provision of information on tobacco-associated diabetic complications, by using video messages featuring former smokers' stories was also suggested. CONCLUSIONS: To promote smoking cessation among individuals with diabetes, they need to be informed about how smoking affects their condition. Utilizing video messages featuring real-life stories of former smokers with diabetes who experienced tobacco-associated diabetic complications may be influential. Additionally, providing diabetes-specific intensive smoking cessation support is crucial to help them quit.

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.

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.

The effect of gum chewing on postoperative ileus in open colorectal surgery patients: A review.

BACKGROUND: Postoperative ileus is a common complication of abdominal surgery, leading to prolonged hospital stay and associated costs. Gum chewing may be a safe, cheap intervention to reduce postoperative ileus. METHODS: The aim was to investigate the effect of gum chewing on postoperative ileus in open colorectal surgery patients. A literature search was conducted between December 2018 and March 2019 on CINAHL, Cochrane Central Register of Controlled Trials, and Cochrane Database of Systematic Reviews, MEDLINE, Academic Search Complete, PubMed, Scopus and Google Scholar. The keywords used included 'ileus', 'chewing gum', 'mastication' and 'sham feeding'. Papers had to include adults undergoing open colorectal surgery. The studies were appraised using Critical Appraisal Skills Programme tools and the results summarised using a narrative review. RESULTS: A total of three systematic reviews and three randomised controlled trials were included in the study. The studies show a significant to highly significant effect of gum chewing on postoperative ileus-related outcomes. The trials however in general utilised a weak design. CONCLUSIONS: Gum chewing decreases postoperative ileus following colorectal surgery. More robust trials are required to confirm these findings. Due to the low risk of harm and cost of using gum chewing, its use is recommended even in the interim.

Brief tobacco cessation interventions: Practices, opinions, and attitudes of healthcare professionals.

INTRODUCTION: Although brief smoking cessation interventions that follow the 5As algorithm (Ask, Advise, Assess, Assist, Arrange) can trigger smokers to quit, routine delivery remains low in Europe. This study aimed to identify the extent of smoking cessation practices of healthcare professionals interested in tobacco cessation, and their opinions and attitudes. METHODS: A quantitative, cross-sectional survey design was adopted. Healthcare professionals (n=133) who attended one of ten training sessions on brief interventions for smoking cessation, held every month between September 2018 and June 2019 in Malta, were recruited. Univariate logistic regression and non-parametric tests were carried out to identify associations by participants' characteristics. Potential confounders were ruled out following multivariate analyses. RESULTS: Most participants were female nurses who had never smoked. While most professionals reportedly asked (76.3%), advised (83.5%) and assessed (70.5%) patients for cessation, fewer provided assistance (40.9%) and arranged followup (24.2%). Compared to other participants, doctors were more likely to have counselled patients over the previous week. Most professionals were favourably disposed towards counselling patients to quit, however, they claimed they had insufficient time to do so. Although most found it difficult to get clients to quit, former smokers were more likely to disagree when compared to those who never smoked (OR=6.86; 95% CI: 2.17-21.71; p=0.001). CONCLUSIONS: While more initiatives to train healthcare professionals in providing smoking cessation interventions are recommended, lack of sufficient time, being an organisational barrier, requires healthcare management exploration and action. Given that former smokers were more confident in helping patients quit, engaging them in training activities would be of added value.