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Chronic Disease Patients

For the health professional, treating a smoker with chronic disease presents additional challenges. Smokers with chronic disease can experience increased hospitalization time, complications, and increased risk of death. It is important for clinicians to have the latest information about the impact of chronic disease on patients who use tobacco.

Diabetes

Men and women who smoke are at approximately 50% greater risk of developing diabetes compared to men and women who do not smoke. Smoking increases blood glucose levels, glucose intolerance, blood pressure, and it is an independent risk factor for developing Type 2 diabetes. Smoke contains cadmium, which is associated with diabetes, and smoking may be directly toxic to the pancreas. Smoking also leads to higher abdominal fat, which can contribute to insulin resistance.

Smoking can also exacerbate vision problems, and in conjunction with diabetes, can raise the risk of gum disease and teeth loss, nerve damage and the risk of heart attack or stroke. Smokers with diabetes are 11 times more likely to die of a heart attack or stroke. Smoking raises the amputation rate of foot and legs, and increases numbness and poor blood flow. It also triples the risk of kidney disease and inhibits the effectiveness of drugs that help prevent it.

A Concern for Maine

Maine has the highest rate of smoking among people with diabetes in New England. In the past 15 years, the number of people in the United States with diagnosed diabetes has more than doubled. New data show that up to 40% of people ages 40 – 74 in Maine have pre-diabetes.

Diabetes related hospitalization increased 13% from 1996 to 2002. Data from Maine's mortality records from 1979 though 2000 shows a 62% increase in deaths attributable to diabetes - a figure that could be even greater due to underreporting because it is considered a secondary cause of death.

New Concerns in Clinical Care

A recent study published in Diabetes Care shows that although the prevalence of smoking has decreased over the last decade in the U.S., one in six adults with diabetes still smokes. Diabetes experts recommend that diabetic smokers be advised about smoking cessation and closely monitored for signs of complications by health care professionals, but diabetic smokers are reportedly less likely to receive the recommended care. A survey of health plan members reported that diabetic smokers were likely to have fewer diabetes care visits and receive less frequent preventive care than diabetic nonsmokers.

Read the Diabetes Care study.


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Cardiovascular Disease

Nearly 2,400 people die each day in the United States from cardiovascular disease. CVD claims more lives each year than cancer, chronic lower respiratory disease, accidents and diabetes combined. The two most common types of cardiovascular disease, disease of the heart and cerebrovascular disease or stroke, account for more deaths than any other cause in Maine.

Smoking is a Direct Cause of CVD

Cigarette smoking increases the risk of coronary heart disease by itself. When it acts with other factors, it greatly increases risk. Smoking increases blood pressure, decreases exercise tolerance, and increases the tendency for blood to clot. Smoking also increases the risk of recurrent coronary heart disease after bypass surgery.

In addition, smoking decreases HDL (good) cholesterol. Cigarette smoking combined with a family history of heart disease also seems to greatly increase the risk. Studies show that cigarette smoking is an important risk factor for stroke, and women who take oral contraceptives and smoke increase their risk of stroke many times. Inhaling cigarette smoke produces several effects that damage the cerebrovascular system, and smoking also creates a higher risk for peripheral arterial disease and aortic aneurysm.

New Concerns in Clinical Care

A recent report from the Centers for Disease Control and Prevention reports that although the age-adjusted prevalence of cardiovascular disease decreased 11%, the decrease in CVD prevalence did not occur in all subpopulations with diabetes. This study spotlights the need for continued interventions to reduce modifiable CVD risk factors among persons with diabetes, to better control diabetes, and to decrease CVD prevalence further. Read the study.

Secondhand Smoke and Heart Disease

Among nonsmokers, secondhand smoke is estimated to cause from 45,000 premature deaths from heart disease. Nonsmokers who are exposed to secondhand smoke at home or at work increase their risk of developing heart disease by 25-30%.

Breathing secondhand smoke can have immediate adverse effects on blood and blood vessels, potentially increasing the risk of a heart attack and causing coronary heart disease by interfering with the normal functioning of the heart, blood, and vascular systems.

No Safe Level of Exposure

The immediate impact of even short exposures to secondhand smoke appears to be almost as large as that observed in active smokers. Even a short time in a smoky room can cause blood platelets to become stickier; even brief secondhand smoke exposure can damage the lining of blood vessels. Short exposures to secondhand smoke can decrease coronary flow velocity reserves to levels observed in smokers and reduce heart rate variability. Adults who breathe 5 hours of secondhand smoke daily have higher levels of LDL cholesterol that can clog the arteries of the heart.

Persons who already have heart disease are at especially high risk of suffering adverse effects from breathing secondhand smoke, and should take special precautions to avoid even brief exposures.

Important Information for Clinicians

Upon quitting smoking, patients experience drop in blood pressure and pulse rate within 20 minutes. Chances of a heart attack decrease within 24 hours, and within a year, excess risk of coronary heart diseases is reduced by half.


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Asthma

Asthma is a leading chronic illness among children and youth in the United States. In 2004, 5.1 million school-aged children and youth were reported to currently have asthma. Asthma is the third-leading cause of hospitalization for children younger than 15 years of age.

Children with asthma who are exposed to secondhand smoke have, generally, increased asthma severity and decreased lung function. The rate of asthma has doubled in the last 20 years with the burden falling disproportionately on low income and minority communities.

A Concern for Maine

Maine asthma rates among adults are higher than the national average. MaineCare population reports a higher prevalence of asthma, and higher prevalence of persistent asthma, and a higher rate of hospitalizations. Asthma is the leading cause of disability and the most common chronic disorder in children, having a significant impact on Maine's health care system including the cost of health care.

One quarter of Maine adults with asthma are current smokers. In addition, almost 1 in 3 kindergartners were exposed to secondhand smoke on a routine basis, and nearly 1 in 5 households reported that one or more children had been diagnosed with asthma.

Managing Asthma

Asthma has a tremendous impact on the social and economic fabric of our state. It is important that patients learn about their disease and how to manage it. Medical management, appropriate medication use, and control of environmental factors are the keys to successful management. For patients with this chronic disease, an Asthma Action/Management plan should be in place, and children should have a Maine School Asthma Plan in their school.

Visit the Maine Asthma Prevention and Control Program.


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Chronic Obstructive Pulmonary Disease

Approximately 10 million people in the United States have been diagnosed with Chronic Obstructive Pulmonary Disease, which includes chronic bronchitis and emphysema. Among current smokers, chronic lung diseases (chronic bronchitis and emphysema) account for 73% of smoking attributable conditions. Smoking causes 80 to 90% of COPD cases, and smokers are 10 times more likely than nonsmokers to die of the disease. 8150.2 out of every 10,000 adults age 45 and older in Maine die of COPD.

Mortality Rates and COPD

COPD is currently the fourth leading cause of morbidity and mortality in the United States. COPD is also the only major disease that is rising in prevalence and mortality while all other major causes of death are declining. Prevalence and mortality data greatly underestimate the total burden of COPD because the disease is usually not diagnosed until it is clinically apparent and moderately advanced. Mortality data also underestimates COPD as a cause of death because the disease is more likely to be cited as an underlying cause of death, or may not be cited at all, rather than being the attributed cause of death.

COPD: A Concern for Clinical Care

The association of COPD with smoking has also contributed to its lack of importance. Until recently it was seen as a self-inflicted consequence of a bad habit, rather than the tragic outcome of an addiction. There is also confusion around the term COPD among patients and healthcare professionals, which complicates epidemiologic studies of COPD. Patients may be diagnosed with smoker's lung, emphysema, bronchitis, chronic bronchitis, chronic obstructive bronchitis or obstructive lung disease and not identify with the term COPD.


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