Smoking remains the leading cause of preventable morbidity and mortality in the US, and American Indians/Alaska Natives (AI/ANs) suffer a disproportionate burden of tobacco-related disease. AI/ANs also have the highest type 2 diabetes (T2D) prevalence of any racial group, with an age-adjusted prevalence of 15.9% among AI/AN adults aged 20 or older compared to 7.6% among Non-Hispanic whites in the US. The harms of commercial cigarette smoking are particularly profound among individuals with T2D who continue to smoke, with an accelerated progression of microvascular and macrovascular complications and an increased risk of death. Although AI/ANs in Oklahoma are known to have a higher smoking prevalence than the general population, the impact of smoking on T2D and complications is unclear. Furthermore, it is unknown whether AI/AN smokers with T2D are aware of their increased risks or if they receive evidence-based tobacco cessation interventions in the context of their T2D care. To address this critical gap in research, we propose an epidemiological pilot study of AI/AN T2D patients to examine tobacco use patterns and health outcomes. The Cherokee Nation is one of the largest tribes in the nation and is the only tribal nation that currently maintains a tribally-operated Surveillance, Epidemiology, and End Results cancer registry. By linking the cancer registry with Cherokee Nation Electronic Medical Records (CNEMR) and the diabetes registry, Cherokee Nation is well-suited to examine diabetes- and tobacco-related health outcomes by smoking status. Through a mixed- methods study, we will measure perceived risks of smoking and identify facilitators and barriers to cessation to then design and pilot test a tailored smoking cessation intervention in this unique population.
The specific aims of this study are to: 1) Compare diabetes- and smoking-related health outcomes, which include glycemic control, blood pressure control, cholesterol, neuropathy, retinopathy, amputation, and tobacco-related cancers among patients with T2D by smoking status; 2) Identify the perceived risks of smoking and the facilitators and barriers to smoking cessation among Cherokee Nation patients with T2D as perceived by both patients and providers; and 3) Determine the feasibility, acceptability, and potential effectiveness of a tailored and coordinated smoking cessation intervention within T2D care. During the pilot intervention, we will use mobile- based real-time ecological momentary assessments (EMA) to capture brief daily assessments on urges to smoke, stress, motivation, and exposure to secondhand smoke and will biochemically validate abstinence using remote carbon monoxide monitors. With the results from the pilot study, we expect to better understand the feasibility and acceptability of the designed intervention in this study population as well as the benefits or challenges with using the mobile technology in this setting. We expect to gather evidence for Cherokee Nation to consider any potential health systems changes in delivering tobacco cessation services for patients with T2D as a way to optimize and coordinate cessation within their diabetes management program.
