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Prevalence and Associated Factors of Cigarette Smoking Among Type 2 Diabetes Patients in Pakistan

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Prevalence and Associated Factors of Cigarette Smoking Among Type 2 Diabetes Patients in Pakistan 73 International Journal of Collaborative Research on Internal Medicine & Public Health Prevalence and Associated Factors of Cigarette Smoking among Type 2 Diabetes Patients in Pakistan Naila Khalid 1 *, Ejaz Ahmad Khan 2, Shifa Saleem 1, Adeel Tahir 3, Hassan Mahmood 4, 5 Sarah Saleem 1 Association for Social Development, Islamabad, Pakistan 2 Health Services Academy, Islamabad, Pakistan 3 National Tuberculosis Control, Islamabad, Pakistan 4 Pakistan Medical Research Council, Islamabad, Pakistan 5 Ministry of Health, Kingdom of Saudi Arabia * Corresponding Author: Naila Khalid No. 79, Street 14, Falcon Complex, Lithrar Road, Rawalpindi, Pakistan Mobile: + 92 322 4889622 | Email: [email protected] Abstract Background: Pakistan ranks six in top ten countries with highest number of diabetics. Contributing factors are age, positive family history and obesity. Factors, such as smoking, increase the risk of cardiovascular events among diabetic patients. The study was planned to document the prevalence and associated factors of cigarette smoking among type-2 diabetes mellitus patients being seen at tertiary care hospitals in Rawalpindi Pakistan. Methodology: A both qualitative and quantitative, cross sectional study was conducted, in order to determine the prevalence and associated factors of cigarette smoking among type 2 diabetics. Our study population was type 2 diabetic patients of 25 or more years of age. For qualitative part, we conducted two Focus Group Discussions (FGDs) with 6-8 participants, followed by semi-structured questionnaire as the qualitative part of the study. Results: Prevalence of cigarette smoking among type 2 diabetes mellitus patients was 27%. There was significant association of male sex (p=0.00), number cigarettes smoked in a day (p=0.000, CI=1.92-2.135), duration of disease (p=0.000, CI=1.500-1.685), duration of cigarette smoking (p=0.000, CI=1.500-1.685), and at least one episode of Cardio Vascular Disease (CVD) (p=0.026). Smoking was initiated at early age and mainly influenced by peers and elderly in the family. Patients, who had diabetes for less than 20 years, were 1.41 times more likely to be smokers than the one who were diabetics for more than 20 years. Study Limitation: The study has limitation of being a small cross-sectional study, the results of which cannot be generalized. However, it provides basis for larger studies on the subject in Pakistan. Vol. 6 No. 4 (2014) 74 International Journal of Collaborative Research on Internal Medicine & Public Health Conclusion: The study concluded that smoking is prevalent among type 2 diabetic male patients and is associated with the initiation of smoking at younger age and the duration of the disease. Key words: Diabetes mellitus, prevalence, smoking, risk factors Introduction Diabetes mellitus is a group of metabolic diseases in which, an individual has high blood sugar which could be due to the fact that pancreas is unable to produce insulin or because cells do not utilize the insulin been produced. 1 Type-2diabetes formerly called non-insulin-dependent or adult-onset diabetes is caused by the body’s ineffective use of insulin. It often results from excess body weight and physical inactivity. 2 A total of 366 million people around the world had Diabetes Mellitus in the year 2011 and, it has been estimated that by the year 2030 the world will have 552 million type-2 diabetics.3Most (80%) of these diabetics belong to Low and Middle Income Countries (LMICs) having between 40 to 59 years of age. 3 Diabetes caused 4.6 million deaths in 2011. 3-4 Based on prevalence of diabetes, the International Diabetes Federation (IDF) has divided world into different regions. One-fifth of all adults with diabetes in the world live in South-east Asia region most of whom are from India. About 61.3 million diabetic patients in 2011 reside in India. 5 Six out of ten countries with highest prevalence of diabetes belong to Middle East and North African region Pakistan being one of them. 5 In the Middle East and North African region about 32.8 million people or 9.1% of the adult population has diabetes mellitus. 5As a part of this region Pakistan ranks sixth among the global top ten countries with highest number of people with diabetes. 6 According to National Diabetes Survey of Pakistan (NDSP-1990) the prevalence of type-2 diabetes above the age of 25 year is 11%. 7 Prevalence of diabetes mellitus and Impaired glucose tolerance is 22.04% in urban and 17.5% in rural communities in Pakistan. 8-9 High prevalence of Type-2 diabetes mellitus in developing countries poses significant challenges to health systems. Diabetes mellitus is a costly disease, due to its chronicity and multi-organ involvement. Sufficient data related to economic burden of diabetes is available from developed countries, on contrary there is no or limited data is present from developing countries and there is no standardize guideline to be observed in conducting cost estimation. 10 India, China and Indonesia have the highest number of people with diabetes mellitus in Asia region. 10 The total number of cases in these three countries is expected to increase more than double from 61 million in 2000 to 163 million in 2030.9 By the year 2015 deaths due to diabetes will rise 51% in Pakistan. 11 China and India will suffer cumulative Gross Domestic Product (GDP) loss of 13.8% and 16.7% respectively, over the next ten year period.10 It is expected that Pakistan will lose 31 billion dollars by year 2015 from premature deaths due to stroke, heart diseases and diabetes. 11 In Iran healthcare system consumes more than 8.69% of total health expenditure. The total national cost of Iran for diagnosed Type-2 diabetes mellitus in 2009 is estimated at 3.78 billion USA dollars.12 Vol. 6 No. 4 (2014) 75 International Journal of Collaborative Research on Internal Medicine & Public Health Major factors associated with diabetes are age, positive family history, and obesity. 8Another factor which increases the risk of Cardiovascular diseases among type-2 diabetic patients is smoking. There is a strong evidence of positive relationship between cigarette smoking and diabetes mellitus.13 There is a positive association of dose-dependent cigarette smoking and diabetes mellitus.14 Active as well as passive smoking increases the risk to developing type-2 diabetes mellitus.15 Tobacco use is further associated with increase of mortality and morbidity in diabetic patients due to poor metabolic control.16 One of the study in Pakistan reveals that about 40% of diabetic patients are exposed to passive smoking and about 13% are active smokers.17 Literature Review According to International Diabetes Federation (IDF), about 80% of four million diabetes related deaths that occur every year take place in the developing world. 18 Due to resource constraints, the IDF has suggested to focus more on prevention of diabetes complications in Low and Middle Income Countries (LMICs).18 Development of educational intervention programs intended to compact high numbers of diabetes complications will be an appropriate strategy. 18 Reduction in diabetes related deaths in developing countries can be achieved by intensified diabetes self- management education. 19 Large prospective cohort study was conducted by American Cancer Society (ACS) as Cancer Prevention Study 1 from 1959 to 1972, data was used to determine the association of cigarette smoking and diabetes mellitus. The results showed positive dose-related relationship between cigarette smoking and diabetes mellitus.14 Another 7 year old cohort study was conducted to prove the association of passive and active smoking in development of type-2 diabetes mellitus in the elderly population in Germany. Study excluded already diagnosed with type-2 diabetes mellitus patients. Study revealed that both passive and active smoking increase the risk of type-2 diabetes mellitus.15 National Diabetes Survey of Pakistan (NDSP-1990) reported a very high unawareness rate for diabetes, with 36.3% of the people with diabetes being unaware of their condition. Survey has revealed that knowledge relating to diabetes and its prevention is significantly low even in the urban metropolitan areas: only 40% of the people known to have diabetes treated at tertiary health care facilities in Karachi had correct knowledge relating to diabetes and its complications.7 Data was gathered retrospectively from 210 patients with type-2 diabetes visiting outpatient department of a tertiary care hospital in Karachi Pakistan. Results of the study revealed that most significant predictors for metabolic syndrome were female gender, low HDL cholesterol levels and high systolic blood pressure. Study suggested early initiation of primary prevention strategies to cope with alarming high frequency of metabolic syndrome. 20 Diabetic patients are at an increased risk of developing cardiovascular diseases but there exists lack of awareness regarding the tobacco use, diabetes and its complications. A study was done to evaluate the CVD-related lifestyle factors among type-2 diabetes patients in outpatient clinics in Karachi, Pakistan. Results of the study showed that majority of the patients Vol. 6 No. 4 (2014) 76 International Journal of Collaborative Research on Internal Medicine & Public Health are physically inactive and have adverse psychosocial factors. About 40% are exposed to passive smoking and 13% are active smokers.17 Descriptive cross-sectional study was conducted from March 2008 to June 2008 at Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine and metabolic disorders (BIRDEM) Hospital, Shahbagh Dhaka to find out the pattern of tobacco consumption among diabetic patients.21 The study suggested that tobacco consumers are mostly in 40 and 50 years age group and belonged to lower-middle class socio-economic status. Prevalence of tobacco use among diabetic patients in Pakistan was studied by Sheikh et al in Civil hospital Karachi (2001).
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