1. Smoking cessation for diabetes patients by primary health care nurses – how well are we doing? Dr Barbara Daly, Prof. Bruce Arroll, A/P Nicolette Sheridan A/P Timothy Kenealy Acknowledgements Primary health care nurses of Auckland Novo Nordisk Diabetes Ministry of Health (New Zealand) Charitable Trust of the Auckland Faculty of the Royal NZ College of GPs

2. Background - diabetes Large increase in the incidence of type 2 diabetes from 124,000 in 2001 to 205,000 (6%) in 2012/13 adult survey 1 Large increase for Pacific peoples from 10% to 13% 1 7% for both Māori and Asian populations 1 Shortage of health professionals to manage the condition 2,3 Expanded roles for primary health care (PHC) nurses 4 Practice nurses (largest group) District nurses Specialist nurses o Diabetes Nurse Specialists (DNS) & o Chronic Care Management (CCM) nurses o Nurse practitioners

3. Diabetes patients who smoke have poorer cardiovascular outcomes o CV events, 5 o Chronic kidney disease & its progression 6,7 o Peripheral vascular disease 8 o Lower limb amputations 8

4. PHC nurses survey 2006-8 Aims 1.Identify the key issues for PHC nurses in the management of diabetes 2.Describe the role played by PHC nurses, and compare the different nurse groups 3.Describe their knowledge of diabetes management 4.Identify training needs for PHC nurses

5. Methods Cross-sectional survey 287 PHC nurses randomly sampled 26% of total PHC nurses 86% response rate (representative of all nurses)  210 Practice nurses (PNs)  49 District nurses (DNs)  28 Specialist nurses (SNs)  Completed postal & telephone questionnaires on education, experience, knowledge & management  Information also collected on 265 diabetes patients consulted on a randomly selected day

6. Results Knowledge of risk factors for diabetes / complications 9 96% of nurses identified excess body weight 89% retinopathy Knowledge of risk factors for complications 86% elevated HbA1c / BGLs Only 17% identified smoking Only 14% stroke Lack of associations between knowledge of, and assessment of CV risk factors

7. Awareness of diabetes complications – by nurse group 9 P-values: * * * <0.001; * * 0.01; * <0.05

8. Awareness of risk factors for diabetes-related complications – by nurse group 9 P-values: * * * <0.001; * * 0.01; * <0.05

9. Prevalence of smoking in diabetes patients slightly less than population Tobacco use (n=264) 10  Smokers 16% (More for DNs patients)  Non-smokers 81%  Not known 3% (more for DNs patient)

10. Management of smoking cessation 10 Patients consulted by DNs were more likely to smoke Patients >66 years less likely Of those who wished to stop:  Only 50% were offered nicotine replacement therapy.

11. Conclusions PHC nurses esp. practice & district nurses need to increase their knowledge of CV risk factors. Measurement of blood pressure and advice on diet, physical activity and smoking cessation were not related to patient’s cardiovascular risk. Primary health care nurses are ideally placed to develop capability and expertise in smoking cessation. Further education and training for nurses. Need more research on nurse-led smoking intervention trials to test if more effective than usual care

12. Discussion points Latest three large intensive glucose control trials 11-13 Smoking rates halved by the end of the trial periods in both groups (authors not sure why). Focus was on lowering glucose not smoking. People who know they are at a higher risk of poor outcomes are more likely to make quit attempts and stop. 14-16

13. References 1.Ministry of Health. The New Zealand Health Survey. Annual update of key findings 2012/13. Wellington (New Zealand): Ministry of Health 2013. 2.PricewaterhouseCoopers. Type 2 Diabetes: Managing for Better Health Outcomes. Wellington (New Zealand): Diabetes New Zealand Inc, 2001. 3.New Zealand Society for the Study of Diabetes. League table for adult diabetes specialist physician services in New Zealand. Secondary League table for adult diabetes specialist physician services in New Zealand. 2009. http://www.nzssd.org.nz/healthprofs/workforce_physician.html. http://www.nzssd.org.nz/healthprofs/workforce_physician.html 4.Expert Advisory Group on Primary Health Care Nursing. Investing in health: whakatohutia te oranga tangata. A framework for activating primary health care nursing in New Zealand. Wellington (New Zealand): Ministry of Health, 2002. 5.Brown WV. Risk factors for vascular disease in patients with diabetes. Diabetes, obesity & metabolism 2000;2 Suppl 2:S11-8. 6.Ito H, Antoku S, Furusho M, et al. The Prevalence of the Risk Factors for Atherosclerosis among Type 2 Diabetic Patients Is Greater in the Progressive Stages of Chronic Kidney Disease. Nephron extra 2013;3(1):66-72. 7.Chakkarwar VA. Smoking in diabetic nephropathy: sparks in the fuel tank? World journal of diabetes 2012;3(12):186-95. 8.Marso SP, Hiatt WR. Peripheral arterial disease in patients with diabetes. J Am Coll Cardiol 2006;47(5):921-9.

14. References continued 9.Daly B, Arroll B, Sheridan N, Kenealy T, Scragg R. Diabetes knowledge of nurses providing community care for diabetes patients in Auckland, New Zealand. Prim Care Diab. 2014;8(3):215-23. 10.Daly B, Kenealy T, Arroll B, Sheridan N, Scragg R. Do primary health care nurses address cardiovascular risk in diabetes patients? Diabetes Res Clin Pract. 2014;106:212-20. 11.Gerstein HC, Miller ME, Byington RP, Goff DC, Jr., Bigger JT, Buse JB et al. Effects of intensive glucose lowering in type 2 diabetes, N Engl J Med 2008; 358:2545-59. 12.Patel A, MacMahon S, Chalmers J. intensive blood glucose control and vascular outcomes in patients with type 2 diabetes, N Engl J Med 2008; 358:2560-72. 13.Duckworth W, Abraira C, Moritz T, Reda D, Emanuele N, Reaven PD et al. Glucose control and vascular complications in veterans with type 2 diabetes, N Engl J Med 2009; 360:129-39. 14.Young RP, Hopkins RJ, Smith M, Hogarth DK. Smoking cessation: the potential role of risk assessment tools as motivational triggers. Postgrad Med J 2010;86(1011):26-33. 15. Zwar N. Smoking cessation-what works? Aust Fam Physician 2008;37(1-2):10-14. 16.Tzelepis F, Paul CL, Wiggers J, Walsh RA, Knight J, Duncan SL, et al. A randomised controlled trial of proactive telephone counselling on cold-called smokers' cessation rates. Tob Control 2011;20(1):40-6.