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Trends in cigarette smoking among Spanish diabetic adults, 1987–2009
diabetes research and clinical practice 98 (2012) e1–e3
Contents available at Sciverse ScienceDirect
Diabetes Research and Clinical Practice journ al h ome pa ge : www .elsevier.co m/lo cate/diabres
Brief report
Trends in cigarette smoking among Spanish diabetic adults, 1987–2009 Ana Lopez-de-Andres *, Rodrigo Jime´nez-Garcı´a, Valentin Herna´ndez-Barrera, A´ngel Gil-de-Miguel, Ma Isabel Jime´nez-Trujillo, Pilar Carrasco-Garrido Preventive Medicine and Public Health Teaching and Research Department, Health Sciences Faculty, Rey Juan Carlos University, Avda de Atenas s/n, Alcorco´n 28922, Madrid, Spain
article info
abstract
Article history:
We examine trends in cigarette smoking in adults with and without diabetes in Spain.
Received 7 November 2011
Among diabetic men, prevalence of smoking was lower in 2009 (20.7%) than in 1987 (34.6%);
Received in revised form
however among diabetic women, the prevalence significantly increased. Prevalence of
13 June 2012
smoking in diabetic adults was lower than for those without diabetes. # 2012 Elsevier Ireland Ltd. All rights reserved.
Accepted 18 June 2012 Published on line 6 July 2012 Keywords: Diabetes Smoking Trends Sex Age groups
1.
Introduction
Cigarette smoking is an independent and modifiable risk factor for the development of diabetes mellitus (DM) [1] and increases the risks of mortality and cardiovascular morbidity in subjects with diabetes [1]. There is little information available on the distribution of smoking in diabetics. In the USA, England and Germany, diabetics are about as likely to be smokers as the general population [2–4]. In Spain, trend data indicate that smoking among diabetics decreases significantly with age, for men and women alike [5].
We examine trends in cigarette smoking over 20 years in diabetic Spanish adults, based on the data from Spanish National Health Surveys (NHS) from 1987 to 2006 and from the European Health Survey (EHS) in Spain for 2009.
2.
Methods
The present study involved the use of individual data obtained from the Spanish NHS from 1987 to 2006; and the EHS in Spain for 2009 [6,7].
* Corresponding author at: Unidad de Docencia e Investigacio´n en Medicina Preventiva y Salud Pu´blica, Facultad de Ciencias de la Salud, Avda. de Atenas s/n, 28922 Alcorco´n, Madrid, Spain. Tel.: +34 91 4888623; fax: +34 91 4888848. E-mail address: [email protected] (A. Lopez-de-Andres). 0168-8227/$ – see front matter # 2012 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.diabres.2012.06.007
e2
1.05 1.02 1.05 1.02 1.03 1.01 7.9(6.4–9.5) 22.8(22.1–23.5) 22.2(17.8–26.7) 30.1(29.1–31.0) 1.6(0.7–2.5) 3.2(2.6–3.8) *
IRR, adjusted incidence rate ratios. Significant association (P < 0.05) for time trend on comparing the variables among diabetics during the 22 years of the study. ** Statistically significant (P < 0.05) association on comparing the variables between diabetics and non-diabetics for each National Health Survey.
5.6(4.6–6.7) 22.5(21.9–23.1) 16.2(13.0–19.4)** 29.8(29.0–30.6) 1.0(0.3–1.6)** 2.7(2.2–3.2) 6.1(4.5–7.7) 22.4(21.7–23.2) 17.2(12.3–22.1)** 30.2(29.2–31.2) 1.2(0.4–2.0) 1.5(1.1–1.9) 6.0(4.4–7.6) 23.9(23.2–24.7) 16.2(11.6–20.8)** 32.1(31.1–33.1) 1.5(0.3–2.7) 1.8(1.3–2.4) 3.2(1.7–4.7) 20.1(19.4–20.8) 7.4(4.0–10.8)** 25.9(24.9–26.8) 1.3(0.0–2.8) 4.6(3.6–5.7) 2.8(1.7–3.9) 15.8(15.3–16.4) 6.8(4.6–9.1) 21.1(20.4–21.8) 1.0(0.0–2.2) 1.6(1.1–2.2)
5.0(3.4–6.6) 22.2(21.3–23.1) 15.3(10.3–20.2) 29.9(28.6–31.1) 0.5(0.0–1.1) 1.6(0.8–2.4)
20.7(18.0–23.5) 34.1(33.1–35.0) 31.2(26.3–36.1)** 38.9(37.8–40.0) 13.1(10.0–16.1) 15.1(13.5–16.7) 21.7(19.1–24.4) 34.9(34.0–35.8) 33.0(28.2–37.8) 39.5(38.5–40.5) 13.4(10.4–16.4) 16.7(15.2–18.3) 26.1(22.6–29.7) 37.2(36.3–38.2) 34.7(28.6–40.8) 42.3(41.2–43.4) 19.8(15.6–24.0) 17.3(15.7–19.0) 26.8(23.1–30.5) 41.6(40.6–42.6) 40.7(34.3–47.2) 47.4(46.2–48.5) 16.6(12.3–20.9) 18.7(16.8–20.7) 29.5(24.4–34.6) 48.5(47.5–49.6) 45.1(37.9–52.2) 53.9(52.7–55.0) 18.1(11.1–25.1) 27.6(25.3–29.9) 34.6(30.0–39.1) 52.7(51.9–53.6) 52.9(46.7–59.0) 57.8(56.8–58.7) 21.8(14.7–25.5)** 32.9(30.7–35.0)
32.4(26.5–38.3) 45.4(44.1–46.7) 45.5(37.1–53.9) 51.0(49.6–52.5) 22.8(14.6–30.9) 23.2(20.3–26.1)
868 20,193
Both Person with diabetes Person without diabetes Men Diabetes* No diabetes* Diabetes, 16–64 years* No diabetes, 16–64 years* Diabetes, 65 years* No diabetes, 65 years* Women Diabetes* No diabetes* Diabetes, 16–64 years* No diabetes, 16–64 years* Diabetes, 65 years No diabetes, 65 years
1176 28,471
605 12,187
1148 19,919
1455 20,195
2156 27,322
1772 20,416
IRR 2009 2006 2003 2001 1995–1997
Among Spanish diabetic men, age adjusted prevalence of smoking was much lower in 2009 than in 1987 (20.7% in 2009 vs. 34.6% in 1987) with a significant trend (P < 0.001). In all years of the study, the age adjusted prevalence of smoking in diabetic men was lower than for those without diabetes (Table 1). In all age groups, prevalence of smoking among diabetic men was significantly (P < 0.01) lower in 2009 (31.2% in participants aged 16–64 years and 13.1% in those aged above 64) than in 1987 (52.9% and 21.8%, in the two age groups, respectively). The prevalence of smoking in diabetic men, in all years of the study, was highest among participants aged 16–64 years and decreased with advancing age. Smoking among diabetic men was lower than for men without diabetes in all age groups and in all years of the study. In 2009, diabetic men aged 16–64 years had a lower prevalence than those without diabetes (31.2% vs. 38.9%). Prevalence of smoking was much lower in diabetic men aged above 64 than those without diabetes during 1987 (21.8% vs. 32.9%) (P < 0.05). Trends of smoking prevalence among diabetic women significantly increased during the period of study (2.8% in 1987 vs. 7.9% in 2009) (P < 0.05). During the period of study, the age adjusted prevalence of smoking in diabetic women was lower than for non-diabetic women. Prevalence of smoking among diabetic women aged 16–64 years was significantly higher (P < 0.01) in 2009 than in 1987 (22.2% vs. 6.8%). Smoking among diabetic women decreased with age during all years of the study (Table 1). By age groups and in all years of the study, trends of smoking prevalence among diabetic women were lower than for those without diabetes. In 1993, 2001 and 2003 diabetic participants aged 16–64 years had significantly (P < 0.01) lower prevalence than those without diabetes (7.4% vs. 25.9% in 1993; 16.2% vs. 32.1% in 2001; and 17.2% vs. 30.2% in 2003). In 2006, for both age groups studied, diabetic women had a
1993
Results
1987
3.
Table 1 – Age specific and age adjusted prevalence of smoking, by selected demographic characteristics and self-reported diabetes status in Spain, 1987–2009.
Subjects were classified as diabetic and included in the study if they answered affirmatively to either or both of the following questions: ‘‘Has your doctor told you that you are currently suffering from diabetes?’’ and/or ‘‘Have you taken any medication to treat diabetes in the last two weeks?’’ Smoking status was categorized as current smokers and nonsmokers (including persons who have never smoked and former smokers). The questions used were identical in all surveys. [6,7]. We examined trends in smoking prevalence by age and sex in people with and without diabetes. Age adjustment was performed using the direct standardization method using the 2009 Spanish population as a Ref. [8]. To assess trends in rates of hospital admissions, the adjusted incidence rate ratios were calculated using multivariate Poisson regression models. Estimates were made using the ‘‘svy’’ (survey commands) function of the STATA program. Statistical significance was set at P < 0.05 (two-tailed).
0.97 0.98 0.98 0.98 0.98 0.96
diabetes research and clinical practice 98 (2012) e1–e3
diabetes research and clinical practice 98 (2012) e1–e3
significantly (P < 0.05) lower prevalence of smoking than nondiabetic women (16.2% vs. 29.8% in women aged 16–64 years and 1.0% vs. 2.7% in those aged above 64).
4.
Discussion
Our main finding is that smoking prevalence in diabetic men decreased significantly from 1987 to 2009, however a significantly upward trend was observed in diabetic women. This smoking increase among diabetic women was observed in those aged 16–64 years; however, in the elderly the absolute increase was small. Our results not only indicate similar current smoking prevalence to those obtained by other study conducted in Spain, but also report higher prevalence among males than females [9]. The upward trend of smoking in diabetic women likely reflects a number of factors reported in the literature. Zhang et al. suggested an association between lack of physical activity, poor fruit and vegetable intake and higher intake of alcohol or caffeine with more tobacco use among diabetic women [10]. We think that these risk factors for tobacco use, most of which are possibly related to social pressure, would also affect women without diabetes. Studies conducted in the USA report contradictory results in smoking trends, variously observing an increase, no change and a decrease [4,11,12]. We found lower prevalence of current smoking among diabetics compared to non-diabetics. In Germany, Schipf et al. reported that prevalence of current smokers was lower among persons with than without Type 2 DM [4]. The strength of our study lies in its large sample size and standardized methodology. Arguably, the main limitations are as follows: (1) all of the information obtained within the interviews may be subject to recall error or the tendency of interviewees to give socially desirable responses; and (2) data on relevant variables, such as type of diabetes or diabetes duration, are not collected and may act as confounding factors in certain associations. In conclusion, our study is an investigation which documents a decrease in the smoking prevalence among diabetic men in Spain. Trends of current smoking prevalence among diabetic women are troublesome and call for urgent implementation of health promotion, prevention, and diabetes management strategies.
Conflict of interest The authors declare that they have no conflict of interest.
e3
Acknowledgement The work was supported by a grant from the ISCIII (ETES: PI09/ 90515)
references
[1] Willi C, Bodenmann P, Ghali WA, Faris PD, Cornuz J. Active smoking and the risk of type 2 diabetes: a systematic review and meta-analysis. J Am Med Assoc 2007;298(22):2654–64. [2] Ford ES, Mokdad AH, Gregg EW. Trends in cigarette smoking among US adults with diabetes: findings from the Behavioral Risk Factor Surveillance System. Prev Med 2004;39(6):1238–42. [3] Gulliford MC, Sedgwick JE, Pearce AJ. Cigarette smoking, health status, socio-economic status and access to health care in diabetes mellitus: a cross-sectional survey. BMC Health Serv Res 2003;3(1):4. [4] Schipf S, Schmidt CO, Alte D, Werner A, Scheidt-Nave C, John U, et al. Smoking prevalence in Type 2 diabetes: results of the Study of Health in Pomerania (SHIP) and the German National Health Interview and Examination Survey (GNHIES). Diabet Med 2009;26(8):791–7. [5] Jimenez-Garcia R, Hernandez-Barrera V, Jimenez-Trujillo I, Garrido PC, Lopez de Andres A, Gil de Miguel A. Trends in cardiovascular risk factors and lifestyle behaviors among Spanish adults with diabetes (1993–2003). J Diabetes Complications 2009;23(6):394–400. [6] Ministerio de Sanidad, Servicios Sociales e Igualdad. Spanish National Health Survey. Available at: http:// www.msc.es/estadEstudios/estadisticas/ encuestaNacional/home.htm [accessed 06.13.12]. [7] Ministerio de Sanidad, Servicios Sociales e Igualdad. European Health Survey in Spain; 2009, Available at: http:// www.msc.es/estadEstudios/estadisticas/EncuestaEuropea/ home.htm [Accessed 06.13.12]. [8] Instituto Nacional de Estadı´stica (INE). Population Estimates; 2010, Available at: http://www.ine.es [accessed 06.15.11]. [9] Larranaga I, Arteagoitia JM, Rodriguez JL, Gonzalez F, Esnaola S, Pinies JA, et al. Socio-economic inequalities in the prevalence of Type 2 diabetes, cardiovascular risk factors and chronic diabetic complications in the Basque Country, Spain. Diabet Med 2005;22(8):1047–53. [10] Zhang L, Curhan GC, Hu FB, Rimm EB, Forman JP. Association between passive and active smoking and incident type 2 diabetes in women. Diabetes Care 2011;34(4):892–7. [11] Imperatore G, Cadwell BL, Geiss L, Saadinne JB, Williams DE, Ford ES, et al. Thirty-year trends in cardiovascular risk factor levels among US adults with diabetes: National Health and Nutrition Examination Surveys, 1971–2000. Am J Epidemiol 2004;160(6):531–9. [12] Okoro CA, Mokdad AH, Ford ES, Bowman BA, Vinicor F, Giles WH. Are persons with diabetes practicing healthier behaviors in the year 2001? Results from the Behavioral Risk Factor Surveillance System. Prev Med 2004;38(2):203–8.
Contents available at Sciverse ScienceDirect
Diabetes Research and Clinical Practice journ al h ome pa ge : www .elsevier.co m/lo cate/diabres
Brief report
Trends in cigarette smoking among Spanish diabetic adults, 1987–2009 Ana Lopez-de-Andres *, Rodrigo Jime´nez-Garcı´a, Valentin Herna´ndez-Barrera, A´ngel Gil-de-Miguel, Ma Isabel Jime´nez-Trujillo, Pilar Carrasco-Garrido Preventive Medicine and Public Health Teaching and Research Department, Health Sciences Faculty, Rey Juan Carlos University, Avda de Atenas s/n, Alcorco´n 28922, Madrid, Spain
article info
abstract
Article history:
We examine trends in cigarette smoking in adults with and without diabetes in Spain.
Received 7 November 2011
Among diabetic men, prevalence of smoking was lower in 2009 (20.7%) than in 1987 (34.6%);
Received in revised form
however among diabetic women, the prevalence significantly increased. Prevalence of
13 June 2012
smoking in diabetic adults was lower than for those without diabetes. # 2012 Elsevier Ireland Ltd. All rights reserved.
Accepted 18 June 2012 Published on line 6 July 2012 Keywords: Diabetes Smoking Trends Sex Age groups
1.
Introduction
Cigarette smoking is an independent and modifiable risk factor for the development of diabetes mellitus (DM) [1] and increases the risks of mortality and cardiovascular morbidity in subjects with diabetes [1]. There is little information available on the distribution of smoking in diabetics. In the USA, England and Germany, diabetics are about as likely to be smokers as the general population [2–4]. In Spain, trend data indicate that smoking among diabetics decreases significantly with age, for men and women alike [5].
We examine trends in cigarette smoking over 20 years in diabetic Spanish adults, based on the data from Spanish National Health Surveys (NHS) from 1987 to 2006 and from the European Health Survey (EHS) in Spain for 2009.
2.
Methods
The present study involved the use of individual data obtained from the Spanish NHS from 1987 to 2006; and the EHS in Spain for 2009 [6,7].
* Corresponding author at: Unidad de Docencia e Investigacio´n en Medicina Preventiva y Salud Pu´blica, Facultad de Ciencias de la Salud, Avda. de Atenas s/n, 28922 Alcorco´n, Madrid, Spain. Tel.: +34 91 4888623; fax: +34 91 4888848. E-mail address: [email protected] (A. Lopez-de-Andres). 0168-8227/$ – see front matter # 2012 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.diabres.2012.06.007
e2
1.05 1.02 1.05 1.02 1.03 1.01 7.9(6.4–9.5) 22.8(22.1–23.5) 22.2(17.8–26.7) 30.1(29.1–31.0) 1.6(0.7–2.5) 3.2(2.6–3.8) *
IRR, adjusted incidence rate ratios. Significant association (P < 0.05) for time trend on comparing the variables among diabetics during the 22 years of the study. ** Statistically significant (P < 0.05) association on comparing the variables between diabetics and non-diabetics for each National Health Survey.
5.6(4.6–6.7) 22.5(21.9–23.1) 16.2(13.0–19.4)** 29.8(29.0–30.6) 1.0(0.3–1.6)** 2.7(2.2–3.2) 6.1(4.5–7.7) 22.4(21.7–23.2) 17.2(12.3–22.1)** 30.2(29.2–31.2) 1.2(0.4–2.0) 1.5(1.1–1.9) 6.0(4.4–7.6) 23.9(23.2–24.7) 16.2(11.6–20.8)** 32.1(31.1–33.1) 1.5(0.3–2.7) 1.8(1.3–2.4) 3.2(1.7–4.7) 20.1(19.4–20.8) 7.4(4.0–10.8)** 25.9(24.9–26.8) 1.3(0.0–2.8) 4.6(3.6–5.7) 2.8(1.7–3.9) 15.8(15.3–16.4) 6.8(4.6–9.1) 21.1(20.4–21.8) 1.0(0.0–2.2) 1.6(1.1–2.2)
5.0(3.4–6.6) 22.2(21.3–23.1) 15.3(10.3–20.2) 29.9(28.6–31.1) 0.5(0.0–1.1) 1.6(0.8–2.4)
20.7(18.0–23.5) 34.1(33.1–35.0) 31.2(26.3–36.1)** 38.9(37.8–40.0) 13.1(10.0–16.1) 15.1(13.5–16.7) 21.7(19.1–24.4) 34.9(34.0–35.8) 33.0(28.2–37.8) 39.5(38.5–40.5) 13.4(10.4–16.4) 16.7(15.2–18.3) 26.1(22.6–29.7) 37.2(36.3–38.2) 34.7(28.6–40.8) 42.3(41.2–43.4) 19.8(15.6–24.0) 17.3(15.7–19.0) 26.8(23.1–30.5) 41.6(40.6–42.6) 40.7(34.3–47.2) 47.4(46.2–48.5) 16.6(12.3–20.9) 18.7(16.8–20.7) 29.5(24.4–34.6) 48.5(47.5–49.6) 45.1(37.9–52.2) 53.9(52.7–55.0) 18.1(11.1–25.1) 27.6(25.3–29.9) 34.6(30.0–39.1) 52.7(51.9–53.6) 52.9(46.7–59.0) 57.8(56.8–58.7) 21.8(14.7–25.5)** 32.9(30.7–35.0)
32.4(26.5–38.3) 45.4(44.1–46.7) 45.5(37.1–53.9) 51.0(49.6–52.5) 22.8(14.6–30.9) 23.2(20.3–26.1)
868 20,193
Both Person with diabetes Person without diabetes Men Diabetes* No diabetes* Diabetes, 16–64 years* No diabetes, 16–64 years* Diabetes, 65 years* No diabetes, 65 years* Women Diabetes* No diabetes* Diabetes, 16–64 years* No diabetes, 16–64 years* Diabetes, 65 years No diabetes, 65 years
1176 28,471
605 12,187
1148 19,919
1455 20,195
2156 27,322
1772 20,416
IRR 2009 2006 2003 2001 1995–1997
Among Spanish diabetic men, age adjusted prevalence of smoking was much lower in 2009 than in 1987 (20.7% in 2009 vs. 34.6% in 1987) with a significant trend (P < 0.001). In all years of the study, the age adjusted prevalence of smoking in diabetic men was lower than for those without diabetes (Table 1). In all age groups, prevalence of smoking among diabetic men was significantly (P < 0.01) lower in 2009 (31.2% in participants aged 16–64 years and 13.1% in those aged above 64) than in 1987 (52.9% and 21.8%, in the two age groups, respectively). The prevalence of smoking in diabetic men, in all years of the study, was highest among participants aged 16–64 years and decreased with advancing age. Smoking among diabetic men was lower than for men without diabetes in all age groups and in all years of the study. In 2009, diabetic men aged 16–64 years had a lower prevalence than those without diabetes (31.2% vs. 38.9%). Prevalence of smoking was much lower in diabetic men aged above 64 than those without diabetes during 1987 (21.8% vs. 32.9%) (P < 0.05). Trends of smoking prevalence among diabetic women significantly increased during the period of study (2.8% in 1987 vs. 7.9% in 2009) (P < 0.05). During the period of study, the age adjusted prevalence of smoking in diabetic women was lower than for non-diabetic women. Prevalence of smoking among diabetic women aged 16–64 years was significantly higher (P < 0.01) in 2009 than in 1987 (22.2% vs. 6.8%). Smoking among diabetic women decreased with age during all years of the study (Table 1). By age groups and in all years of the study, trends of smoking prevalence among diabetic women were lower than for those without diabetes. In 1993, 2001 and 2003 diabetic participants aged 16–64 years had significantly (P < 0.01) lower prevalence than those without diabetes (7.4% vs. 25.9% in 1993; 16.2% vs. 32.1% in 2001; and 17.2% vs. 30.2% in 2003). In 2006, for both age groups studied, diabetic women had a
1993
Results
1987
3.
Table 1 – Age specific and age adjusted prevalence of smoking, by selected demographic characteristics and self-reported diabetes status in Spain, 1987–2009.
Subjects were classified as diabetic and included in the study if they answered affirmatively to either or both of the following questions: ‘‘Has your doctor told you that you are currently suffering from diabetes?’’ and/or ‘‘Have you taken any medication to treat diabetes in the last two weeks?’’ Smoking status was categorized as current smokers and nonsmokers (including persons who have never smoked and former smokers). The questions used were identical in all surveys. [6,7]. We examined trends in smoking prevalence by age and sex in people with and without diabetes. Age adjustment was performed using the direct standardization method using the 2009 Spanish population as a Ref. [8]. To assess trends in rates of hospital admissions, the adjusted incidence rate ratios were calculated using multivariate Poisson regression models. Estimates were made using the ‘‘svy’’ (survey commands) function of the STATA program. Statistical significance was set at P < 0.05 (two-tailed).
0.97 0.98 0.98 0.98 0.98 0.96
diabetes research and clinical practice 98 (2012) e1–e3
diabetes research and clinical practice 98 (2012) e1–e3
significantly (P < 0.05) lower prevalence of smoking than nondiabetic women (16.2% vs. 29.8% in women aged 16–64 years and 1.0% vs. 2.7% in those aged above 64).
4.
Discussion
Our main finding is that smoking prevalence in diabetic men decreased significantly from 1987 to 2009, however a significantly upward trend was observed in diabetic women. This smoking increase among diabetic women was observed in those aged 16–64 years; however, in the elderly the absolute increase was small. Our results not only indicate similar current smoking prevalence to those obtained by other study conducted in Spain, but also report higher prevalence among males than females [9]. The upward trend of smoking in diabetic women likely reflects a number of factors reported in the literature. Zhang et al. suggested an association between lack of physical activity, poor fruit and vegetable intake and higher intake of alcohol or caffeine with more tobacco use among diabetic women [10]. We think that these risk factors for tobacco use, most of which are possibly related to social pressure, would also affect women without diabetes. Studies conducted in the USA report contradictory results in smoking trends, variously observing an increase, no change and a decrease [4,11,12]. We found lower prevalence of current smoking among diabetics compared to non-diabetics. In Germany, Schipf et al. reported that prevalence of current smokers was lower among persons with than without Type 2 DM [4]. The strength of our study lies in its large sample size and standardized methodology. Arguably, the main limitations are as follows: (1) all of the information obtained within the interviews may be subject to recall error or the tendency of interviewees to give socially desirable responses; and (2) data on relevant variables, such as type of diabetes or diabetes duration, are not collected and may act as confounding factors in certain associations. In conclusion, our study is an investigation which documents a decrease in the smoking prevalence among diabetic men in Spain. Trends of current smoking prevalence among diabetic women are troublesome and call for urgent implementation of health promotion, prevention, and diabetes management strategies.
Conflict of interest The authors declare that they have no conflict of interest.
e3
Acknowledgement The work was supported by a grant from the ISCIII (ETES: PI09/ 90515)
references
[1] Willi C, Bodenmann P, Ghali WA, Faris PD, Cornuz J. Active smoking and the risk of type 2 diabetes: a systematic review and meta-analysis. J Am Med Assoc 2007;298(22):2654–64. [2] Ford ES, Mokdad AH, Gregg EW. Trends in cigarette smoking among US adults with diabetes: findings from the Behavioral Risk Factor Surveillance System. Prev Med 2004;39(6):1238–42. [3] Gulliford MC, Sedgwick JE, Pearce AJ. Cigarette smoking, health status, socio-economic status and access to health care in diabetes mellitus: a cross-sectional survey. BMC Health Serv Res 2003;3(1):4. [4] Schipf S, Schmidt CO, Alte D, Werner A, Scheidt-Nave C, John U, et al. Smoking prevalence in Type 2 diabetes: results of the Study of Health in Pomerania (SHIP) and the German National Health Interview and Examination Survey (GNHIES). Diabet Med 2009;26(8):791–7. [5] Jimenez-Garcia R, Hernandez-Barrera V, Jimenez-Trujillo I, Garrido PC, Lopez de Andres A, Gil de Miguel A. Trends in cardiovascular risk factors and lifestyle behaviors among Spanish adults with diabetes (1993–2003). J Diabetes Complications 2009;23(6):394–400. [6] Ministerio de Sanidad, Servicios Sociales e Igualdad. Spanish National Health Survey. Available at: http:// www.msc.es/estadEstudios/estadisticas/ encuestaNacional/home.htm [accessed 06.13.12]. [7] Ministerio de Sanidad, Servicios Sociales e Igualdad. European Health Survey in Spain; 2009, Available at: http:// www.msc.es/estadEstudios/estadisticas/EncuestaEuropea/ home.htm [Accessed 06.13.12]. [8] Instituto Nacional de Estadı´stica (INE). Population Estimates; 2010, Available at: http://www.ine.es [accessed 06.15.11]. [9] Larranaga I, Arteagoitia JM, Rodriguez JL, Gonzalez F, Esnaola S, Pinies JA, et al. Socio-economic inequalities in the prevalence of Type 2 diabetes, cardiovascular risk factors and chronic diabetic complications in the Basque Country, Spain. Diabet Med 2005;22(8):1047–53. [10] Zhang L, Curhan GC, Hu FB, Rimm EB, Forman JP. Association between passive and active smoking and incident type 2 diabetes in women. Diabetes Care 2011;34(4):892–7. [11] Imperatore G, Cadwell BL, Geiss L, Saadinne JB, Williams DE, Ford ES, et al. Thirty-year trends in cardiovascular risk factor levels among US adults with diabetes: National Health and Nutrition Examination Surveys, 1971–2000. Am J Epidemiol 2004;160(6):531–9. [12] Okoro CA, Mokdad AH, Ford ES, Bowman BA, Vinicor F, Giles WH. Are persons with diabetes practicing healthier behaviors in the year 2001? Results from the Behavioral Risk Factor Surveillance System. Prev Med 2004;38(2):203–8.