摘要：Objectives. We assessed educational disparities in smoking rates among adults with diabetes in managed care settings. Methods. We used a cross-sectional, survey-based (2002–2003) observational study among 6538 diabetic patients older than 25 years across multiple managed care health plans and states. For smoking at each level of self-reported educational attainment, predicted probabilities were estimated by means of hierarchical logistic regression models with random intercepts for health plan, adjusted for potential confounders. Results. Overall, 15% the participants reported current smoking. An educational gradient in smoking was observed that varied significantly ( P <.003) across age groups, with the educational gradient being strong in those aged 25 to 44 years, modest in those aged 45 to 64 years, and nonexistent in those aged 65 years or older. Of particular note, the prevalence of smoking observed in adults aged 25–44 years with less than a high school education was 50% (95% confidence interval: 36% to 63%). Conclusions. Approximately half of poorly educated young adults with diabetes smoke, magnifying the health risk associated with early-onset diabetes. Targeted public health interventions for smoking prevention and cessation among young, poorly educated people with diabetes are needed. Smoking is recognized as the leading preventable cause of death and one of the most potent risk factors for cardiovascular disease and cancer. The total annual direct and indirect costs of smoking in the United States for 1995–1999 were estimated to be $158 billion. 1 In the United States during 1997–2001, cigarette smoking and tobacco exposure resulted in approximately 438000 premature deaths, 5.5 million years of potential life lost, and $92 billion in productivity losses annually. 2 Diabetes confers a similar burden in annual health care expenditures ($132 billion). 3 Smoking may be a particularly important risk multiplier for adults with diabetes, because it is associated with hyperglycemia, microvascular complications, insulin resistance, and microalbuminuria 4 – 6 and greatly increases an already elevated risk of cardiovascular disease, 7 , 8 end-stage renal disease, 9 , 10 and death. 11 , 12 Moreover, although quitting smoking reduces the mortality risk, the detrimental effects can persist for years after quitting, especially for smokers with diabetes. 13 In the general patient population, poverty and lower educational attainment are linked to a higher prevalence of smoking. 14 Nonetheless, relatively little is known about smoking patterns among adults with diabetes and, in particular, about the influence of social disparities, such as educational differences, on the prevalence of smoking in this group. Understanding which subpopulations are most at risk for smoking would help health plans and policymakers target their smoking cessation and prevention interventions among enrollees with diabetes. Translating Research Into Action for Diabetes (TRIAD) is an ongoing study of quality of care and self-care for people with diabetes in managed care settings in 7 US states that began in 2000. 15 As part of TRIAD, we examined the relation between socioeconomic status and various health behaviors among people with diabetes. TRIAD surveyed a large cohort of adults with diabetes enrolled in managed care, enabling a detailed examination of smoking and social factors in addition to other factors that contribute to risk for future complications. Here we focus on the relation between educational attainment and smoking.
