Tobacco Influence on Peripheral Vascular Disease

Peripheral vascular disease can often lead to morbidity or mortality. The disease is caused by atherosclerosis with one of the major causes being smoking. Toxic chemicals present in tobacco, including nicotine, have a disastrous effect. Among atherosclerotic patients, diabetes mellitus is a major risk factor, and these two conditions may result in lower extremity artery problems and coronary artery disease. While smoking is associated with cardiovascular events, there is still little knowledge among patients regarding the problem.

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Therefore, this study will determine if smoking cessation education can lead to improvements in cholesterol and glucose intolerance levels. The clinical question in the PICOT format is: In adult patients (35 to 55 years old) attending clinics/hospitals for diabetes mellitus and PVD care provided by nurses (P), education on smoking cessation (I), as opposed to no education on smoking cessation (C), causes improved cholesterol and glucose intolerance levels (O) in one year (T). This question will be answered using a quasi-experimental study design involving 512 patients between the ages of 35 and 55 attending hospitals for the care of diabetes mellitus and PVD. The findings of this study can help reduce care costs and avoid hospital-acquired infections that occur as a result of longer hospital stays.

Peripheral Vascular Disease in Diabetes Mellitus


Peripheral vascular disease (PVD) is a condition that has the potential of causing loss of limbs or death. The condition manifests as deficient tissue perfusion that is caused by existing atherosclerosis, and it is complicated by either thrombi or emboli (Thiruvoipati, Kielhorn & Armstrong, 2015). Many people live unknowingly with the condition in varying stages of development, but patients in acute settings such as those with acute limb ischemia may be considered to be in life-threatening situations. Therefore, they may need emergency intervention to reduce the possibility of morbidity and mortality. PVD is chiefly a result of atherosclerosis. It is worth noting that the atheroma consists of important cholesterol joined to proteins with a fibrous intravascular covering. The process of atherosclerotic may slowly progress to the point of completing occlusion of medium-and-large sized arteries. The occlusion of the arteries, particularly in lower limbs, may cause morbidity, including ischemia, gangrene, claudication, foot ulcers, amputation, or even infection.

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The strongest risk factors for PAD are smoking and DM (Huysman & Mathieu, 2009). Additionally, diabetes, age, and peripheral neuropathy can increase the risk of PAD in patients that have pre-existing DM (Thiruvoipati et al., 2015). Patients with PAD who also have DM often stay longer in hospitals and are likely to incur significant costs. They use more hospital resources as opposed to patients who have PAD alone. DM is associated with severe below-the-knee PAD, such as anterior tibial, popliteal, posterior, and peroneal tibial arteries, while smoking is associated with proximal peripheral artery disease in aorto-iliofemoral vessels. Endothelial dysfunction, inflammation, dysfunction of smooth muscle cell as well as hypercoagulability remain the major factors in diabetic arteriopathy (Thiruvoipati et al., 2015). Education on strict diabetes control is advocated for in patients with PVD. Education on smoke cessation has a positive impact on diabetic patients with peripheral vascular disease.

Statement of the Problem

Smoking results in cardiovascular events, such as atherosclerotic changes, which cause narrowing of vascular lumen and induce hypercoagulable state. That, in turn, causes the risk of acute thrombosis. In addition, a study by WHO has shown that non-tobacco smokers are not spared either since tobacco smoke has nearly 4000 known chemicals out of which at least 250 can cause harm to inhalers, while over 50 are related to human cancer. Unfortunately, if smoked within an enclosed place, the smoke from tobacco is harmful even to nonsmokers (WHO, 2012). This could explain the fact that over 480,000 people die from the effects of cigarette smoking in the U.S alone, which is nearly one death in every 5 and is worse than the effects of HIV, vehicle-related injuries, firearms, drugs and alcohol use combined. Globally, smoking has been linked to 9 in every 10 deaths resulting from lung cancer in both genders (CDCP, 2017).

Fortunately, quitting smoking can help victims reduce the risk of such diseases as heart attack, stroke, and cancer. However, it is unfortunate the several attempts by clinicians to stimulate quit attempts have not yielded the required results, hence, the need for new strategies and more efforts. Among the strategies that have proven to be working is education intended to emphasize the myth that smoking is an important health hazard. In fact, studies show that lung cancer has no cure. The problem is that smoking is being increasingly stigmatized as a behavior of the lower class and ir rarely addressed in health-related policies or even being given attention by researchers. With the urgent need for reduction in smoking prevalence, this study could not have come at a better time. Moreover, many patients are not aware of this danger and nurse-led education strategies have become increasing essential ways of intervention globally. Such strategies help improve patient health care at affordable costs.

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Purpose of the Study

The purpose of this study will be to determine whether smoking cessation education among diabetes mellitus patients with PVD will result in positive changes in cholesterol and glucose intolerance levels

Research Question (s)/Hypothesis

  1. Research Question 
    Does education on smoke cessation have a positive impact on diabetic patients with peripheral vascular disease?
  2. The PICOT Question 
    In adult patients (35 to 55 years old) attending clinics/hospitals for diabetes mellitus and PVD care provided by nurses (P), education on smoking cessation (I), as opposed to no education on smoking cessation (C), causes improved cholesterol and glucose intolerance levels (O) in one year (T).
  3. Hypothesis 
    Education on smoking cessation causes improved cholesterol and glucose intolerance levels in a period of one year

Definition of Terms

  • Peripheral vascular disease-this is a blood circulation disorder that makes blood vessels that are outside of the heart and the brain narrow, block, or even spasm.
  • Peripheral artery disease-this is a disease that is characterized by building up of plaques in the arteries carrying blood to various parts of the body, including the head, limbs, and organs.
  • Atherosclerosis-this is a disease that is characterized by plaques building inside arteries
  • Perfusion-this refers to the passage of fluids through the circulatory or lymphatic systems to a tissue or an organ.
  • Morbidity-refers to being diseased
  • Mortality-large scale death/the state of being exposed to death
  • Occlusion-blockage or closing of a blood vessel or even a hollow organ
  • Atheroma-degeneration of artery walls that occurs due to accumulation of fatty deposits, thereby restricting circulation while increasing the risk of thrombosis
  • Cholesterol-a sterol compound that is found in body tissues and cell membranes and can be associated with increased risk of coronary heart disease

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Theoretical Framework

The theoretical framework that has been chosen for this project is Donabedian’s 2003 structure-process-outcomes framework (Garcia, 2016). The framework provides an organized perspective on how to improve health care as a strategy for enhancing patient outcomes. The proposed framework incorporates three important aspects that must be considered when seeking to improve the quality of health care, including structure, process, and outcomes. This theory considers structures as the setting where the provision of medical care to a patient occurs (Hall & Rousel, 2014). Examining the quality of care setting structure is helpful in identifying opportunities or limitations that can restrict or enhance care.

The Donabedian framework describes the process of integration and completion of activities in a healthcare setting, including health promotion, diagnosis, treatment, and rehabilitation (Garcia, 2016). The tasks can be completed by primary caregivers or healthcare providers. The Donabedian framework does not focus on the quality of the structures of the processes; instead, it focuses on the outcomes of the processes (Hall & Rousel, 2014). Desirable or undesirable changes may occur in a population or even an individual due to a given healthcare program (Garcia, 2016). The changes may include patient empowerment through improved health promotion, prevention practices, self-management, or healthcare satisfaction. Therefore, the Donabedian framework will be used to guide the study by directing the process of implementation and evaluation of nurses-led education program.

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Literature Review

There are currently more than 170 million people globally with diabetes mellitus, and the burden of the disease is estimated to increase to nearly 366 million by 2030 (Thiruvoipati et al., 2015). Altered insulin secretion and insufficient response to secreted insulin are reportedly the major causes of diabetes mellitus. Among atherosclerotic disease patients, diabetes mellitus (DM) remains a major risk factor. According to Rhee & Kim (2015), DM is associated with the risk of cardiovascular mortality and morbidity, and atherosclerosis is associated with DM. It can cause complications in vascular beds, such as carotid vessels, coronary arteries, and lower extremity arteries.

The main factor that contributes to PVD is smoking which, when combined with the process of atherosclerosis, may have disastrous outcomes (Lopes-Costa & Amato-Vealey, 2016). In the United States, 16% of the adults, 24% of students in high school, and nearly 8% of students in middle school are smokers (Gordon & Flanagan, 2016). Toxic chemicals that are found in tobacco smoke amounts to nearly 7,357 chemical compounds, including nicotine (Gordon & Flanagan, 2016).

Mueller, et al., (2014) conducted a study to assess mortality rates among patients with atherosclerotic PAD according to age and diabetes. Additionally, it aimed to determine the probable death predictors. The study was based on the concept that atherosclerotic PAD remains one of the most prevalent, morbid, and mortal diseases. The investigators, using a prospective and case control study design, involved 487 participants with PAD admitted to hospitals. The findings of this study showed that mortality rates after five years varied significantly among PAD patients according to age and diabetes. Though the predictors for death differed, notable causes included limb ischemia, C - reactive protein (hs-CRP), as well as natriuretic peptide prohormone (NT-proBNP).

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In another case, Agarwal, et al., (2012) conducted a cross-sectional study to assess PAD in diabetics and related risk factors and their association with coronary arterial disease. The study was conducted on the belief that PAD, which is a microvascular complication of type 2 diabetes mellitus, had not received much attention. The investigators used univariate tests to assess PAD predictors with a study population of 146 patients, 79 and 67 men and women respectively. The findings of the study were that risk factors associated with PAD included higher age, higher blood pressure, longer duration of diabetes, smoking, coronary artery disease, and higher levels of hemoglobin A. The prevalence of CAD was higher in PAD patients; therefore, the presence of PAD should increase the clinician’s awareness of high chances of underlying coronary artery disease.

  • Methodology

This quantitative study will involve a quasi-experimental method with both pre-and post-tests. Pre-test measurements will be taken for cholesterol and glucose intolerance levels before the commencement of the educational intervention. Post-test measurements will be taken following the application of the educational interventions at intervals of three months for one year. In the end, there will be an analysis of variance between the pre-and post-intervention measurements to determine if changes will have taken place as a result of the educational intervention.

  • Study Design

The participants will be told the objective of the study and asked to take part voluntarily. Nurse educators will provide education on the importance of smoking cessation or reducing the level of smoking by reducing the number of smoked cigarettes daily. Thereafter, the nurse educator will measure the levels of cholesterol and glucose intolerance every three months during the intervention period.

  • Sampling

The study will involve a total of 512 patients who will be visiting clinic/hospital settings for care for diabetes mellitus and PVD. Both males and females of all races will be involved in the study with the study population consisting of individuals between the ages of 35 and 55. Participation will be voluntary, and even those participating in the study will be free to leave at any point of the study. Individuals who do not fall within the prescribed age bracket will be excluded. Similarly, those who do not suffer from both type 2 diabetes mellitus and PVD or do not smoke will not be included in the study.

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  • Instrumentation

Study participants will be given journals where they will record their cholesterol and glucose levels. Additionally, they will be given home cholesterol testing kits that they will use to measure their cholesterol levels between appointments with care providers. Similarly, the patients involved in the study will be provided with glucose meters to measure their glucose levels while at home. The collected results will be presented during the scheduled meetings with care providers.

  • Protection of Human Rights

The participants will be told their rights to participate or refuse to participate in the study. Anyone who refuses to participate in the study will not be victimized. Before taking part in the study, the potential participants will fill out consent forms to show that their participation will be out of their free will and without any kind of coercion. In addition, the study participants will have their identities concealed; they will be given specific codes that will help identify them. Similarly, data from the study participants will be kept in computer systems with passwords and safety cabinets. Importantly, the study will have to be approved by the university’s review board to ensure it meets the prescribed standards.

  • Discussion

This study may help to show that, while there have been other health problems or disease conditions that are associated with smoking, PVD and diabetes could also be noteworthy problems. High costs may be incurred while treating the conditions; however, through appropriate intervention strategies, the conditions can be alleviated using minimal costs. Similarly, the reduced number of days in the hospital may decrease the possibility of acquiring nosocomial infections.

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Peripheral Vascular Disease is a comorbid condition with Diabetes Mellitus. As discussed, appropriate educational interventions are vital for positive outcomes during care. The investigator proposes to use a quantitative study approach involving a quasi-experimental method with both pre-and post-tests. In this approach, pre-test measurements will be taken for cholesterol and glucose intolerance levels before the commencement of the educational intervention. To enable the researcher to establish the outcome, post-tests measurements will be taken after the application of the educational interventions. Through this approach, the investigator hopes to develop an intervention method that will be acceptable to both caregivers and patients. Even though the project will run for more than one year, the researcher plans to attract enough funds by partnering with relevant organizations.

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