Andrew J. Karter ¹, Mark R. Stevens ², Edward W. Gregg ², Arleen F. Brown ³, Chien-Wen Tseng ⁴, David G. Marrero ⁵, O. Kenrik Duru ³, Tiffany L. Gary ⁶, John D. Piette ⁷, Beth Waitzfelder ⁸, William H. Herman ⁹, Gloria L. Beckles ¹⁰, Monika M. Safford ¹¹, Susan L. Ettner ^3*

¹ Kaiser Permanente
² Centers for Disease Control and Prevention, Division of Diabetes Translation
³ University of California, Los Angeles
⁴ Pacific Health Research Institute, Honolulu, HI
⁵ Indiana University Diabetes Research and Training Center
⁶ Johns Hopkins Bloomberg School of Public Health
⁷ University of Michigan
⁸ Pacific Health Reseach Institute
⁹ The University of Michigan
¹⁰ Centers for Disease Control and Prevention
¹¹ University of Alabama at Birmingham

^* To whom correspondence should be addressed. E-mail: settner{at}mednet.ucla.edu.

	Abstract

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.

Key Words: Diabetes, Managed Care, Prevention, Socioeconomic Factors, Smoking Cessation, Tobacco Control

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