The procedure followed was minimally invasive. A screening instrument was kept at the hospital reception where all the patients had to register after entering the hospital. Smokers were identified by the counselor from this screening tool which inquired the patient’s smoking status. Patients attending the clinic routinely go to the lab for a blood glucose examination and then have a waiting period before lab results are ready and they can be seen by the doctor. During this time, the counselor met patients who had indicated a history of smoking on the screening instrument. After being informed about the study details written consent from the patients was obtained. From those who gave consent, the counselor collected baseline information using a pre tested structured interview schedule. Details about basic demographic information, smoking history, current smoking patterns and presence of any other chronic diseases (hypertension, cardiovascular disease, stroke, chronic obstructive pulmonary disease, and cancer) were collected.
Subsequently the counselor randomized the patients equally into two groups; intervention–1 and intervention–2 groups, with block size four. Sequentially, every four patients enrolled were randomized into the two intervention groups using a computer generated random sequence to achieve a block size of four, to facilitate interim analysis. Their medical records were then flagged with different colored stickers by the counselor in order to identify group assignment. After the interview, the patient consulted the doctor. The doctor gave the patient a standard diabetes specific tobacco cessation message. The doctor also showed the patient visual images of common diabetes complications exacerbated by smoking. At the end of consultation the doctor instructed the patient to meet with the counselor. The counselor provided educational materials on tobacco and diabetes developed by the QTI on the harm of tobacco for diabetes patients that built on formative research and followed a question answer format for all the patients  and gave follow up dates for consultation to all patients.
Intervention–2 group patients received three diabetic specific tobacco counseling sessions (at first contact, at one month and at three months) lasting about 30 minutes in each session following the 5 ‘A’s (Ask, Advise, Assess, Assist and Arrange) and 5 ‘R’s (Relevance, Risks, Rewards, Roadblocks and Repetition) . In this session, after going over the educational material, developed by the QTI for smoking cessation, with the patient (to establish relevance and support the doctor’s advice) the counselor assessed each patient’s readiness to quit. If ready to quit, the counselor assisted him by discussing practical quit tips, how to get through an initial period of withdrawal, and how to deal with common withdrawal symptoms, emphasizing that these only lasted for a few days. If not ready to quit, the counselor briefly identified roadblocks and challenges to quitting, and encouraged the patient to think about quitting after reconsidering the risks of smoking for developing diabetes complications and the benefits of quitting as a means of preventing complications as a prime motivator.
All patients were given smoking cessation advice on each visit by the doctor for the next six months. Participants in intervention–2 group additionally received face to face counseling sessions on each visit for the next six months. Thus patients in the intervention group-2 received three counseling sessions: first at baseline, second at month one and third at month three of follow-up.
The doctors and diabetes educators selected to counsel patients in the study sites were initially given training on the harm of tobacco for diabetes patients including: 1) a review of epidemiological data on smoking as a diabetes risk factor, 2) complications strongly associated with smoking among those afflicted with diabetics, and 3) the mechanisms through which smoking contributes to vascular constriction and obstructed blood flow. Educational materials developed by the QTI for diabetes patients that explain these facts in simple terms were provided to the counselor to give to patients. Doctors and the counselors were also trained in basic brief intervention cessations skills. Doctors were instructed to ask all patients about their smoking status and to strongly advise patients not to smoke using a standardized diabetes specific cessation message linking smoking to the complications of diabetes. Doctors were provided a visual aid illustrating how tobacco narrows the passage of blood in the vascular system and pictures illustrating diabetes complications at distal points of the vascular system such as eyes, feet, fingers, and penis. In sum, the doctors were instructed to actively deliver two of the Five As, Ask and Advise, using illness specific visual aids. The counselors were given additional training in tobacco cessation counseling and instructed to actively conduct all of the five ‘A’s with patients in intervention group–2 each time they attended the clinic and 5 ‘R’s when necessary. The counselors were instructed to document the details of cessation offered to at least 15 patients using five ‘A’s and five ‘R’s. An examination was conducted by one of the authors (MN) based on these 15 brief interventions to assess their cessation skills. A certificate titled “basic tobacco cessation competency” was issued on successful performance in the examination by the University of Arizona.