NEW DELHI: Smoking among people living with type 2 diabetes (T2D) is a major driver of cardiovascular morbidity and premature mortality, said a latest study.
Published in the Journal of Diabetes in 2026, the study said that complete cessation of combustible tobacco should remain the primary goal in T2D management.
Highlighting that smokers have a 37 per cent higher risk of type 2 diabetes, the study said that smoking cessation is a “clinical priority” as evidence shows that former smokers with diabetes have lower risks of mortality and cardiovascular events than current smokers.
Speaking with this paper, Prof. Anoop Misra, co-author of the article, said, “While discussing other aspects of diabetes and its management, smoking cessation advice is either not given or not stressed strongly in India.”
“It should be clearly told to the patients that it can increase the risk of heart attacks and lower limb amputation manifold,” said the Chairman of Fortis C-DOC Centre of Excellence for Diabetes.
Type 2 diabetes (T2D) is one of the most pressing non-communicable disease challenges globally.
In 2022, an estimated 828 million adults were living with diabetes, an increase of approximately 630 million since 1990. According to the 2023 Indian Council of Medical Research-India Diabetes (ICMR-INDIAB) study, India has an estimated 101 million people with diabetes, 136 million pre diabetics and 315 million people with hypertension in 2021.
The article said that the rapid rise of T2D has unfolded alongside another long-standing epidemic: combustible tobacco use.
According to the World Health Organisation, approximately 1.3 billion people use tobacco worldwide, and tobacco causes more than 7 million deaths each year, most of them in low- and middle-income countries.
Unlike type 1 diabetes, which is autoimmune in origin, T2D has a well-established link with smoking.
“In T2D, smoking is not a peripheral lifestyle factor. It is a clinically significant risk amplifier. Smoking not only increases the risk of developing T2D but also worsens outcomes after diagnosis. Among patients with diabetes, smoking is associated with higher risks of cardiovascular events, peripheral arterial disease, and mortality,” it said.
“The tobacco–T2D nexus therefore represents a preventable and modifiable driver of disease burden,” said the authors, which included experts from Nuffield Department of Population Health, University of Oxford, Oxford, UK and Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy.
It highlighted that while clinicians routinely monitor glycemia, blood pressure, and lipid levels, stratify cardiovascular risk, and intensify treatment when targets are not achieved, smoking cessation, despite its well-established role in reducing vascular injury and end-organ damage, remains inconsistently integrated into routine diabetes care.
“In many settings, smoking status is recorded irregularly, addressed briefly, or deferred to follow-up that never occurs. As a result, a major modifiable exposure persists in a population already at elevated risk of complications,” it added.
While diabetes care has successfully operationalised pharmacological and behavioural risk reduction across multiple domains, tobacco treatment remains marginal, fragmented, and weakly institutionalised, it added.
It was also seen that many patients don’t opt for quitting smoking because they fear weight gain, glucose fluctuations, and lack of motivation and support.
In such cases, counselling and structured follow-up need to be taken up, as it has been seen that smoking is considered a coping strategy, thus deepening nicotine dependence and reducing the likelihood of successful unassisted cessation.
The article stressed that tobacco smoking should be treated as a core diabetes care target, documented and addressed alongside HbA1c, blood pressure, LDL cholesterol, and weight.
However, those who are not yet ready should still receive follow-up plans that maintain engagement and periodically reassess readiness. “Early follow-up during the high-risk cessation window, when withdrawal symptoms and relapse risk are greatest, is particularly important.”
Evidence also shows that, among people with diabetes, active smoking is associated with markedly higher risks of all-cause and cardiovascular mortality, as well as increased rates of cardiovascular events, compared with non-smoking.
It also said that smoking alters the metabolism of several antidiabetic medications, with potential implications for drug efficacy.
Thus, cessation may therefore improve pharmacological diabetes management independently of its cardiovascular benefits.
“These benefits warrant positioning cessation as a core component of diabetes risk management rather than as an optional lifestyle recommendation. Yet, in practice, cessation support is often deprioritised,” it added.
It said that where repeated quit attempts are unsuccessful, pragmatic harm-reduction strategies may be considered, provided the primary goal remains complete transition away from combustible tobacco.
“As diabetes prevalence rises most rapidly in settings with limited cessation infrastructure, closing this implementation gap is not only clinically sound but essential to equitable chronic disease management,” it concluded.