The daily routine for millions with diabetes worldwide includes checking their blood sugar, managing diet, taking medicines, tracking blood pressure and managing cholesterol.However, experts say that many treat smoking – a major risk factor in diabetes care – as an afterthought.Doctors rarely ask how many cigarettes a patient smokes, and patients rarely consider quitting as part of diabetes care. Ironically, quitting smoking tremendously alters the disease outcome, and continued smoking during diabetes can lead to complications like cardiovascular disease, disabilities, organ failure and even premature death.What a new study has foundA new commentary in the Journal of Diabetes argues that active smoking is an independent risk factor for type 2 diabetes; there is a 37% higher risk among current smokers compared to people who never smoked. In spite of being a “preventable and modifiable driver of the disease complications and deaths”, smoking remains poorly integrated into the care routine.Two of the authors of the paper, Dr. Riccardo Polosa, an eminent physician and professor at the University of Catania, Italy, and Dr. Anoop Misra, Chairman of Fortis C-DOC Centre for Excellence for Diabetes, Metabolic Disease, told The Wire that “smoking cessation, despite its well-established role in reducing vascular injury and end-organ damage, remains inconsistently integrated into routine diabetes care”.Quitting smoking is not part of diabetes careThe paper insists that smoking, despite being a driver of many complications and even death, is not integrated into diabetes care.In many cases, clinics record the smoking status of diabetic patients irregularly, address it briefly, or defer it to follow-ups that never occur.“It is unfortunate that smoking remains an under-recognised factor. The main problem is not lack of evidence, but an evidence-to-practice gap. Many diabetologists do not feel adequately trained to deliver smoking-cessation support, and referral pathways are often limited or absent. At the same time, many smokers do not perceive smoking as part of their diabetes risk profile,” lead author of the commentary, Dr.Riccardo Polosa, said.Dr. Polosa recommends that clinicians treat smoking status as a routine vital sign for all diabetes patients, documenting it at every visit. He further advises that smoking cessation counseling should be integrated into standard diabetes care, including assessment of nicotine dependence, readiness to quit, and initiation of structured treatment pathways as is done for elevated HbA1c or blood pressure.Why smoking is a riskThe scale of the problem is staggering. Globally, 828 million people are living with diabetes (an increase of 630 million since 1990), while 1.3 billion people use tobacco. According to the WHO, 7 million deaths are recorded each year due to tobacco use, and most of them are in low and middle-income countries.Smoking not only worsens the complications of diabetes, it also can be a cause for developing diabetes in the first place.Various studies across the world have shown that people who smoke are 30-40% more likely to develop type 2 diabetes than people who don’t smoke. “Smoking blocks key insulin signaling receptors and induces stress hormones and inflammation, all of which cause blood sugar to rise,’’ said Dr. Anoop Misra, co-author of the paper.Chemicals in cigarette smoke also react with oxygen in the body, causing cell damage – a condition called oxidative stress. Both oxidative stress and inflammation may increase your risk of developing diabetes.People who smoke have a higher risk of belly fat, which can also raise the risk for type 2 diabetes, even in people who are not overweight.“Our paper provides strong relative-risk estimates, even though it does not generate a single global figure for attributable deaths. Among people with diabetes who smoke, cardiovascular mortality is about 50% higher than in non-smokers. That alone should be more than enough to convince policymakers to make smoking cessation a routine, funded component of diabetes care,’’ says Dr. Polosa.While Diabetes in itself elevates cardiovascular risk, smoking causes additional damage, accelerating vascular damage and organ failure.What the numbers sayConsidering the damaging consequences, one might think that a diabetes diagnosis would lead one to quit smoking. But the data suggest otherwise. Diabetes diagnosis doesn’t mean an automatic behavioural turning point.The paper says “a systematic review and meta-analysis of 74 studies across 33 countries, including approximately 3.2 million participants, estimated a global mean tobacco use prevalence of 20.8% among people with type 2 diabetes. That means that about 1 out of every 5 people with diabetes smokes.By region, the number of smokers with diabetes was highest in East Asia and the Pacific, followed by South Asia, and the lowest in Europe and some parts of Africa.In the general population, 1 out of 4 people without diabetes smoke. However, in South Asia, including India, the direction was reversed, with type 2 diabetes patients more likely to smoke than the general population.Why patients don’t quitThe failure to quit smoking is not simply a lack of willpower. Patients sometimes face unique barriers to quitting, such as the fear of gaining weight or worsening blood sugar. The researchers say that the early phases of quitting can cause metabolic fluctuations that discourage patients.“Smoking cessation can cause short-term instability in diabetes management, particularly through increased appetite, weight gain, transient fluctuations in glycaemic control, and changes in drug exposure as smoking-induced enzyme activity declines after quitting. However, evidence suggests that these effects are usually temporary and clinically manageable, and should not be a reason to delay cessation,’’ said Polosa.He says weight gain deserves particular attention, as it may attenuate some of the short-term cardiovascular benefits of quitting.“The practical message for clinicians is clear: do not avoid smoking cessation because of metabolic concerns; anticipate and manage them proactively. This means closer glucose monitoring, lifestyle and weight-management support, early follow-up, and reassurance that temporary metabolic fluctuations are outweighed by the long-term benefits of quitting,” Dr. Polosa said. He insists that quitting smoking may change the way diabetes medicines work, hence doctors need to review and adjust medication after a patient quits.Sometimes mental health also has a role to play in this decision. Diabetes-related stress, anxiety and depression can reinforce smoking as a coping mechanism and deepen dependence. Without structural support, quitting becomes difficult.Researchers say that the way medicine is practiced today, smoking is not central to diabetes care as doctors prioritise other markers, such as glucose levels, blood pressure and lipid profile. This is what the authors describe as “therapeutic inertia”. It means that there is no lack of knowledge but failure to implement it.Dr. Polosa said good glycemic control still matters, but it does not neutralise the harm from smoking. Smoking acts through additional pathways (vascular injury, renal damage, inflammation, and drug-interaction effects) that are not captured by HbA1c alone.“So a smoker with a good HbA1c is still at substantially higher risk than a non-smoker with the same glycemic control,” Dr. Polosa says.“Smoking may not erase every benefit of good diabetes care, but it can significantly blunt the overall benefit and leave major residual cardiovascular and renal risk. Good diabetes management and smoking cessation are complementary, not interchangeable,” he added.India’s double burdenThe implications may be more stark for India, as the country is facing two epidemics simultaneously – tobacco use and diabetes. Over 100 million people in India are living with diabetes. Roughly 14% of Indian adults (120-275 million) are tobacco users.With extremely high patient load, doctors in both the public and private sectors may not be getting enough time to stress the importance of quitting smoking as part of diabetes care. Another complication is the use of smokeless tobacco like gutka and khaini, which is often not addressed while discussing diabetes care.“We must urgently concentrate awareness efforts in the lower socio-economic strata in India, where the burden of diabetes is rising rapidly. Physicians must communicate – clearly and unequivocally –mthe risks of smoking and tobacco use. The dual burden of diabetes and tobacco use in India represents a critical public health challenge. While cigarettes remain a concern, the far more widespread use of bidis and oral tobacco in these populations is particularly alarming, compounded by low awareness of their profound cardiovascular risk,” Dr. Misra. As diabetes continues to rise globally, the cost of ignoring tobacco use will only increase. Researchers insist that the overlap of the two epidemics is inevitable but preventable.Toufiq Rashid is an independent journalist.