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Diabetes Metab J. Dec 2012; 36(6): 399–403.
Published online Dec 12, 2012. doi:  10.4093/dmj.2012.36.6.399
PMCID: PMC3530709

Smoking and Type 2 Diabetes Mellitus

Abstract

Cigarette smoking is a well-known risk factor in many diseases, including various kinds of cancer and cardiovascular disease. Many studies have also reported the unfavorable effects of smoking for diabetes mellitus. Smoking increases the risk of developing diabetes, and aggravates the micro- and macro-vascular complications of diabetes mellitus. Smoking is associated with insulin resistance, inflammation and dyslipidemia, but the exact mechanisms through which smoking influences diabetes mellitus are not clear. However, smoking cessation is one of the important targets for diabetes control and the prevention diabetic complications.

Keywords: Diabetes complications, Diabetes mellitus, Smoking

INTRODUCTION

Smoking is one of the modifiable risk factors for many chronic diseases, such as cardiovascular disease (CVD), cancer, chronic obstructive lung disease, asthma, and diabetes. However, the adverse effects of smoking on diabetes have been generally under recognized. In the guidelines from the Korean Diabetes Association, smoking cessation is recommended as one of the most important steps in preventing the cardiovascular complications of diabetes [1]. Many studies have shown that the adverse effects of smoking on diabetes mellitus are not only diabetic macrovascular complications but the causal nature of its association with diabetes and the progression of diabetic microvascular complications has yet to be explored.

Although smoking is known to decrease body weight, it is associated with central obesity [2]. Smoking also increases inflammation and oxidative stress [3], to directly damage β-cell function [4] and to impair endothelial function [5].

The prevalence of smoking in Korean men is near 50%, which is the highest smoking rate in the Western Pacific region. In addition to obesity, the high prevalence of smoking is one of the major health problems for Korea's public health.

This review is about the various smoking effects on diabetes mellitus, diabetic complications, and diabetic incidence. Understanding the hazardous effects of smoking on diabetes mellitus may lead to more emphasis on smoking prevention and smoking cessation as important strategies in the management of diabetes mellitus.

SMOKING AND DIABETES INCIDENCE

There is much evidence that smoking increases the risk of diabetes. Several cohort studies in Korea have reported that smoking was associated with an increased risk for the development of diabetes. Cho et al. [6] followed 4,041 men for 4 years in rural and urban settings in Korea, and found that past and current smokers had a significantly increased risk for type 2 diabetes, and the risk increased with the number of cigarettes smoked. Another study reported a 14-year-long prospective cohort study, in which the risk of diabetes among men and women who smoked 20 cigarettes or more per day was 1.55 (95% confidence interval [CI], 1.51 to 1.60) compared to those who never smoked [7].

A Japanese study reported similar results of a positive correlation between cigarette consumption and risk for diabetes [8]. The health professionals' follow-up study demonstrated that the risk for diabetes among men who smoked ≥25 cigarettes per day was 1.94 (95% CI, 1.25 to 3.03) [9]. Another British study showed the risk for diabetes in smoking men was around 1.7, after adjusting for confounding factors, such as age, body mass index, physical activity, alcohol intake, social class, and antihypertensive treatment [10].

There have been few studies on the effect of smoking on the risk of diabetes in women as generally the prevalence of smoking is lower in women than men. However, the results from the Nurses' Health Study in the United States (114,247 women, 1,227,589 person-years follow-up) showed that the risk for diabetes in smokers was 1.42 after adjustment for other risk factors [11].

The same cohort was followed for 16 years, and a new analysis was performed. The predictable risk factors for diabetes were overweight and obesity, as in men, low physical activity, a poor diet, current smoking, and abstinence from alcohol were all independently associated with the risk for diabetes. The adjusted risk for diabetes in smokers was 1.4 compared with non-smokers [12].

THE EFFECT OF SMOKING ON INSULIN ACTION

The exact mechanism for why smoking increases the risk of diabetes and deteriorates glucose homeostasis has not been fully elucidated, but the available evidence shows that smoking increases insulin resistance.

In healthy young men, acute smoking showed an increased insulin resistance [13]. Smokers had a significantly increased homeostatic model assessment insulin resistance index an hour after smoking [14]. The smoking reduced insulin mediated glucose uptake by 10% to 40% in men who smoked compared with non-smoking men [15,16]. In type 2 diabetic subjects, insulin and C-peptide responses to oral glucose load were significantly higher in smokers than non-smokers and the insulin resistance, as determined by the euglycemic clamp technique, was positively correlated in a dose dependent manner [17]. Thus smoking induced insulin resistance in patients with type 2 diabetes, as well as healthy subjects.

In addition to increased insulin resistance, smoking also showed dyslipidemia prone to atherosclerosis. Smokers had higher fasting triglycerides and lower high density lipoprotein cholesterol levels, and an increased proportion of small dense low density lipoprotein particles. Fibrinogen levels and plasminogen activator inhibitor 1 activity were also elevated in smokers [18].

In terms of glucose homeostasis, smoking has a negative effect on glucose control. In a population-based prospective study, cigarette smoking was positively associated in a dose dependent manner with elevated HbA1c after adjustment for possible confounding by dietary variables [19]. This finding was also reported in patients with diabetes in Sweden; smoking type 1 and type 2 patients had a higher mean HbA1c but a lower mean body mass index than non-smokers [20].

SMOKING AND DIABETIC MICROVASCULAR COMPLICATIONS

The smoking effects on microvascular diabetes complications vary across reports. Generally, several studies have shown that smoking has an adverse effect on diabetic nephropathy, but the influence of smoking independently with glucose control, on retinopathy and neuropathy are unclear.

SMOKING AND NEPHROPATHY

Several studies have demonstrated that smoking promotes diabetic microalbuminuria and exacerbates diabetic nephropathy. In the study by Biesenbach et al. [21], a 13-year follow-up study, the progression of nephropathy was clearly increased in smokers. The authors showed that smoking was a risk factor for diabetic kidney disease, independent of age, sex, and duration of diabetes and HbA1c levels.

In prospective studies by Chuahirun and Wesson [22] and Chuahirun et al. [23], the adverse effects on diabetic neprhropathy in type 2 patients were confirmed, even in optimal hypertensive patients.

SMOKING AND RETINOPATHY

The association of smoking and diabetic retinopathy has not been clear. It was reported that retinopathy has been associated with glycemic control and not smoking state [24]. Some studies have reported no association with smoking and retinopathy in type 2 diabetes [24,25]. The United Kingdom Prospective Diabetic (UKPD) study to determine risk factors related to the incidence and progression of diabetic retinopathy followed patients over 6 years from diagnosis. The development of retinopathy was associated with glycemia and higher blood pressure, but not smoking [26]. Thus in type 2 patients, the effects of smoking on diabetic retinopathy has not been as clear as with nephropathy.

SMOKING AND NEUROPATHY

There are few studies about smoking and diabetic neuropathy. Smoking may affect diabetic neuropathy differently according to the type of diabetes [27]. In type 2 diabetic patients, smoking was not a risk factor in the presence of polyneuropathy or sensory neuropathy as diagnosed by symptom and sign [27,28]. It was reported that there was no relationship between current or previous levels of smoking and the severity and duration of chronic painful neuropathy [29]. But in the study by Tamer et al. [30], while smoking was not associated with neuropathic complaints, using electromyography-supported neuropathy examination there were significant relationships with smoking, as well as HbA1c. Therefore, more studies are needed to evaluate the association between smoking and neuropathy.

SMOKING AND MACROVASCULAR COMPLICATIONS

Smoking has been shown to be a significant risk factor for all-cause mortality, and for mortality due to CVD and coronary heart disease (CHD) in diabetics. Smokers die on average 8 to 10 years younger than non-smokers, as age is entered into most multi-regression analysis.

SMOKING AND CHD

Smoking is a major risk factor for CVD in non-diabetic subjects, as well as diabetic subjects. In an 8-year prospective study, smoking was significantly associated with an increased risk for CHD in diabetic patients [31]. The UKPD study clearly showed that smoking was a significant and independent risk factor for CHD in type 2 diabetic patients [32]. In the Nurses' Health Study, in women with type 2 diabetes, it was demonstrated that cigarette smoking was associated in a dose-dependent manner with an increased mortality and CHD. Compared with never-smokers, the relative risks for CHD were 1.66 for current smokers of 1 to 14 cigarette per day, and 2.68 for current smokers of 15 or more cigarettes per day [33,34].

Recently, a meta-analysis in the Asia-Pacific region, in men with diabetes, the hazard ratio comparing current smokers with non-smokers was 1.42 for CHD. In Asia, where there are high rates of smoking, and a rapidly increasing prevalence of diabetes, the author concluded that cigarette cessation strategies there were huge benefits in terms of reducing the burden of CVD in men with diabetes [35].

SMOKING AND STROKE

Smoking also increases the risk of stroke in patients with diabetes, but may not be as strong as CHD. In the UKPD study, mathematical models were developed to estimate the risk of stroke, and the variables were smoking, duration of diabetes, age, sex, systolic blood pressure, total cholesterol to high density lipoprotein cholesterol ratio, and presence of arterial fibrillation [36]. In a study using the general practice research database in the United Kingdom, smoking was an additional risk factor for stroke in type 2 diabetic patients [37]. Another 4-year prospective study, also showed that smoking and HbA1c were predictors of stroke among the type 2 diabetic patients without a history of a previous stroke [38].

The relative risk of smoking for stroke has not been as high as that for CHD. In the Nurses' Health Study, in smokers who smoked 1 to 14 cigarette per day, the risk was significant for CHD but not for stroke. In those who smoked 15 cigarettes or more per day, the relative risk for CHD and stroke were 2.68 and 1.84, respectively [33]. Similar trends were shown in a Swedish study, in which the relative risk of smoking was higher in myocardial infarction (2.33) than for stroke (1.12) in 30 to 59 year-old patients [39].

CONCLUSIONS

There have been many studies showing that smoking has harmful effects on patients with diabetes. Smoking increases diabetic incidence and aggravates glucose homeostasis and chronic diabetic complications. In microvascular complications, the onset and progression of diabetic nephropathy is highly associated with smoking. In macrovascular complications, smoking is associated with a 2 to 3 times higher incidence of CHD and mortality. However, smoking prevention and smoking cessation may not be emphasized enough in diabetic clinics. Thus, educating patients on the importance of not smoking and engaging in smoking cessation programs are important strategies for the management of diabetes.

Footnotes

No potential conflict of interest relevant to this article was reported.

References

1. Ko SH, Kim SR, Kim DJ, Oh SJ, Lee HJ, Shim KH, Woo MH, Kim JY, Kim NH, Kim JT, Kim CH, Kim HJ, Jeong IK, Hong EK, Cho JH, Mok JO, Yoon KH. Committee of Clinical Practice Guidelines, Korean Diabetes Association. 2011 Clinical practice guidelines for type 2 diabetes in Korea. Diabetes Metab J. 2011;35:431–436. [PMC free article] [PubMed]
2. Canoy D, Wareham N, Luben R, Welch A, Bingham S, Day N, Khaw KT. Cigarette smoking and fat distribution in 21,828 British men and women: a population-based study. Obes Res. 2005;13:1466–1475. [PubMed]
3. Morrow JD, Frei B, Longmire AW, Gaziano JM, Lynch SM, Shyr Y, Strauss WE, Oates JA, Roberts LJ., 2nd Increase in circulating products of lipid peroxidation (F2-isoprostanes) in smokers: smoking as a cause of oxidative damage. N Engl J Med. 1995;332:1198–1203. [PubMed]
4. Spector TD, Blake DR. Effect of cigarette smoking on Langerhans' cells. Lancet. 1988;2:1028. [PubMed]
5. Noma K, Goto C, Nishioka K, Hara K, Kimura M, Umemura T, Jitsuiki D, Nakagawa K, Oshima T, Chayama K, Yoshizumi M, Higashi Y. Smoking, endothelial function, and Rho-kinase in humans. Arterioscler Thromb Vasc Biol. 2005;25:2630–2635. [PubMed]
6. Cho NH, Chan JC, Jang HC, Lim S, Kim HL, Choi SH. Cigarette smoking is an independent risk factor for type 2 diabetes: a four-year community-based prospective study. Clin Endocrinol (Oxf) 2009;71:679–685. [PubMed]
7. Jee SH, Foong AW, Hur NW, Samet JM. Smoking and risk for diabetes incidence and mortality in Korean men and women. Diabetes Care. 2010;33:2567–2572. [PMC free article] [PubMed]
8. Uchimoto S, Tsumura K, Hayashi T, Suematsu C, Endo G, Fujii S, Okada K. Impact of cigarette smoking on the incidence of type 2 diabetes mellitus in middle-aged Japanese men: the Osaka Health Survey. Diabet Med. 1999;16:951–955. [PubMed]
9. Rimm EB, Chan J, Stampfer MJ, Colditz GA, Willett WC. Prospective study of cigarette smoking, alcohol use, and the risk of diabetes in men. BMJ. 1995;310:555–559. [PMC free article] [PubMed]
10. Wannamethee SG, Shaper AG, Perry IJ. British Regional Heart Study. Smoking as a modifiable risk factor for type 2 diabetes in middle-aged men. Diabetes Care. 2001;24:1590–1595. [PubMed]
11. Rimm EB, Manson JE, Stampfer MJ, Colditz GA, Willett WC, Rosner B, Hennekens CH, Speizer FE. Cigarette smoking and the risk of diabetes in women. Am J Public Health. 1993;83:211–214. [PubMed]
12. Hu FB, Manson JE, Stampfer MJ, Colditz G, Liu S, Solomon CG, Willett WC. Diet, lifestyle, and the risk of type 2 diabetes mellitus in women. N Engl J Med. 2001;345:790–797. [PubMed]
13. Attvall S, Fowelin J, Lager I, Von Schenck H, Smith U. Smoking induces insulin resistance: a potential link with the insulin resistance syndrome. J Intern Med. 1993;233:327–332. [PubMed]
14. Seet RC, Loke WM, Khoo CM, Chew SE, Chong WL, Quek AM, Lim EC, Halliwell B. Acute effects of cigarette smoking on insulin resistance and arterial stiffness in young adults. Atherosclerosis. 2012;224:195–200. [PubMed]
15. Facchini FS, Hollenbeck CB, Jeppesen J, Chen YD, Reaven GM. Insulin resistance and cigarette smoking. Lancet. 1992;339:1128–1130. [PubMed]
16. Eliasson B, Mero N, Taskinen MR, Smith U. The insulin resistance syndrome and postprandial lipid intolerance in smokers. Atherosclerosis. 1997;129:79–88. [PubMed]
17. Targher G, Alberiche M, Zenere MB, Bonadonna RC, Muggeo M, Bonora E. Cigarette smoking and insulin resistance in patients with noninsulin-dependent diabetes mellitus. J Clin Endocrinol Metab. 1997;82:3619–3624. [PubMed]
18. Eliasson B, Attvall S, Taskinen MR, Smith U. The insulin resistance syndrome in smokers is related to smoking habits. Arterioscler Thromb. 1994;14:1946–1950. [PubMed]
19. Sargeant LA, Khaw KT, Bingham S, Day NE, Luben RN, Oakes S, Welch A, Wareham NJ. Cigarette smoking and glycaemia: the EPIC-Norfolk Study. European Prospective Investigation into Cancer. Int J Epidemiol. 2001;30:547–554. [PubMed]
20. Nilsson PM, Gudbjornsdottir S, Eliasson B, Cederholm J. Steering Committee of the Swedish National Diabetes Register. Smoking is associated with increased HbA1c values and microalbuminuria in patients with diabetes: data from the National Diabetes Register in Sweden. Diabetes Metab. 2004;30:261–268. [PubMed]
21. Biesenbach G, Grafinger P, Janko O, Zazgornik J. Influence of cigarette-smoking on the progression of clinical diabetic nephropathy in type 2 diabetic patients. Clin Nephrol. 1997;48:146–150. [PubMed]
22. Chuahirun T, Wesson DE. Cigarette smoking predicts faster progression of type 2 established diabetic nephropathy despite ACE inhibition. Am J Kidney Dis. 2002;39:376–382. [PubMed]
23. Chuahirun T, Khanna A, Kimball K, Wesson DE. Cigarette smoking and increased urine albumin excretion are interrelated predictors of nephropathy progression in type 2 diabetes. Am J Kidney Dis. 2003;41:13–21. [PubMed]
24. Guillausseau PJ, Massin P, Charles MA, Allaguy H, Guvenli Z, Virally M, Tielmans D, Assayag M, Warnet A, Lubetzki J. Glycaemic control and development of retinopathy in type 2 diabetes mellitus: a longitudinal study. Diabet Med. 1998;15:151–155. [PubMed]
25. Moss SE, Klein R, Klein BE. Cigarette smoking and ten-year progression of diabetic retinopathy. Ophthalmology. 1996;103:1438–1442. [PubMed]
26. Stratton IM, Kohner EM, Aldington SJ, Turner RC, Holman RR, Manley SE, Matthews DR. UKPDS 50: risk factors for incidence and progression of retinopathy in type II diabetes over 6 years from diagnosis. Diabetologia. 2001;44:156–163. [PubMed]
27. Mitchell BD, Hawthorne VM, Vinik AI. Cigarette smoking and neuropathy in diabetic patients. Diabetes Care. 1990;13:434–437. [PubMed]
28. Harris M, Eastman R, Cowie C. Symptoms of sensory neuropathy in adults with NIDDM in the U.S. population. Diabetes Care. 1993;16:1446–1452. [PubMed]
29. Benbow SJ, Williams G, MacFarlane IA. Smoking habits and painful diabetic neuropathy. J Diabetes Complications. 1997;11:334–337. [PubMed]
30. Tamer A, Yildiz S, Yildiz N, Kanat M, Gunduz H, Tahtaci M, Celebi H. The prevalence of neuropathy and relationship with risk factors in diabetic patients: a single-center experience. Med Princ Pract. 2006;15:190–194. [PubMed]
31. Morrish NJ, Stevens LK, Fuller JH, Jarrett RJ, Keen H. Risk factors for macrovascular disease in diabetes mellitus: the London follow-up to the WHO Multinational Study of Vascular Disease in Diabetics. Diabetologia. 1991;34:590–594. [PubMed]
32. Turner RC, Millns H, Neil HA, Stratton IM, Manley SE, Matthews DR, Holman RR. Risk factors for coronary artery disease in non-insulin dependent diabetes mellitus: United Kingdom Prospective Diabetes Study (UKPDS: 23) BMJ. 1998;316:823–828. [PMC free article] [PubMed]
33. Al-Delaimy WK, Willett WC, Manson JE, Speizer FE, Hu FB. Smoking and mortality among women with type 2 diabetes: the Nurses' Health Study cohort. Diabetes Care. 2001;24:2043–2048. [PubMed]
34. Al-Delaimy WK, Manson JE, Solomon CG, Kawachi I, Stampfer MJ, Willett WC, Hu FB. Smoking and risk of coronary heart disease among women with type 2 diabetes mellitus. Arch Intern Med. 2002;162:273–279. [PubMed]
35. Kengne AP, Nakamura K, Barzi F, Lam TH, Huxley R, Gu D, Patel A, Kim HC, Woodward M. Asia Pacific Cohort Study Collaboration. Smoking, diabetes and cardiovascular diseases in men in the Asia Pacific region. J Diabetes. 2009;1:173–181. [PubMed]
36. Kothari V, Stevens RJ, Adler AI, Stratton IM, Manley SE, Neil HA, Holman RR. UKPDS 60: risk of stroke in type 2 diabetes estimated by the UK Prospective Diabetes Study risk engine. Stroke. 2002;33:1776–1781. [PubMed]
37. Mulnier HE, Seaman HE, Raleigh VS, Soedamah-Muthu SS, Colhoun HM, Lawrenson RA, De Vries CS. Risk of stroke in people with type 2 diabetes in the UK: a study using the General Practice Research Database. Diabetologia. 2006;49:2859–2865. [PubMed]
38. Giorda CB, Avogaro A, Maggini M, Lombardo F, Mannucci E, Turco S, Alegiani SS, Raschetti R, Velussi M, Ferrannini E. DAI Study Group. Incidence and risk factors for stroke in type 2 diabetic patients: the DAI study. Stroke. 2007;38:1154–1160. [PubMed]
39. Nilsson PM, Cederholm J, Eeg-Olofsson K, Eliasson B, Zethelius B, Fagard R, Gudbjornsdottir S. Swedish National Diabetes Register. Smoking as an independent risk factor for myocardial infarction or stroke in type 2 diabetes: a report from the Swedish National Diabetes Register. Eur J Cardiovasc Prev Rehabil. 2009;16:506–512. [PubMed]

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