3.16 Smoking and diabetes

Last updated: March 2015
Suggested citation: Bellew, B, Greenhalgh, EM & Winstanley, MH. 3.16 Smoking and diabetes. In Scollo, MM and Winstanley, MH [editors]. Tobacco in Australia: Facts and issues. Melbourne: Cancer Council Victoria; 2015. Available from http://www.tobaccoinaustralia.org.au/3-16-smoking-and-diabetes

 

Diabetes mellitus (diabetes) is an umbrella term for a number of metabolic diseases which affect the body's ability to control blood glucose levels; it is a disease marked by high blood glucose levels resulting from defective insulin production, insulin action or both. The hormone insulin is produced in the pancreas, and helps the body use glucose for energy. If insulin production or the effectiveness of an individual's insulin is impaired, then diabetes may result.1

There are three major types of diabetes: type 1 (sometimes referred to as 'insulin dependent diabetes'), type 2 (sometimes referred to as 'non-insulin dependent' or 'adult onset' diabetes); and gestational diabetes. Type 1 diabetes most often occurs in childhood or young adulthood (though it can occur at any age), and is the result of low levels of or the inability to produce insulin. People with type 1 diabetes need insulin replacement for survival.1 Based on data from the 2007–08 National Health Survey, 10% of people with diabetes reported that they had type 1, while the majority (88%) of people with diabetes reported type 2. Another 2% of people reported diabetes, but did not know which type.2 These figures correspond to an estimated 818 200 persons (4% of the population) in 2007–08 with diabetes mellitus who had been medically diagnosed (excluding those with gestational diabetes).2

As noted, type 2 is the most common form of diabetes; it occurs mostly in people aged 40 years and over and is marked by reduced or less effective insulin. Although uncommon in childhood, it is becoming increasingly recognised in that younger age group.1 Gestational diabetes, the onset of diabetes in pregnancy, occurs in a small proportion of otherwise unaffected women and is usually transient, although women who develop gestational diabetes have a higher risk of developing type 2 diabetes later in life. The Australasian Diabetes in Pregnancy Society estimates that about 5% of pregnant women are affected by gestational diabetes.3

Some population groups are at much higher risk for diabetes, notably Indigenous Australians, people born overseas, and those subject to the poorest socio-economic circumstances. Aboriginal and Torres Strait Islander peoples are three times as likely as non-Indigenous people to have diabetes and have much greater hospitalisation and death rates than other Australians. Rates of diabetes, hospitalisations and/or mortality are more common among overseas-born people from the South Pacific Islands, Southern Europe, Middle East, North Africa and Southern Asia. Diabetes prevalence and death rates for the worst-off fifth of the population are nearly twice as high as for the best-off fifth of the population.1

Many factors contribute to the onset and development of diabetes. Type 1 diabetes is believed to be caused by particular biological interactions and exposure to environmental agents among people genetically predisposed to diabetes. Obesity, physical inactivity and unhealthy diet play a role in the onset of type 2 diabetes, as well as genetic predisposition such as family history, ethnic background and age. There is some evidence that depression can increase the risk of developing type 2 diabetes and diabetes complications. It is thought that the increased risk of type 2 may be due to elevated stress levels and weight gain. Poor foetal nutrition leading to low birthweight for gestational age may predispose some individuals to type 2 diabetes. If these individuals are exposed to other risk factors (such as obesity and physical inactivity) the likelihood of developing type 2 diabetes becomes greater.1

The risk factors for gestational diabetes are similar to those for type 2 diabetes: women are at higher risk if they are of relatively advanced age or obese when pregnant. There are also a number of additional risk factors for diabetes complications, including high blood pressure, high blood cholesterol and tobacco smoking. The 'metabolic syndrome'—the clustering of a number of risk factors including abdominal obesity, impaired fasting blood glucose, raised blood pressure, raised blood triglycerides and reduced blood HDL-cholesterol—substantially increases the risk of type 2 diabetes.1

As well as being life threatening in its own right, diabetes can lead to a range of other serious health problems, including coronary heart disease, stroke, peripheral vascular disease, kidney disease, eye disease, and complications in pregnancy and childbirth.4 Smoking greatly increases the risk of pancreatic cancer in patients with diabetes mellitus and there is evidence that a combined risk of family history of pancreatic cancer, current smoking and current diabetes mellitus confers a 10-fold increase in risk of being diagnosed with this cancer.5, 6 Among male cancer survivors there is evidence that a history of smoking before diagnosis, obesity and insulin resistance increase the risk for several second primary cancers, indicating the need for screening for second primary cancers among cancer survivors with these risk factors.7 Smoking is related to low bone mass and increased risk of fracture risk in postmenopausal women in the general population, but recent evidence suggests that women with diabetes who are current smokers have more than a three-fold increase in risk (3.47; 95% CI, 1.82–6.62) of non-vertebral fractures than diabetic women who were never smokers.8

Among the lifestyle-related factors, smoking makes the largest contribution to the absolute risk of macrovascular complications for people with diabetes. The added risk from smoking is greater than in people without diabetes.9 Smokers with type 1 and type 2 diabetes are at increased risk of illness and premature death, mostly through development of cardiovascular disease, but other disease processes associated with diabetes may also be made worse by smoking. Smokers with type 1 diabetes in particular may have a higher risk of developing kidney disease, and possibly eye and nerve damage as well, whereas smokers with type 2 diabetes are more likely to increase their risk of coronary heart disease, stroke and peripheral vascular disease. Studies of individuals with diabetes consistently demonstrate that smokers have a heightened risk of cardiovascular disease, premature death and increased rate of microvascular complications of diabetes.4

The 2014 US Surgeon General’s report concluded that smoking causes type 2 diabetes, with the risk of developing diabetes 30–40% higher for active smokers than nonsmokers. Further, there is a positive dose-response relationship between the number of cigarettes smoked and the risk of developing diabetes. The report highlights that reducing tobacco use should be promoted as a key public health strategy to prevent and control the increasing worldwide epidemic of diabetes.10

Plausible biological mechanisms for this association include include increased central obesity in smokers, increased inflammation and oxidative stress,10 increased insulin resistance, altered insulin secretion and other impairments to pancreatic function noted in smokers.11 Further corroboration for the Surgeon General’s finding that smokers are more likely to develop type 2 diabetes than non-smokers has been provided in a 2007 systematic review11 and recent studies conducted in Japan,12 Korea,13,14 Taiwan,15 China16 and the US.11

There is also evidence that exposure to secondhand smoke is positively and independently associated with the risk of type 2 diabetes, from several observational studies recently conducted in the US,17,18 Germany19 and Japan.20 Some recent evidence suggests that smoking cessation among people with diabetes can lead to short-term increased risk of diabetes (probably because of weight gain) and that this may deter smokers with diabetes from attempting to quit.21,22 The research indicates that any temporary increase in risk may occur in the first three years after quitting, thereafter gradually decreasing to zero.21 Other studies also report that the risk of type 2 diabetes in former smokers returns to that of non-smokers after a number of years.10 A 2015 retrospective cohort study of more than 10,000 adults found that smoking cessation is associated with deterioration in glycaemic control in smokers with type 2 diabetes, which lasts for 3 years and is unrelated to weight gain.23 This evidence underscores the need for smoking cessation to be accompanied by other strategies for diabetes prevention and early detection, as recommended in current clinical guidelines in the US and in Australia.4,9

In conclusion, cigarette smoking produces insulin resistance and chronic inflammation, which can accelerate macrovascular and microvascular complications, including nephropathy. Many clinical and experimental studies have found significant associations between cigarette smoking and development of diabetes, impaired glycaemic control, and diabetic complications (microvascular and macrovascular). A different lifestyle of smokers, in contrast to that maintained by non-smokers, may also contribute to these effects. The development of type 2 diabetes is yet another harmful consequence of cigarette smoking, and one that adds to the heightened risks of CVD; smoking cessation is crucial to facilitating glycaemic control and limiting development of complications.24


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References

1. Australian Institute of Health and Welfare. Diabetes: Australian facts 2008. AIHW cat. no. CVD 40. Canberra: AIHW, 2008. Available from: http://www.aihw.gov.au/publication-detail/?id=6442468075

2. Australian Bureau of Statistics (ABS). 4364.0 National Health Survey: Summary of Results, 2007-2008 (Reissue) Released 25/08/2009. 2009. Available from: http://www.abs.gov.au/AUSSTATS/abs@.nsf/Latestproducts/4364.0Main%20Features12007-2008%20(Reissue)?opendocument&tabname=Summary&prodno=4364.0&issue=2007-2008%20(Reissue)&num=&view=

3. Australasian Diabetes in Pregnancy Society. Corporate website. Sydney, New South Wales: ADPS, 2011 [viewed 24 May 2011] . Available from: http://adips.org

4. American Diabetes Association. Standards of medical care in diabetes-2011. Diabetes Care 2011;34(suppl. 1):S11-S61. Available from: http://care.diabetesjournals.org/content/34/Supplement_1/S11.long

5. Dite P, Trna J, Belobradkova J, Novotny I, Hermanova M, Vlckova P, et al. Pancreatic cancer--association with diabetes mellitus and smoking. Vnitrni lekarstvi 2011;57(2):159-62. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21416856

6. Matsubayashi H, Maeda A, Kanemoto H, Uesaka K, Yamazaki K, Hironaka S, et al. Risk factors of familial pancreatic cancer in Japan: current smoking and recent onset of diabetes. Pancreas 2011;40(6):974-8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21487321

7. Park SM, Lim MK, Jung KW, Shin SA, Yoo KY, Yun YH, et al. Prediagnosis smoking, obesity, insulin resistance, and second primary cancer risk in male cancer survivors: National Health Insurance Corporation Study. Journal of clinical oncology 2007;25(30):4835-43. Available from: http://jco.ascopubs.org/content/25/30/4835.full.pdf+html

8. Jorgensen L, Joakimsen R, Ahmed L, Stormer J and Jacobsen BK. Smoking is a strong risk factor for non-vertebral fractures in women with diabetes: the Tromso Study. Osteoporosis International 2011;22(4):1247-53. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20607217

9. Diabetes Australia and Royal Australian College of General Practitioners. Diabetes management in general practice: guidelines for Type 2 diabetes, 15th edn. South Melbourne, Victoria: RACGP, 2009. Available from: https://www.racgp.org.au/Content/NavigationMenu/ClinicalResources/RACGPGuidelines/Diabetesmanagement/200910diabetesmanagementingeneralpractice.pdf

10. US Department of Health and Human Services. The health consequences of smoking - 50 years of progress. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014. Available from: http://www.surgeongeneral.gov/library/reports/50-years-of-progress

11. Willi C, Bodenmann P, Ghali W, Faris P and Cornuz J. Active smoking and the risk of type 2 diabetes. A systematic review and meta-analysis. Journal of the American Medical Association 2007;298(22):2654-64. Available from: http://jama.ama-assn.org/content/298/22/2654.full.pdf+html

12. Kawada T, Otsuka T, Inagaki H, Wakayama Y, Li Q, Ji Li Y, et al. Association of smoking status, insulin resistance, body mass index, and metabolic syndrome in workers: a 1-year follow-up study. Obesity Research & Clinical Practice 2010;4(3):e163–9. Available from: http://www.sciencedirect.com/science/journal/1871403X

13. Jee SH, Foong AW, Hur NW and Samet JM. Smoking and risk for diabetes incidence and mortality in Korean men and women. Diabetes Care 2010;33(12):2567-72. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20823342

14. Cho N, Chan J, Jang H, Lim S, Kim H and Choi S. Cigarette smoking is an independent risk factor for type 2 diabetes: a four-year community-based prospective study. Clinical Endocrinology 2009;71(5):679-85. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19508609

15. Hsu CC, Hwang SJ, Tai TY, Chen T, Huang MC, Shin SJ, et al. Cigarette smoking and proteinuria in Taiwanese men with type 2 diabetes mellitus. Diabetic Medicine 2010;27(3):295-302. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20536492

16. Xie X, Liu Q, Wu J and Wakui M. Impact of cigarette smoking in type 2 diabetes development. Acta Pharmacologica Sinica 2009;30(6):784–7. Available from: http://www.nature.com/aps/journal/v30/n6/full/aps200949a.html

17. Zhang L, Curhan G, Hu F, Rimm E and Forman J. Association between passive and active smoking and incident type 2 diabetes in women. Diabetes Care 2011;34(4):892–7. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21355099

18. Houston TK, Person SD, Pletcher MJ, Liu K, Iribarren C and Kiefe CI. Active and passive smoking and development of glucose intolerance among young adults in a prospective cohort: CARDIA study. British Medical Journal 2006;332:1064-9. Available from: http://www.bmj.com/content/332/7549/1064.full.pdf+html

19. Kowall B, Rathmann W, Strassburger K, Heier M, Holle R, Thorand B, et al. Association of passive and active smoking with incident type 2 diabetes mellitus in the elderly population: the KORA S4/F4 cohort study. European Journal of Epidemiology 2010;25(6):393-402. Available from: http://www.njgasp.org/Association_of_passive_and_active_smoking_diabetes_04_2010_study.pdf

20. Hayashino Y, Fukuhara S, Okamura T, Yamato H, Tanaka H, Tanaka T, et al. A prospective study of passive smoking and risk of diabetes in a cohort of workers: the High-Risk and Population Strategy for Occupational Health Promotion (HIPOP-OHP) study. Diabetes Care 2008;31(4):732-4. Available from: http://care.diabetesjournals.org/content/31/4/732.full.pdf

21. Yeh H, Duncan B, Schmidt M, Wang N and Brancati F. Smoking, smoking cessation, and risk for type 2 diabetes mellitus: a cohort study. Annals of Internal Medicine 2010;152(1):10–7. Available from: http://www.acponline.org/acp_news/misc/smoking.pdf

22. Tonstad S. Cigarette smoking, smoking cessation, and diabetes. Diabetes Research and Clinical Practice 2009;85(1):4-13. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19427049

23. Lycett D, Nichols L, Ryan R, Farley A, Roalfe A, et al. The association between smoking cessation and glycaemic control in patients with type 2 diabetes: a THIN database cohort study. The Lancet Diabetes & Endocrinology. Available from: http://dx.doi.org/10.1016/S2213-8587(15)00082-0

24. US Department of Health and Human Services. How tobacco smoke causes disease: the biology and behavioral basis for smoking-attributable disease. A report of the US Surgeon General. Rockville, Maryland: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2010. Available from: http://www.surgeongeneral.gov/library/tobaccosmoke/report/index.html

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