TOBACCO AND DIABETES

Mini-Lecture

Module: Tobacco and Endocrine System

 Goal and objectives

Goal of Mini-Lecture: Provide student with knowledge on

the burden of smoking among diabetes and the association
between smoking and diabetes.

Learning Objectives:
At the end of the lecture, student will be able to:
Describe the burden of smoking among diabetics
Explain the association between smoking and diabetes,
and impact of smoking on diabetes
Describe efforts to encourage diabetics to quit smoking
 Smoking: a risk factor for diabetes
Smoking increases the risk of diabetes with a clear dose-
response phenomenon. (Eliasson, 2003; Willi et al., 2007)

Three longitudinal studies in the US showed that smoking

increases the risk for diabetes among men and women.
The Health Professionals study: RR for diabetes among
men who smoked 25 cigarettes per day was 1.94.
The Physicians Health Study: RR for diabetes among men
who smoked 20 cigarettes per day was 1.70.
The Nurses' Health Study: RR for diabetes among women
was 1.42
(Eliasson, 2003)
 Smoking and diabetes the
mechanisms

Chronic cigarette smoking adversely affect insulin sensitivity

both in healthy subjects and in type II DM patients, and its
association is dose-dependent. (Eliasson, 2003; Targher et al., 1997)

Smokers exhibits insulin resistance syndrome with:

higher serum free fatty acids and triglyceride levels
lower high-density lipoprotein cholesterol
higher proportion of atherogenic small dense low-density
lipoprotein particles
elevated fibrinogen levels and plasminogen activator
inhibitor 1 activity
(Eliasson, 2003)
 Smoking and diabetes
complications

Prevalence of DM complication = 53% (macrovascular 31%,

microvascular 8%, both macro-and microvascular 11%,
other complications 3%) (Chaturvedi, 2007)
Macrovascular Microvascular
Complications Complications
Coronary Heart Disease Nephropathy 50% of all
leading cause of death renal failure patients
among DM patients
Congestive Heart Disease Neuropathy impotence
and slow healing wound
Stroke Retinopathy 5% of
(Woodward et al., 2003; Liebl et al., 2002)
global blindness cases
 Cost of smoking and diabetes
Diabetes posts significant health and economic costs to
patients, their families and their countries.

Economic impact: If the prevalence of diabetes were to rise as

estimated, by 2025, 7-13% of worlds healthcare budget will be
spent on diabetes (IDF, 2008)

Together with diabetes complications, smoking is a predictor

for hospitalization cost among the diabetics. The incremental
hospitalization cost for diabetic smoker is US$ 250, after
adjustment for age, obesity index and presence of diabetic
complications. (Pagano et al., 2007)
 Cessation for diabetics in
clinical practice

The American Diabetes Association has recommended

and provided guidelines for the prevention and cessation
of tobacco use in clinical diabetes care, which include:
Assessment of smoking status and history
Counselling on smoking prevention and cessation
Effective systems for delivery of smoking cessation
(American Diabetes Association, 2003)

The recommendation from International Diabetes

Federation on smoking among diabetes is somehow
unclear and not highlighted.
(Alberti et al., 2007)
 Smoking and diabetes retinopathy

Most common and specific complication of DM, and

significantly predicts mortality in diabetics. (Cheung and
Wong, 2008)

Hyperglycaemia, hypertension, dyslipidemia

Increased oxidative stress & impaired endothelial dysfunction in microcirculation

Local inflammation causes microvascular disease (e.g., retinopathy)

(leucocyte adhesion, platelet recruitment, cytokine release)

Systemic Inflammatory Milieu

Activated blood cells gain access to systemic circulation
(TNF-, sCD40L, IL-6, IFN-, IL-12, sP-sel, CRP)

Lesion-prone artery SMOKING

Atheroma Formation and Maturation
 Smoking and diabetes nephropathy
Cigarette smoking damages glomerular structure, even
among diabetics with normal renal function. This impact is
shown by a decline of glomerular filtration rate (GFR)
accompanied by proteinuria among diabetic smokers
compared to diabetic never-smokers. (Orth et al., 2005)

A low GFR without proteinuria might be caused by vascular

damage associated with cigarette smoking. (Orth et al., 2005)

Continued cigarette smoking exacerbates the nephropathy of

type 2 diabetes despite standard renoprotection therapy.
(Chuahirun et al., 2004)
 Smoking and diabetes neuropathy
Few studies have been done to assess the association
between smoking and neuropathy, mainly because:
Neuropathy may take a long time to develop
Neuropathy may affect the different sensory, motor, and
autonomic nerve fibres to varying degrees individually
Difficult to standardize study methods (Eliasson, 2003)

Smoking increases the risk of neuropathy by 68% (OR=1.68,

95%CI 1.20-2.36) among type I diabetics after adjusting for
duration of diabetes, glycosylated Hb, CVD and other CVD
risk factors. (Tesfaye et al., 2005)
 Global burden of diabetes

DM Prevalence Estimates in Prediction in

aged 20+ years 2000 2030
World 4.6% (171 million) 6.4% (366 million)
Developed world 6.3% (56 million) 8.4% (82 million)
Developing world 4.1% (115 million) 6.0% (284 million)
Indonesia 6.7% (8.5 million) 10.6% (21.3
million)
India 5.5% (32 million) 8.0% (80 million)
A significant high proportion of premature diabetics in
developing countries (25% aged 20-44 years, 51% aged
45-64 years)
 Smoking among diabetes patients
in Indonesia Results from QTI

QTI identified 778 male adult diabetes patients from diabetes

clinics in Yogyakarta Provinces.

Two thirds (65%) smoked before being diagnosed with

diabetes, and 32% had smoked in the last 6 months.

Overall, 26% of diabetic patients who had ever smoked

continued to smoke following diagnosis.

Patients underestimated the risk of smoking for diabetics, and

the benefit of quitting smoking for their diabetes control.
(Padmawati et al., 2008)
 Smoking and cardiovascular
diseases among diabetics

Smoking increases the risk for cardiovascular diseases

(CVD) among diabetics.

Compared with never smokers, female diabetic smokers

have 66%-168% higher risk of developing CVD.
RR = 1.21 for quitters
RR = 1.66 for current smokers (1-14 cigs/day)
RR = 2.68 for current smokers (15 or more cigs/day)
(Al-Delaimy et al., 2002)
 Smoking and stroke among
diabetics
Smoking, together with age and HbA1c significantly predicts
the occurrence of first stroke among diabetic men, but not
among women.

In women, age and microvascular complication significantly

predicts first stroke.

The Hazard Ratio of smoking for first stroke among diabetics

is: 2.29 (95%CI 1.363.87) among men, and 1.18 (95%CI
0.472.94) among women.
(Giorda et al., 2007)
 Smoking cessation for diabetics

Smoking cessation is an effective strategy to prevent

diabetes and its complication.

The British Heart Study among middle-age men showed :

a short term increase risk of diabetes in 5 years after
quitting, mainly because of weight gain
risk reverted to that of never-smokers in those who had
given up at least 20 years before screening.
(Wannamethee et al., 2001)

The risk for developing coronary heart disease among

diabetic women who had quit for more than 10 years is
similar to a never-smoker diabetic. (Al-Delaimy et al., 2002)