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An international panel of 35 experts from 13 countries has issued the first consensus recommendations focused specifically on smoking cessation in type 2 diabetes, published in Diabetes Research and Clinical Practice by the DiaSmokeFree Working Group. The group, convened by the University of Catania's Center of Excellence for the Acceleration of Harm Reduction, argues that existing guidance from major diabetes organizations amounts to brief advice to stop smoking, with no direction on drug selection, drug-smoke interactions, or structured cessation pathways.
Smoking prevalence among people with type 2 diabetes is somewhat lower than in the general population, but it has declined more slowly, and daily consumption tends to be heavier. Pooled data cited in the document link smoking to a 55% increase in all-cause mortality and a 49% increase in cardiovascular mortality in this population, with elevated risks for coronary disease, stroke, peripheral artery disease, and lower-limb amputation. Evidence for nephropathy is strongest among microvascular complications; associations with retinopathy and neuropathy remain unclear.
On treatment, the panel found type 2 diabetes-specific evidence limited for most options. Varenicline is the only agent it strongly recommends as first-line, supported by a GRADE-evaluated meta-analysis and a dedicated randomized trial showing roughly fourfold higher continuous abstinence at one year without significant weight gain. Nicotine replacement and bupropion receive moderate recommendations when varenicline is unavailable or contraindicated. The panel found no evidence that brief 5As counseling or motivational interviewing improves quit rates in this population, while intensive programs with repeated contacts of more than 20 minutes and structured follow-up performed better. GLP-1 receptor agonists, e-cigarettes, and digital tools are flagged as promising but unproven in type 2 diabetes.
The document gives particular attention to drug-smoke interactions. Tobacco smoke induces CYP1A2 and UGT enzymes, accelerating clearance of pioglitazone, dapagliflozin, and canagliflozin; after quitting, exposure rises and dose reduction may be needed. Bupropion and nicotine can inhibit OCT2, raising metformin and linagliptin concentrations. The panel recommends follow-up within two weeks and at four weeks after a quit date to monitor glucose, weight, blood pressure, and interaction effects.
Provider and system barriers are addressed directly. Surveys cited show only 13% of diabetologists feel competent supporting cessation, and patients with diabetes receive less cessation support than those with other chronic conditions. The panel recommends that health systems and payors integrate cessation into routine diabetes care and consider reimbursement for pharmacological and behavioral interventions to remove financial barriers. Most recommendations reflect graded expert consensus rather than high-certainty evidence, and the authors note that adaptation for lower-resource settings will likely require task-shifting and lower-cost options.
