India's Diabetes Burden Puts Tobacco Quitting Support at the Centre of Care

47,240 diabetes deaths linked to tobacco in 2023

Tobacco use accounted for an estimated 47,240 diabetes deaths in India in 2023, according to a 2026 analysis of Global Burden of Disease 2023 estimates published in BMJ Open. That represented 7.9% of diabetes deaths in the country, making support to quit tobacco a substantial part of the diabetes prevention and treatment challenge.

The analysis also attributed 1.77 million disability-adjusted life years to tobacco in relation to diabetes. This measure combines years lost through early death with years lived in poor health. The figures are population estimates calculated through modelling, which uses health data to estimate how much disease is attributable to a particular risk factor.

India's wider diabetes burden makes the findings especially pressing. The ICMR-INDIAB study estimated that 101 million people were living with diabetes and another 136 million had prediabetes, a condition in which blood glucose is above the normal range but below the threshold for diabetes.

International recommendations now offer a more detailed response for people with type 2 diabetes who smoke: combine counselling with appropriate medication, arrange early follow-up and monitor changes in glucose, weight and blood pressure. Evidence from Kerala also shows how counselling delivered within diabetes care can help more patients quit.

Why tobacco belongs in a diabetes consultation

Smoking is associated with insulin resistance, meaning the body responds less effectively to the hormone that helps glucose move from the blood into cells. It can also impair glucose regulation and increase the risk of developing type 2 diabetes.

People already living with diabetes face another problem. Tobacco exposure adds to their risks of heart disease and damage to blood vessels, making quitting relevant to both preventing diabetes and managing its complications.

Dr Anoop Misra, chairman of the Fortis CDOC Centre of Excellence for Diabetes, Metabolic Diseases and Endocrinology in New Delhi, helped write the international recommendations. He described the benefits of cessation and the need for practical treatment:

Quitting can substantially reduce the risk of heart disease, stroke, kidney disease and limb complications. The new recommendations move beyond simply saying 'quit' to a structured approach combining counselling, medication and relapse prevention,

A treatment plan, not a single instruction

Thirty-five experts from 13 countries developed the international consensus recommendations, published in Diabetes Research and Clinical Practice. Their 34 recommendations address a gap between telling people with diabetes to stop smoking and providing the treatment needed to help them do so.

The guidance calls for smoking cessation to become a routine part of diabetes management for every patient who smokes, regardless of the strength of nicotine dependence or the number of previous attempts to quit. Nicotine dependence is the addiction that can make stopping difficult even when someone understands the health risks.

Clinicians are advised to offer varenicline, a prescription medicine used to help people stop smoking, as the first choice of medication where it is available. Nicotine replacement therapy or bupropion are alternatives when varenicline is unavailable or unsuitable for the patient.

Nicotine replacement therapy supplies nicotine without tobacco smoke to help manage withdrawal. Medication choice should be assessed by a healthcare professional, alongside the patient's diabetes treatment and other health needs. The recommendations pair medicines with structured behavioural support and repeated contact through diabetes services.

The first month needs planned follow-up

The consensus recommends reviewing patients within two weeks and again at four weeks. These appointments give clinicians an early opportunity to assess difficulties with quitting and check blood glucose control, body weight and blood pressure.

Clinicians should also review relevant interactions between smoking and medicines. Tobacco smoke can affect how the body processes some drugs, so stopping smoking may change the monitoring or treatment a patient needs.

Some people gain weight after quitting, and glucose control can change temporarily. Weight management, physical activity and appropriate blood glucose monitoring can therefore accompany cessation treatment from the beginning.

Misra explained how these changes should be handled within diabetes care:

Weight gain or transient changes in glucose after quitting should be anticipated and managed, not used as reasons to continue smoking. In diabetes, smoking cessation should be treated as a clinical intervention - with the same seriousness as controlling glucose, blood pressure and cholesterol,

Kerala evidence shows the value of extra counselling

A study among people with diabetes in Kerala offers a concrete example of what additional support can achieve. All participants received strong advice from a doctor to quit smoking, along with leaflets explaining the need to stop. The intervention group also received a session of counselling lasting 30 minutes, tailored to diabetes and delivered by a trained, certified health professional who was not a doctor.

At six months, 51.8% of the counselling group reported quitting, compared with 12.5% of the comparison group. The gap was 39.3 percentage points, and the reported quit rate was more than four times as high among those receiving the additional counselling.

At one year, the reported quit rates were 45.8% and 19.8%, respectively, a difference of 26 percentage points. The figures were self-reported, and the later results show why cessation programmes need to assess progress beyond the first few weeks.

K. R. Thankappan, of the Achutha Menon Centre for Health Science Studies at the Sree Chitra Tirunal Institute for Medical Sciences and Technology, discussed these findings in an article on tobacco cessation published by the Indian Journal of Medical Research. The article recommends bringing cessation counselling into diabetes clinics and routine health services.

Why repeated attempts need repeated support

Nicotine addiction can involve several attempts to quit before a person stops for good. Returning to smoking after an initial period without it creates a need for renewed support, including a review of withdrawal symptoms, medication and situations that prompt tobacco use.

Figures cited in the diabetes prevention discussion show that 38.5% of smokers had attempted to quit in the preceding year, while 14.2% of people who had ever smoked daily had successfully quit. These percentages describe different groups: the first measures recent attempts among smokers, while the second measures successful quitting among people with a history of daily smoking.

Nearly half of cigarette and bidi smokers who tried to quit were unable to stay abstinent beyond a month. Bidis are tobacco rolled in a leaf. The early return to smoking helps explain the recommendations for contact within two weeks and again at four weeks.

For patients, sustained support means being able to return for help after a lapse. For diabetes services, it means recording tobacco use, offering treatment and arranging another appointment rather than ending the conversation with advice alone.

India's earlier services exposed gaps in access

India began establishing tobacco cessation clinics in 2002 through the Ministry of Health and Family Welfare, with support from the World Health Organization's India office. The initial 13 clinics subsequently increased to 19, according to Thankappan's article.

During their first five years, 34,741 tobacco users attended. Baseline information was recorded for 23,320 people. Among those described in the treatment data, 69% received behavioural intervention alone and 31% received behavioural intervention together with medication.

At the sixth week of follow-up, 14% reported completely quitting tobacco, while another 22% reported reducing consumption by at least half. Complete cessation remains the treatment goal. The article identified limited attendance and a very small proportion of patients from rural areas as major weaknesses of the clinic model.

The older national survey figures discussed in the article also showed missed opportunities during healthcare visits: fewer than half of smokers and 27% of people using smokeless tobacco had been advised to quit by healthcare providers. Those figures describe the period covered by that survey, rather than present service coverage.

How the response has developed

India's experience and the newer international recommendations trace a shift from specialist cessation clinics towards treatment embedded in ordinary healthcare. The main milestones span more than two decades:

• 2002: India's health ministry began establishing 13 tobacco cessation clinics with support from the World Health Organization's India office.
• 2022: The Centre of Excellence for the Acceleration of Harm Reduction at the University of Catania in Italy established the DiaSmokeFree Working Group to develop guidance tailored to diabetes.
• 2023: The year covered by the Global Burden of Disease estimates used to assess tobacco's contribution to diabetes deaths and lost healthy life in India.
• 2026: The BMJ Open analysis estimated 47,240 diabetes deaths and 1.77 million disability-adjusted life years attributable to tobacco in India in 2023.

The DiaSmokeFree collaboration brought together specialists in diabetes, internal medicine, smoking cessation, behavioural science and guideline development across five continents. Its recommendations connect cessation treatment with the metabolic checks that people with diabetes already need.

What routine diabetes services would need to change

Diabetes clinics can turn the recommendations into a repeatable process: ask about tobacco use, discuss quitting, offer counselling and suitable medication, and book follow-up. The consensus also proposes electronic prompts, automated referrals and coordination between professionals so that support does not depend on a patient finding a separate service.

Thankappan's article points to a role for trained professionals other than doctors. The Kerala diabetes study used such a professional to deliver the additional counselling, showing how a clinic can share the work while keeping tobacco treatment connected to diabetes care.

India's services also need to ask about smokeless tobacco alongside cigarettes and bidis. The international consensus focuses on smoking in people with type 2 diabetes, while India's cessation services must address the range of tobacco products patients use.

The consensus calls for more research into strategies tailored to diabetes, newer medicines, electronic cigarettes and digital tools. Evidence-based medicines, counselling and continued follow-up form its recommended clinical approach. A timetable for implementing the recommendations across India's diabetes services has not been announced.

Key Points

• A 2026 analysis estimated that tobacco accounted for 47,240 diabetes deaths in India in 2023, or 7.9% of diabetes deaths.
• The ICMR-INDIAB study estimated 101 million people with diabetes and 136 million with prediabetes in India.
• International recommendations call for counselling, appropriate medication and reviews within two weeks and again at four weeks.
• A Kerala diabetes study reported quitting rates of 51.8% with additional counselling versus 12.5% without it at six months.
• Glucose checks, weight management and support after a return to smoking should accompany efforts to quit.