For a person living with type 2 diabetes, smoking is not simply another lifestyle habit to be addressed during a routine consultation. It is a risk factor that can trigger cardiovascular disease, stroke and other forms of vascular damage. It is also associated with poorer blood sugar control and premature mortality.That makes smoking cessation more than a general health recommendation. For people with type 2 diabetes, it should be regarded as a routine and essential component of diabetes care. This is a message from the international consensus recommendations developed by the DiaSmokeFree Working Group on how smoking should be integrated into the prevention and management of the disease.Says Dr Anoop Misra, one of the co-authors and Executive Chairman, Fortis C-Doc for Diabetes and Allied Sciences, “India faces a dual burden of tobacco use in the form of smoking and smokeless tobacco, among the highest in the world. According to the Global Adult Tobacco Survey (GATS) conducted in 2016–17, the overall prevalence of smoking tobacco use is 10.38% and smokeless tobacco use is 21.38% in India. Of all adults, 28.6% currently consume tobacco either in smoke or smokeless form, including 42.4% of men and 14.2% of women. Today a patient came, he had heart and kidney failure, but continued to take hookah and tobacco. I repeatedly told him to stop, but he said that it is tradition in his village.”Also Read | Here’s how soon smoking starts damaging your lungsThe guidelines, he argues, uniformly apply to all people with diabetes who smoke regardless of country. “The new recommendations move beyond simply saying ‘quit’ to a structured approach combining counselling, medication and relapse prevention. 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.”The case for quitting is especially strong in diabetesOnce diabetes is established, continued smoking can further increase the risk of cardiovascular and cerebrovascular disease. The available evidence also points to benefits from cessation for peripheral arterial disease and, likely, diabetic kidney disease. For complications such as retinopathy and neuropathy, however, the evidence is less certain.Also Read | Diabetes is not the same for men and women: Why females may be more vulnerableQuitting, therefore, should not be presented as an optional extra that can wait until blood glucose is under better control. It is part of reducing the patient/s broader health risk.Quitting is difficult and needs case-specific interventionThe consensus recommendations emphasise the importance of individualised care. Some people may be ready to quit immediately; others may be ambivalent or not yet prepared to make the attempt. A brief conversation may be appropriate for one patient, while another may need sustained behavioural support and pharmacological treatment.Story continues below this adThe evidence suggests that the strongest approach combines pharmacotherapy with behavioural support and a plan for managing relapse. Brief advice has a role, but intensive, individualized interventions are more effective than brief interventions alone.The pharmacological evidence specifically involving people with type 2 diabetes remains limited. Even so, the consensus group identifies varenicline as the only medication with a strong first-line recommendation where it is accessible and appropriate. Varenicline is not the only option. Nicotine replacement therapy and bupropion are considered reasonable alternatives when varenicline is unavailable or contraindicated. The evidence supporting these alternatives is more limited, underscoring the need for further research specifically in people with type 2 diabetes.The choice of treatment, however, should not be separated from the rest of the cessation strategy. Medication works best when it forms part of a broader programme that includes behavioural support, follow-up and preparation for possible relapse.Stopping cigarettes can change more than smoking statusThere is another issue that clinicians need to keep in mind: quitting smoking can alter the way some medicines behave in the body.Story continues below this adCigarette smoke can affect drug metabolism and transport through pathways involving enzymes and transporters. When smoking stops, these effects can change, potentially altering exposure to certain medicines. So after cessation, clinicians should be alert to the possibility of increased drug exposure and consider dose adjustment where appropriate.These interactions are a reminder that quitting smoking is a physiological change, not simply the removal of cigarettes from a patient’s daily routine.The weeks after quitting deserve attentionThe period immediately following cessation can bring changes that patients may not expect. The consensus recommendations advise preparing patients for transient metabolic changes and monitoring them early. Controlling blood sugar, blood pressure, weight and treatment-related adverse effects should be followed, particularly during the early stages of cessation.Weight gain is one of the concerns that can arise after quitting. It should be anticipated and addressed proactively, but it should not obscure the larger cardiovascular benefit of stopping smoking.Story continues below this adThe recommendations suggest follow-up within two weeks and again at four weeks, with attention to glycaemic control, weight, blood pressure and possible drug-smoking interactions. For clinicians, these early contacts can also provide an opportunity to reinforce progress, identify difficulties and respond quickly if the patient is struggling to remain abstinent.What about newer approaches?Researchers are investigating whether treatments already used in diabetes care might also have a role in smoking cessation. There is some early evidence involving GLP-1 receptor agonists, but the findings are not consistent. A small study combining exenatide with nicotine replacement therapy reported higher six-week abstinence than nicotine replacement therapy alone. A larger study involving dulaglutide, however, did not demonstrate an additional smoking-cessation benefit.For now, the evidence is insufficient to make these drugs established smoking-cessation treatments for people with type 2 diabetes.Putting these recommendations into practice may be particularly difficult in low- and middle-income countries, where access to medications such as varenicline and structured behavioural programmes can be limited. There may also be shortages of trained healthcare personnel and inadequate infrastructure for delivering intensive cessation services. The consensus recommendations, therefore, point towards practical adaptations, including task-shifting, lower-cost behavioural interventions and integrating smoking cessation into existing chronic disease services.