Relation of Smoking With Total Mortality and Cardiovascular Events Among Patients With Diabetes Mellitus: A Meta-Analysis and Systematic Review.

BACKGROUND The prevalence of smoking in diabetic patients remains high, and reliable quantification of the excess mortality and morbidity risks associated with smoking is important for diabetes management. We performed a systematic review and meta-analysis of prospective cohort studies to evaluate the relation of active smoking with risk of total mortality and cardiovascular events among diabetic patients. METHODS AND RESULTS We searched Medline and Embase databases through May 2015, and multivariate-adjusted relative risks were pooled by using random-effects models. A total of 89 cohort studies were included. The pooled adjusted relative risk (95% confidence interval) associated with smoking was 1.55 (1.46-1.64) for total mortality (48 studies with 1,132,700 participants and 109,966 deaths), and 1.49 (1.29-1.71) for cardiovascular mortality (13 studies with 37,550 participants and 3163 deaths). The pooled relative risk (95% confidence interval) was 1.44 (1.34-1.54) for total cardiovascular disease (16 studies), 1.51 (1.41-1.62) for coronary heart disease (21 studies), 1.54 (1.41-1.69) for stroke (15 studies), 2.15 (1.62-2.85) for peripheral arterial disease (3 studies), and 1.43 (1.19-1.72) for heart failure (4 studies). In comparison with never smokers, former smokers were at a moderately elevated risk of total mortality (1.19; 1.11-1.28), cardiovascular mortality (1.15; 1.00-1.32), cardiovascular disease (1.09; 1.05-1.13), and coronary heart disease (1.14; 1.00-1.30), but not for stroke (1.04; 0.87-1.23). CONCLUSIONS Active smoking is associated with significantly increased risks of total mortality and cardiovascular events among diabetic patients, whereas smoking cessation is associated with reduced risks in comparison with current smoking. The findings provide strong evidence for the recommendation of quitting smoking among diabetic patients.