Coronary heart disease incidence and mortality, and all-cause mortality among diabetic and non-diabetic people according to their smoking behavior in Finland
More details
Hide details
Department of Medical and Population Health Sciences Research, Herberth Wertheim College of Medicine, Florida International University, Miami, USA
Department of Neurosciences and Preventive Medicine, Danube-University Krems, Krems, Austria
Department of Health, National Institute for Health and Welfare, Helsinki, Finland
Institute of Public Health and Clinical Nutrition, University of Eastern Finland, Kuopio, Finland
Hospital District of North Karelia, Joensuu, Finland
Dasman Diabetes Institute, Dasman, Kuwait
Submission date: 2016-04-12
Acceptance date: 2017-01-12
Publication date: 2017-02-02
Corresponding author
Noël C. Barengo   

Department of Medical and Population Health Sciences Research, Herberth Wertheim College of Medicine, Florida International University, 11200 SW 8th Street, AHC2, Miami, FL 33199, USA
Tob. Induc. Dis. 2017;15(February):12
As type 2 diabetes (T2D) patients have a high risk for coronary heart disease (CHD) and all-cause mortality and smoking is a major single risk factor for total and CHD mortality, it is important to understand the impact of smoking to the outcome events in comparison to people without T2D. Studies of excess risk of CHD incidence and mortality, and all-cause mortality in T2D patients related to smoking are controversial. We aimed to assess the risk of CHD incidence and mortality, and all-cause mortality in a large Finnish population cohort consisting of people with and without T2Daccording to smoking status.

Prospective follow-up of 28 712 men and 30 700 women aged 25–64 years living in eastern and south-western Finland. The data on mortality were obtained from the nationwide death register using the unique national personal identification number. Follow-up information regarding CHD was based on the Finnish Hospital Discharge Register for non-fatal outcomes. The Cox proportional hazards models were used to estimate the association between diabetes and smoking subgroups and the risk for total and CHD mortality.

T2D patients who were smoking had higher all-cause mortality in both men (HR 3.76; 95% CI 2.95-4.78) and women (HR 4.51; 95% CI 2.91-7.00) than non-smoking diabetic men (HR 2.03; 95% CI 1.51-2.74) and women (HR 2.11; 95% CI 1.71-2.59). The CHD mortality risk for smoking men with T2D was higher (HR 6.15; 95% CI 4.22-8.96) than in non-smoking diabetic men (HR 2.62; 95% CI 1.60-4.29). Similar results were found in women revealing corresponding HR for CHD mortality of 6.92 (95% CI 2.79-17.19) for smoking, T2D women and 4.06 (95% CI 2.83-5.82) for non-smoking T2D women, respectively. Even though the risk of CHD incidence in T2D patients who had stopped smoking was statistically significantly higher than in their non-smoking non-diabetic counterparts, their CHD incidence was lower than in smoking T2D patients (HR in men 3.00; HR in women 2.80).

It is important to address tobacco consumption in T2D patients, especially during primary health care contacts in order to reduce their high risk of CHD and all-cause mortality.

International Diabetes Federation (IDF). Diabetes atlas. 7th ed. Brussels: IDF; 2015.
The DECODE Study Group. Is the current definition for diabetes relevant to mortality risk from All causes and cardiovascular and noncardiovascular diseasese. Diabetes Care. 2003;26:688–99.
Barengo NC, Katoh S, Moltchanov S, Tajima N, Tuomilehto J. The diabetes-cardiovascular risk paradox: results from a Finnish population-based prospective study. Eur Heart J. 2008;29(15):1889–95.
Laukkanen JA, Mäkikallio TH, Ronkainen K, Karppi J, Kurl S. Impaired fasting plasma glucose and type 2 diabetes Are related to the risk of Out-of-hospital sudden cardiac death and All-cause mortality. Diabetes Care. 2013;36(5):1166–71.
Manuel D, Schultz S. Health-related quality of life and health-adjusted life expectancy of people with diabetes mellitus in Ontario, Canada, 1996–1997. Diabetes Care. 2004;27:407–14.
Murray CJ, Lopez AD. Global mortality, disability, and the contribution of risk factors: global burden of disease study. Lancet. 1997;349:1436–42.
Yusuf S, Hawken S, Ounpuu S, Dans T, Avezum A, Lanas F, et al. INTERHEART study investigators. Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case–control study. Lancet. 2004;364:937–52.
Nilsson PM, Cederholm J, Eeg-Olofsson K, et al. Smoking as an independent risk factor for myocardial infarction or stroke in type 2 diabetes: a report from the swedish national diabetes register. Eur J Cardiovasc Prev Rehabil. 2009;16:506–12.
Al-Delaimy WK, Manson JE, Solomon CG, et al. Smoking and risk of coronary heart disease among women with type 2 diabetes mellitus. Arch Intern Med. 2002;162:273–9.
Al-Delaimy WK, Willett WC, Manson JE, Speizer FE, Hu FB. Smoking and mortality among women with type 2 diabetes: the Nurses’ health study cohort. Diabetes Care. 2001;24:2043–8.
Turner RC, Millns H, Neil HAW, Stratton IM, Manley SE, Matthews DR, et al. Risk factors for coronary artery disease in non-insulin dependent diabetes mellitus: united kingdom prospective diabetes study (UKPDS: 23). BMJ. 1998;316:823–8.
Katakura M, Naka M, Kondo T, et al. Prospective analysis of mortality, morbidity, and risk factors in elderly diabetic subjects: Nagano study. Diabetes Care. 2003;26:638–44.
Church TS, LaMonte MJ, Barlow CE, Blair SN. Cardiorespiratory fitness and body mass index as predictors of cardiovascular disease mortality among men with diabetes. Arch Intern Med. 2005;165:2114–20.
Ostgren CJ, Lindblad U, Melander A, Rastam L. Survival in patients with type 2 diabetes in a swedish community: skaraborg hypertension and diabetes project. Diabetes Care. 2002;25:1297–302.
Faglia E, Favales F, Calia P, et al. Cardiac events in 735 type 2 diabetic patients who underwent screening for unknown asymptomatic coronary heart disease: 5-year follow-up report from the Milan study on atherosclerosis and diabetes (MiSAD). Diabetes Care. 2002;25:2032–6.
Lutgers HL, Gerrits EG, Sluiter WJ, et al. Life expectancy in a large cohort of type 2 diabetes patients treated in primary care (ZODIAC-10). PLoS One. 2009;4(8):e6817.
Adams LA, Harmsen S, St. Sauver JL, et al. Nonalcoholic fatty liver disease increases risk of death among patients with diabetes: a community-based cohort study. Am J Gastroenterol. 2010;105:1567–73.
Qin R, Chen T, Lou Q, Yu D. Excess risk of mortality and cardiovascular events associated with smoking among patients with diabetes: meta-analysis of observational prospective studies. Int J Cardiol. 2013;167(2):342–50.
Vartiainen E, Jousilahti P, Alfthan G, Sundvall J, Pietinen P, Puska P. Cardiovascular risk factor changes in Finland, 1972–1997. Int J Epidemiol. 2000;29(1):49–56.
The World Health Organization MONICA Project (monitoring trends and determinants in cardiovascular disease). a major international collaboration. WHO MONICA project principal investigators. J Clin Epidemiol. 1988;41(2):105–14.
Hu G, Jousilahti P, Barengo NC, Qiao Q, Lakka TA, Tuomilehto J. Physical activity, cardiovascular risk factors, and mortality among Finnish adults with diabetes. Diabetes Care. 2005;28:799–805.
Hu G, Tuomilehto J, Silventoinen K, Barengo NC, Jousilahti P. The effects of physical activity and body mass index on cardiovascular, cancer and all-cause mortality among 47 212 middle-aged Finnish men and women. Int J Obes Relat Metab Disord. 2005;29:894–902.
Pyorala K, Laakso M, Uusitupa M. Diabetes and atherosclerosis: an epidemiologic view. Diabetes Metab Rev. 1987;3:463–524.
Facchini F, Hollenbeck C, Jeppesen J, Chen Y, Reaven G. Insulin resistance and cigarette smoking. Lancet. 1992;339:1128–30.
Walters DP, Gatling W, Houston AC, Mullee MA, Julious SA, Hill RD. Mortality in diabetic subjects: an eleven-year follow-up of a community-based population. Diabetic Med. 1994;11:968–73.
Kothari V, Stevens RJ, Adler AI, Stratton IM, Manley SE, Neil HA, et al. UKPDS 60: risk of stroke in type 2 diabetes estimated by the UK prospective diabetes study risk engine. Stroke. 2002;33:1776–81.
Adler AI, Stevens RJ, Neil A, Stratton IM, Boulton AJ, Holman RR. UKPDS 59 hyperglycemia and other potentially modifiable risk factors for peripheral vascular disease in type 2 diabetes. Diabetes Care. 2002;25:894–9.
Kong C, Nimmo L, Elatrozy T, Anyaoku V, Hughes C, Robinson S, et al. Smoking is associated with increased hepatic lipase activity, insulin resistance, dyslipidaemia and early atherosclerosis in type 2 diabetes. Atherosclerosis. 2001;156:373–8.
Eckert T, Junker C. Motivation for smoking cessation: what role do doctors play? Swiss Med Wkly. 2001;131:521–6.
Liu JL, Tang J-L. Doctors are ethically obliged to advise patients to quit smoking. BMJ. 1998;317:1588.
Barengo NC, Sandström HP, Jormanainen VJ, Myllykangas MT. Attitudes and behaviour in smoking cessation among general practitioners in Finland. Soz Praventivmed. 2005;50(6):355–60.
Ryden L, Standl E, Bartnik M, Van den Berghe G, Betteridge J, de Boer MJ, et al. Guidelines on diabetes, pre-diabetes, and cardiovascular diseases: executive summary. The task force on diabetes and cardiovascular diseases of the european society of cardiology (ESC) and of the european association for the study of diabetes (EASD). Eur Heart J. 2007;28:88–136.
Cigarette Smoking, Diabetes, and Diabetes Complications: Call for Urgent Action
Ping Zhu, Xiong-Fei Pan, Liting Sheng, Henggui Chen, An Pan
Current Diabetes Reports
Response to the letter to the editor regarding “Smoking and coronary heart disease in patients with type 2 diabetes mellitus”
Lixin Li, Chun Xu, Ke-Sheng Wang
Diabetes Research and Clinical Practice
Smoking and coronary heart disease in patients with type 2 diabetes mellitus
Tomoyuki Kawada
Diabetes Research and Clinical Practice
Visit-to-visit HbA1c and glucose variability and the risks of macrovascular and microvascular events in the general population
Ji-Yong Jang, Shinje Moon, Sungsoo Cho, Kyoo Cho, Chang-Myung Oh
Scientific Reports
Davide Campagna, Angela Alamo, Enrico Mondati, Riccardo Polosa
il Diabete
Smoking and Diabetes Control in Adults With Type 1 and Type 2 Diabetes: A Nationwide Study From the 2018 National Program for Prevention and Control of Diabetes of Iran
Ghasem Molla, Faramarz Ismail-Beigi, Bagher Larijani, Pegah Khaloo, Fatemeh Moosaie, Hamid Alemi, Mohammad Mansournia, Tayyeb Ghadimi, Fatemeh Ghaemi, Manouchehr Nakhjavani, Alireza Esteghamati
Canadian Journal of Diabetes
Smoking and diabetes: dangerous liaisons and confusing relationships
D. Campagna, A. Alamo, Pino Di, C. Russo, A. Calogero, F. Purrello, R. Polosa
Diabetology & Metabolic Syndrome
A systematic review considering risk factors for mortality of patients discharged from hospital with a diagnosis of diabetes
Teesta Mukherjee, Tim Robbins, Choi Lim, Sailesh Sankar, Harpal Randeva, Theodoros Arvanitis
Journal of Diabetes and its Complications
Cardiometabolic Morbidity and Mortality with Smoking Cessation, Review of Recommendations for People with Diabetes and Obesity
Katarina Kos
Current Diabetes Reports
Prediabetes versus type 2 diabetes in patients with acute myocardial infarction and current smoking
Yong Kim, Ae-Young Her, Myung Jeong, Byeong-Keuk Kim, Sung-Jin Hong, Seunghwan Kim, Chul-Min Ahn, Jung-Sun Kim, Young-Guk Ko, Donghoon Choi, Myeong-Ki Hong, Yangsoo Jang
The American Journal of the Medical Sciences
Therapeutic potential of herbal medicine for the management of hyperlipidemia: latest updates
Abdur Rauf, Muhammad Akram, Hina Anwar, Muhammad Daniyal, Naveed Munir, Sami Bawazeer, Saud Bawazeer, Maksim Rebezov, Abdelhakim Bouyahya, Mohammad Shariati, Muthu Thiruvengadam, Orynzhamal Sarsembenova, Yahia Mabkhot, Mohammad Islam, Talha Emran, Sergey Hodak, Gokhan Zengin, Haroon Khan
Environmental Science and Pollution Research
Analyzing spatial variations of heart disease and type-2 diabetes: A multi-scale geographically weighted regression approach
Wencong Cui, Nanzhou Hu, Shuyang Zhang, Diya Li, Luis Martinez, Daniel Goldberg, Burak Güneralp, Zhe Zhang
Computational Urban Science
Influence du tabagisme sur la mortalité et les complications chez le sujet diabétique
Abdallah Al-Salameh, Blandine Tramunt, Alexia Rouland
Médecine des Maladies Métaboliques
Smoking and diabetes: sex and gender aspects and their impact on vascular diseases
Blandine Tramunt, Alexia Rouland, Vincent Durlach, Bruno Vergès, Daniel Thomas, Ivan Berlin, Carole Clair
Canadian Journal of Cardiology
Effectiveness of intensive stand-alone smoking cessation interventions for individuals with diabetes: A systematic review and intervention component analysis
Joseph Grech, Ian Norman, Roberta Sammut
Tobacco Induced Diseases
Evidence relating cigarettes, cigars and pipes to cardiovascular disease and stroke: Meta-analysis of recent data from three regions
Peter Lee, Katharine Coombs, Jan Hamling
World Journal of Meta-Analysis
Early detection system of risk factors for diabetes mellitus type 2 utilization of machine learning-random forest
Johannes Ginting, Tri Suci, Chrismis Ginting, Ermi Girsang
Journal of Family and Community Medicine
Assessment HOMA as a predictor for new onset diabetes mellitus and diabetic complications in non-diabetic adults: a KoGES prospective cohort study
Jibeom Lee, Moon-hyun Kim, Ji-Yong Jang, Chang-Myung Oh
Clinical Diabetes and Endocrinology
Journals System - logo
Scroll to top