Smoking, Paan, Gutka and Naswar: What Tobacco Actually Does to Diabetes

Almost everyone who smokes already knows smoking is bad for them. Being told again, more loudly, has never helped anybody put a cigarette down. So this article is not going to do that. What it will do is fill in a gap that most diabetes advice in Pakistan leaves open: the specific, concrete ways tobacco interacts with blood sugar and with the complications you are already being asked to watch for.

That gap matters more here than in most places, because tobacco in Pakistan is not only cigarettes. It is paan, gutka, naswar and mainpuri, all of which are widely treated as the harmless option—the thing you switch to. The evidence does not support that. It also does not support panic. Here is what is actually known.

What Tobacco Does to Blood Sugar

The link between cigarette smoking and diabetes is not a matter of debate. The American Diabetes Association's Standards of Care (opens in a new tab) state plainly that a causal link between cigarette smoking and diabetes has been well established for over a decade. The World Health Organization, in a brief developed jointly with the International Diabetes Federation and the University of Newcastle (opens in a new tab), puts the size of it this way: quitting tobacco lowers the risk of developing type 2 diabetes by 30–40%.

The mechanism, as WHO (opens in a new tab) summarises it, is that smoking impairs the body's ability to regulate blood sugar. This is why smoking matters even to someone whose eating and walking are already in good order—it is working on the same system your medication is working on, in the opposite direction.

For people who already have diabetes, the ADA notes that those who smoke have elevated A1C compared with those who do not. The relationship is dose-dependent: a systematic review cited in the Standards of Care found a dose-response relation between current smoking and type 2 diabetes risk, and that this risk decreases as the time since quitting increases. Both halves of that sentence are worth sitting with. More is worse, and stopping genuinely counts.

The Complications Column

This is the part that tends to be missing from general anti-smoking messaging, and it is the part that matters most if you already have diabetes. Tobacco does not simply add its own separate risks alongside your diabetes. It compounds the specific complications your diabetes reviews are designed to catch.

The ADA's Standards of Care (opens in a new tab) state that people with diabetes who smoke—and those exposed to second-hand smoke—have a heightened risk of macrovascular complications such as cardiovascular and peripheral vascular disease, microvascular complications such as kidney disease and visual impairment, elevated A1C, and premature death, compared with those who neither smoke nor are exposed. WHO lists (opens in a new tab) the severe complications that tobacco use raises the risk of among people with diabetes as:

• Cardiovascular disease
• Kidney failure
• Blindness
• Delayed wound healing
• Lower limb amputation

Read that list next to the standard diabetes checkup schedule and the overlap is almost exact—heart, kidneys, eyes, feet. Diabetes UK summarises (opens in a new tab) the combined effect simply: smoking can double the risk of diabetes complications. The foot connection deserves particular emphasis, because smoking narrows the blood vessels supplying the legs at the same time that diabetes is slowing wound healing and dulling the nerves that would otherwise warn you about a blister.

Paan, Gutka and Naswar Are Not the Safe Option

This is the belief worth addressing directly, because it is extremely common and it is wrong. Chewed and placed tobacco is often understood as a way of avoiding the harms of smoking—no smoke, no lungs, no problem. The products are also woven into ordinary social life in a way cigarettes are not: paan after a heavy meal, naswar through a long working shift.

They are not a fringe habit. Drawing on the Global Adult Tobacco Survey, researchers publishing in PLOS ONE (opens in a new tab) found current smokeless tobacco use among Pakistani adults aged 15 and over at 7.7%, or roughly 9.6 million people—11.4% of men and 3.7% of women.

The same analysis (opens in a new tab) found use concentrated among those with least room to absorb a health shock: 10.6% among adults with less than primary education against 2.2% among college-educated adults, and 13.3% in the poorest fifth of households against 3.0% in the richest. Rural and urban prevalence did not differ significantly.

On the metabolic question specifically, a meta-analysis published in PLOS ONE (opens in a new tab) pooled 17 Asian studies covering 388,134 people. Comparing betel quid chewers with non-chewers, it reported these adjusted relative risks:

Seven of the pooled studies, covering 121,585 people, also found a dose-response relationship—more chewing, more risk. Hypertension was the one outcome where the association did not reach statistical significance.

Alongside the metabolic picture, the ADA notes that smokeless tobacco products carry an increased risk of cardiovascular disease and oral cancer. Diabetes independently raises the risk of gum disease, so keeping tobacco parked against the gums for hours a day stacks two problems in the same small space.

What About Vapes and Sheesha?

Vaping is the newer version of the same hope, and the ADA's position is unambiguous. While combustible tobacco remains the most harmful, e-cigarettes pose significant risks to the cardiovascular and respiratory systems, and findings from the large PATH study indicate that e-cigarettes contribute to nicotine dependence—confirming, in the ADA's phrasing, that there is no safe tobacco product. Recommendation 5.40 in the 2026 Standards of Care carries the highest evidence grade and tells clinicians to advise complete avoidance of tobacco and vaping alike.

Sheesha is not a separate category. It is combustible tobacco, drawn in sessions that typically last far longer than a cigarette, and it falls squarely inside the same guidance. The social framing is different; the smoke is not.

What Quitting Actually Gives Back

The strongest argument for stopping is not fear of what continues—it is how quickly the body starts recovering. The NHS sets out (opens in a new tab) the timeline like this:

The circulation improvement at two to twelve weeks is the one to hold onto if you have diabetes, because it feeds directly into wound healing and foot health. And over the long run, the ADA states (opens in a new tab) that quitting smoking reduces or reverses adverse health effects in addition to increasing life expectancy by up to 10 years.

“Findings show a dose-response relation for current smoking and the risk for type 2 diabetes; this risk decreases as the time since quitting increases.”

The Two Worries That Stop People

The first is weight. It is a real effect, not an excuse, and it matters more when you have diabetes than when you do not. The ADA puts the average post-cessation weight gain at 3–5 kg, and then adds the crucial context: that gain does not necessarily persist long term, and it does not diminish the substantial cardiovascular benefit of quitting. A meta-analysis found that stopping smoking lowered the risk of cardiovascular disease and all-cause mortality regardless of how much weight was gained afterwards. Approaches that modestly reduce that weight gain include structured weight management, exercise programmes and nicotine replacement therapy.

The second worry is having failed before. Most people who quit have several attempts behind them. The NHS notes (opens in a new tab) that reaching 28 days smoke-free significantly increases the chance of quitting for good—which is a more useful target than "forever" and a far more reachable one.

Making an Attempt That Holds

1. 1Tell your diabetes doctor. The ADA's guidance is that tobacco use should be asked about at every visit, and that counselling plus medication should be offered together. If nobody has raised it with you, raise it yourself—more than two-thirds of people trying to quit never receive evidence-based treatment.
2. 2Ask specifically about medication. A secondary analysis of the EAGLES trial found varenicline to be the most efficacious pharmacotherapy for people with diabetes compared with placebo, and it is the American Thoracic Society's first-line recommendation for tobacco dependence. Whether it suits you is a question for your doctor, alongside your other medicines.
3. 3Count chewed tobacco in. Naswar, paan and gutka belong in the same quit plan as cigarettes—swapping one for another is not a step down.
4. 4Log more closely for the first few months. Quitting changes appetite, weight and glucose all at once. Frequent readings turn that period into information rather than guesswork.
5. 5Pick the 28-day marker as your first goal. Then the next one. Long-term abstinence is built out of short completed stretches.

One encouraging finding from the ADA's review: a cluster randomised trial found that cessation support delivered through diabetes education clinics produced significantly higher quit rates and long-term abstinence beyond six months—and it worked regardless of how motivated people were when they started. Motivation was not the prerequisite. Being offered proper help was.

Watch the change in your own numbers

If you are cutting down or quitting, the weeks that follow are worth logging properly—readings, weight and how you feel, in one place. Diatic keeps that record so you and your doctor can see what actually shifted, rather than trying to remember it.

Start logging with Diatic (opens Diatic on Google Play in a new tab)

Nobody manages diabetes perfectly, and nobody quits tobacco on a schedule set by an article. But of all the changes people with diabetes are asked to make, this is the one with the largest effect on the complications that worry them most—and the one where the body starts giving something back within the first day.