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The association of smoking and risk of diabetic retinopathy in patients with type 1 and type 2 diabetes: a meta-analysis



To clarify the relevance between smoking and diabetic retinopathy in patients with type 1 and type 2 diabetes mellitus.


Published evidence were searched in MEDLINE and EMBASE from the databases began until Feb. 2017. Studies evaluating the association between smoking and diabetic retinopathy or evaluating the risk factors of diabetic retinopathy including smoking were included.


Totally 73 studies were identified, among which 19 studies included type 1 diabetes patients and 56 studies included type 2 diabetes patients. In type 1 diabetes, compare with non-smokers, the risk of diabetic retinopathy significantly increased in smokers (risk ratio (RR) = 1.23, 95% CI 1.14, 1.33, P < 0.001), and the risk of proliferative diabetic retinopathy also significantly increased in smokers (RR = 1.48, 95% CI 1.20, 1.81, P < 0.001). In type 2 diabetes, compare with non-smokers, the risk of diabetic retinopathy significantly decreased in smokers (RR = 0.92, 95% CI 0.86, 0.98, P = 0.02) and the risk of proliferative diabetic retinopathy also significantly decreased in smokers (RR = 0.68, 95% CI 0.61, 0.74, P < 0.001).


Compare with non-smokers, the risk of diabetic retinopathy significantly increased in smokers with type 1 diabetes while significantly decreased in smokers with type 2 diabetes. However, this result did not change the importance of smoking cessation for public health.

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Author contributions

L.J. conceived and designed the systematic review protocol; Y.C., W.Y., X.G. performed the study selection and data extraction; X.C. and Y.C. performed the statistical analyses; and X.C., Y.C., X.H., and L.J. prepared the manuscript outlines and drafts. All authors contributed to the critical revision of manuscript drafts, as well as giving final approval for submitted manuscript content.


This study was supported by the National Key R and D Program of China (2016YFC1304901). The funding agency had no role in the study design, data collection or analysis, decision to publish or preparation of the manuscript.

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Corresponding author

Correspondence to Linong Ji.

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Conflict of interest

L.J. has received fees for lecture presentations from AstraZeneca, Merck, Novartis, Lilly, Roche, Sanofi-Aventis and Takeda. L.J. has received consulting fees from companies including AstraZeneca, Merck, Novartis, Lilly, Roche, Sanofi-Aventis and Takeda. L.J. has received grants/research support from AstraZeneca, Bristol-Myers Squibb, Merck, Novartis, and Sanofi-Aventis. The remaining authors declare that they have no conflict of interest.

Ethical approval

This article does not contain any studies with human participants or animals performed by any of the authors. We admit that this meta-analysis is complied with Ethical standards. Since this is a meta-analysis based on the published articles, therefore the ethical approval is not applicable.

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These authors contributed equally: Xiaoling Cai, Yifei Chen.

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Cai, X., Chen, Y., Yang, W. et al. The association of smoking and risk of diabetic retinopathy in patients with type 1 and type 2 diabetes: a meta-analysis. Endocrine 62, 299–306 (2018).

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  • Diabetic retinopathy
  • Smoke
  • Type 1 diabetes
  • Type 2 diabetes