Alcohol, Cannabis, Tobacco: The Diabetes Risk Conversation Clinicians May Be Missing

Diabetes visits often focus on A1C, medications, weight, and cardiovascular risk. Yet another factor may deserve more attention: screening for alcohol, cannabis, tobacco, and other substance use among people with diabetes. New U.S. research suggests these behaviors often occur in distinct patterns and are associated with differences in reported health and hospitalization. Could asking patients only whether they drink or smoke mean missing a bigger clinical picture?

Table of Contents

1. What New Research Reveals About Substance Use and Diabetes
2. Alcohol, Cannabis, and Tobacco: Different Diabetes Risks
3. Why Traditional Substance-Use Screening May Fall Short
4. Practical Substance-Use Screening Strategies for Diabetes Care Teams
5. Conclusion
6. Frequently Asked Questions

What New Research Reveals About Substance Use and Diabetes

A study published October 23, 2026, in Primary Care Diabetes examined substance use patterns among U.S. adults with diabetes. Researchers analyzed data from the 2022–2023 National Survey on Drug Use and Health, which included 89,889 adults, including 6,805 who reported having diabetes.

Rather than evaluating each substance separately, investigators used a statistical method called latent class analysis. This approach identifies groups of people who report similar behaviors. As a result, the research offers a broader picture of substance use patterns that may overlap in everyday life.

Researchers identified three patterns of substance use among adults with diabetes:

• Low or non-use: 67.6% of participants with diabetes.
• Cannabis and binge drinking: 24.4% of participants.
• Polysubstance use: 8.0% of participants.

The study also identified differences in who was more likely to belong to the higher-risk profiles. Male sex, greater mental health burden, and urban residence were associated with membership in these groups. Conversely, marriage and college education were associated with a lower likelihood of membership.

Both higher-risk groups had more than twice the odds of reporting poor self-rated health compared with the low- or non-use group. Additionally, members of the polysubstance-use group had higher odds of hospitalization, with a reported odds ratio of 1.46.

These findings warrant attention, but they require careful interpretation. Because the study used observational, self-reported survey data, it cannot establish that substance use caused poorer health or hospitalization. Other health, social, and economic factors may contribute to the relationships observed.

Nevertheless, the findings suggest that assessing individual substances in isolation may overlook meaningful patterns of use.

The original research is available through PubMed.

Alcohol, Cannabis, and Tobacco: Different Diabetes Risks

For people with diabetes, the risks associated with alcohol, cannabis, and tobacco extend beyond whether someone meets the criteria for a substance use disorder. Even occasional or intermittent use may affect treatment decisions, especially when insulin, glucose monitoring, or cardiovascular complications are involved.

Alcohol presents a particularly important concern for people treated with insulin or sulfonylureas. Drinking can reduce the liver's ability to release glucose, increasing the potential for delayed hypoglycemia. Furthermore, intoxication may make it harder to recognize warning symptoms or respond appropriately.

Patients who drink without eating, skip medication doses, or experience repeated episodes of heavy drinking may face additional challenges. Therefore, clinicians should ask about drinking frequency, quantity, binge episodes, food intake, and medication use rather than simply recording alcohol consumption.

Cannabis raises different questions, particularly in type 1 diabetes. Some observational studies have linked cannabis use with diabetic ketoacidosis (DKA), although these findings do not establish a direct causal relationship.

The American Diabetes Association's 2026 Standards of Care advise people with type 1 diabetes and others at risk for DKA against recreational cannabis use. Additionally, cannabis-associated vomiting may complicate the assessment of hyperglycemia and ketosis.

An earlier Diabetes in Control review of cannabis-related hyperglycemic ketosis discusses why clinicians should consider cannabis exposure when evaluating patients with type 1 diabetes who present with vomiting and elevated ketones.

Tobacco and nicotine exposure also deserve routine attention. Cigarette smoking is a well-established risk factor for cardiovascular disease and worsens several diabetes-related risks. Smoking is associated with kidney disease, vision problems, and premature mortality among people with diabetes.

Importantly, clinicians should distinguish combustible cigarettes from vaping and other nicotine products rather than assuming all exposures are identical. The 2026 ADA guidance recommends routine assessment of tobacco and vaping, avoidance counseling, and evidence-based cessation treatment.

Why Traditional Substance-Use Screening May Fall Short

A familiar clinical question is, "Do you drink, smoke, or use drugs?" Although convenient, this approach may provide too little detail to guide meaningful care.

For example, two patients may both answer yes to alcohol use while having very different drinking patterns. One may consume an occasional drink with dinner, while another experiences recurrent binge-drinking episodes alongside cannabis use.

Similarly, a patient who has stopped smoking cigarettes may still vape nicotine regularly. Without specific follow-up questions, that exposure may remain undocumented.

These findings suggest that asking about alcohol, cannabis, and nicotine together may reveal patterns that separate questions could miss. However, the study did not test whether a particular screening questionnaire improves diabetes outcomes.

Mental health also deserves attention during these conversations. Depression, anxiety, stress, and substance use can overlap, potentially complicating medication routines and diabetes self-management.

Consequently, a nonjudgmental approach is essential. Patients may share more accurate information when clinicians explain that questions about substance use are routine and intended to improve safety, not assign blame.

The 2026 ADA Standards of Care include tobacco, alcohol, and substance use in the comprehensive diabetes assessment.

Practical Substance-Use Screening Strategies for Diabetes Care Teams

Clinicians can translate these findings into routine visits without making every encounter a lengthy behavioral health evaluation. They can start with a few simple questions, then explore specific substance use patterns when patients report potential risks.

First, ask separately about alcohol, cannabis, cigarettes, vaping, and other substances. Next, clarify how often patients use them, the amounts involved, and whether multiple substances are used together.

For alcohol, validated tools such as AUDIT-C can help identify potentially unhealthy drinking. Meanwhile, screening instruments such as the TAPS tool may help assess tobacco, alcohol, prescription medication misuse, and other substance use.

However, screening should lead to an appropriate response. A positive result may warrant a fuller assessment, brief counseling, closer glucose monitoring, or referral for additional support.

Clinicians should also connect the discussion to the patient's treatment plan. For someone using insulin, alcohol counseling may include recognizing delayed hypoglycemia and checking glucose after drinking. In contrast, someone with type 1 diabetes who uses cannabis may benefit from education about vomiting, ketone testing, and emergency symptoms.

Tobacco cessation discussions should include behavioral counseling and appropriate pharmacologic treatment. Diabetes teams can also reinforce the relationship between smoking cessation and long-term cardiovascular protection.

Importantly, clinicians should avoid assuming that every patient who reports substance use has a substance use disorder. The goal is to understand exposure, identify possible risks, and offer individualized support.

Ultimately, comprehensive screening should complement established diabetes care rather than replace essential priorities such as medication access, cardiovascular risk management, and routine follow-up.

Conclusion

The new findings highlight why conversations about substance use should be a routine part of comprehensive diabetes care. Alcohol, cannabis, nicotine, and other substances may occur in overlapping patterns, and these patterns are associated with poorer self-rated health and increased hospitalization odds in certain groups.

However, these associations do not prove causation or establish that broader screening will reduce hospitalizations. Instead, they offer a rationale for more thoughtful clinical conversations and further research.

For diabetes care teams, the central lesson is straightforward: ask specific questions, consider mental health, recognize overlapping exposures, and tailor counseling to each patient's clinical circumstances.

Frequently Asked Questions

1. What did the new study find about substance use among adults with diabetes?

Researchers identified three profiles: low or non-use, cannabis and binge drinking, and polysubstance use. The two higher-risk groups had more than twice the odds of poor self-rated health, while polysubstance use was also associated with higher hospitalization odds.

2. Does substance use directly cause worse diabetes outcomes?

Not necessarily. The study identified associations, not cause-and-effect relationships. Other medical, psychological, and social factors may influence the results.

3. Why should clinicians ask about alcohol and cannabis together?

Patients may use multiple substances, and asking about each separately may not reveal overlapping patterns. Understanding combined use can help clinicians identify potential safety concerns and personalize counseling.

4. Is cannabis safe for people with type 1 diabetes?

The ADA advises against recreational cannabis use in people with type 1 diabetes because of concerns involving ketosis and DKA. Clinicians should discuss these risks, particularly when patients experience recurrent vomiting or unexplained ketosis.

5. How can clinicians improve substance use screening for patients with diabetes?

Ask about specific substances, frequency, quantity, and co-occurring use. Validated screening tools, mental health assessment, respectful counseling, and appropriate referrals can help translate findings into patient-centered care.

This content is not medical advice. For any health issues, always consult a healthcare professional. In an emergency, call 911 or your local emergency services.