Diabetic vascular disease is one of the common complications of diabetes, which can endanger all body organs, and is an important cause of death in patients with diabetes. Current conventional treatment methods have limited effects on severe diabetic vascular disease. Vascular smooth muscle cells (VSMCs) play a key role in the progression of diabetic vascular disease. Therefore, the regulation of VSMCs may have broad application prospects for reversing the diabetic vascular lesion. Here, the authors address the biological characteristics of VSMCs and their phenotypic conversion features in diabetes, as well as the therapeutic strategies of regulation of VSMCs for diabetic vascular disease.