Although there is strong evidence linking cigarette smoke exposure with RA, the specific effect of smoking on radiographic progression of disease is less clear. There is some evidence that smoking may be a risk factor for radiographic progression in early RA.14,15 It is unknown, however, the extent to which smoking cessation can halt progression or reverse pathologic changes associated with RA.
Data from the Consortium of Rheumatology Researchers of North America and from the Better Anti‐Rheumatic PharmacOTherapy (BARFOT) project in early RA in Sweden showed that smoking cessation after the onset of RA did not change the prognosis for smokers with RA.16,17 In fact, it has been reported that the risk for RA may persist for several years after smoking cessation, even among moderate smokers.18
The discovery that cigarette smoke condensate can induce the production of proinflammatory cytokines in synovial fibroblasts has led to growing interest in how smoking affects response to RA treatment, particularly to biologic agents. The available research is conflicting. A study by Maska and colleagues reported that, among patients with early RA and poor prognostic factors, smoking status had no impact on treatment response to early combination therapy (methotrexate + etanercept or methotrexate + hydroxychloroquine + sulfasalazine triple therapy) or initial methotrexate with step-up therapy (methotrexate + etanercept) or to triple therapy .19
Another study reported by the Agency for Healthcare Research and Quality concluded that among individuals with RA of <3 years duration, smoking does not reduce the effectiveness of RA treatment.20 In heavy smokers with advanced disease, however, it appears that smoking can attenuate treatment response. For example, a review by
Change and colleagues of available studies on smoking and RA concluded that smoking aggravates RA and decreases response to TNF-α antagonist treatment. This conclusion was based on serology results, cytokine levels, and pharmacokinetic/pharmacodynamic studies,1 and is supported by a real-life cohort study in patients with axial spondyloarthritis, which also found an association between smoking and impaired response to TNF-α antagonist treatment.21
Although the rates of cigarette smoking among US adults has decreased over the past 50 years from 42.4% to 17.8%,22 rates of smoking cessation among blacks remain consistently lower compared with whites.23 The combination of negative health effects associated with smoking and its role in increasing the risk for RA in some individuals provides a compelling case for continued smoking cessation efforts.3,24
Smoking cessation is one of the most important modiﬁable lifestyle factors that can improve outcomes for those with RA. It has been shown that the risk for anti-CCP antibody-positive RA was reduced with smoking cessation,12 and therefore, counseling against smoking should be mandatory in all rheumatology practices.
Smoking cessation interventions have traditionally been designed for smokers without long-term illness. Interventions for those with speciﬁc long-term diseases such as CVD diabetes mellitus, and chronic obstructive pulmonary disease have received surprisingly little attention, and to date no RA-speciﬁc smoking cessation interventions have been published.3,25 This is reflected in the results of an international study involving 395 rheumatologists from 25 countries, which reported that advice for smoking cessation within rheumatology departments is inconsistent, and a specific protocol for smoking cessation is not consistently available. In fact, only 1 in 5 rheumatology departments had either a specific protocol or written advice for smoking cessation.26
Furthermore, disease-related issues may hinder smoking cessation efforts among those with RA. Five key barriers to smoking cessation have been identified: lack of awareness about the relationship between smoking and RA, smoking as a distraction from the pain of RA, difﬁculty exercising as an alternative distraction, smoking as a coping mechanism for RA, and lack of support in smoking cessation efforts.3,27
These findings highlight the need to improve patient awareness of the impact of smoking on RA and the importance of developing and implementing smoking cessation protocols in rheumatology practices. Providing education to patients and clearly demonstrating the link between RA and smoking may translate to decreased smoking among those with RA.28
Summary and Clinical Applicability
Smoking is a preventable modifiable risk factor for morbidity and mortality associated with RA, and therefore counseling and support for smoking cessation should be mandatory in rheumatology practices. Rheumatologists however lack specific guidance on strategies for smoking cessation, and patients face barriers, including lack of knowledge about the link between smoking and RA, which often translate to lack of motivation to stop smoking.
Strategies for rheumatologists that include guidelines tailored speciﬁcally for those with RA who smoke and that facilitate patient education, exercise, pain management, coping strategies, and support may increase smoking cessation efforts among smokers with RA.
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