Winter 2014 (Volume 24, Number 4)

Top Ten Things Rheumatologists Should (And Might Not) Know About Smoking Cessation

By Adam Ramzy, BHSc;
and Milan Khara, MBChB, CCFP, ABAM

Download PDF

Since researchers first identified smoking as a risk factor for lung cancer and heart disease in 1950,1 there has been a consistently growing body of research outlining the incredible risks associated with smoking cigarettes. In more recent years, a convincing body of research and many large trials and registries (including BARFOT, DANBIO, DESIR, HUNT, NINJA, and SWEFOT), have found relationships between smoking and rheumatologic diseases. We present a basic introduction into the specific rheumatologic risks of smoking and the evidence-based treatment options to help patients become smoke free.

1. Risk Factor

Smoking is the most conclusively proven environmental risk factor for rheumatoid arthritis (RA) and increases risk twofold.2,3 Smoking may also double risk for ankylosing spondylitis (AS)4-6 and evidence is growing to suggest that smoking is linked to the development of systemic lupus erythematous (SLE)7,8 and psoriasis.9,10

2. Patient Outcomes

Smoking has been linked to increased severity and worsened trajectory of RA, SLE, psoriatic arthritis (PsA), and AS.4-6,11-15

3. Treatment Failure

Smoking is the most conclusively proven environmental risk factor for rheumatoid arthritis (RA) and increases risk twofold.2,3 Smoking may also double risk for ankylosing spondylitis (AS)4-6 and evidence is growing to suggest that smoking is linked to the development of systemic lupus erythematous (SLE)7,8 and psoriasis.9,10

4. Addiction

Tobacco dependence is a bona fide addictive disorder, best viewed as a chronic disease; treatment frequently entails repeated interventions, multiple relapses, and multiple quit attempts. Each year 40% of smokers make at least a single quit attempt and many long-term smokers have made more than 20 failed quit attempts.17

5. Obligation

A Canadian clinical practical guideline by the Canadian Action Network for the Advancement, Dissemination and Adoption of Practice-informed Tobacco Treatment (CAN-ADAPTT) states that it is a Grade 1A recommendation for physicians to identify, document, and treat the tobacco usage status of every patient in the healthcare setting.18

6. Counselling

Any intervention is worthwhile—even brief physician counselling sessions have been shown to be effective at helping patients achieve abstinence. Counselling in any form—individual, group, or telephone—has been shown to be effective at increasing rates of smoking cessation.We should focus on practical counselling and social support. Offering more than
30 minutes of counselling can triple rates of abstinence.19

7. Medications

Medication-based treatments for smoking cessation have been validated in a wide array of populations and can be used in isolation or in combination. The use of any nicotine replacement therapy (NRT; gum, patch, spray, inhaler, or lozenge) will approximately double rates of abstinence. Chances of success further increase when multiple types of NRT are used in combination (e.g., patch with gum or oral spray) or are used in combination with buproprion. The use of varenicline alone
(2 mg/day) triples abstinence rates.19

8. NRT and Smoking

Continuing to smoke while using NRT is not dangerous and does not increase risk of adverse cardiovascular events. Patients can begin NRT at any stage of readiness for change and consistently are twice as likely to achieve abstinence.20 The FDA has allowed label changes on NRT products to remove the statement that smoking while using NRT is contraindicated.21,22

9. Cost Effectiveness

Tobacco treatment programs are among the most cost-effective interventions available. Combining counselling and pharmacotherapy is the most effective intervention and may increase chances of a successful quit attempt five-fold.19

10. Moving Forward

You can help patients at any stage along the quit process, from those currently unwilling to quit, to those who have recently quit. There are many resources available to learn more about pharmacological options and the general principles of cessation counselling.19,23


1. Doll R, Hill AB. Smoking and carcinoma of the lung; preliminary report. Br Med J 1950; 2(4682):739-48.

2. Sugiyama D, Nishimura K, Tamaki K, et al. Impact of smoking as a risk factor for developing rheumatoid arthritis: A meta-analysis of observational studies. Ann Rheum Dis 2010; 69(1):70-81.

3. Di Giuseppe D, Discacciati A, Orsini N, Wolk A. Cigarette smoking and risk of rheumatoid arthritis: A dose-response meta-analysis. Arthritis Res Ther 2014; 16(2):R61.

4. Videm V, Cortes A, Thomas R, Brown MA. Current smoking is associated with incident ankylosing spondylitis - the HUNT population-based norwegian health study. J Rheumatol 2014; 41(10):2041-8.

5. Ciurea A, Finckh A. Smoking and spondyloarthritis. Joint Bone Spine 2013; 80(3):234-5.

6. Chung HY, Machado P, van der Heijde D, D'Agostino MA, Dougados M. Smokers in early axial spondyloarthritis have earlier disease onset, more disease activity, inflammation and damage, and poorer function and health-related quality of life: Results from the DESIR cohort. Ann Rheum Dis 2012; 71(6):809-16.

7. Freemer MM, King TE,Jr, Criswell LA. Association of smoking with dsDNA autoantibody production in systemic lupus erythematosus. Ann Rheum Dis 2006; 65(5):581-4.

8. Majka DS, Holers VM. Cigarette smoking and the risk of systemic lupus erythematosus and rheumatoid arthritis. Ann Rheum Dis 2006; 65(5):561-3.

9. Chandran V, Raychaudhuri SP. Geoepidemiology and environmental factors of psoriasis and psoriatic arthritis. J Autoimmun 2010; 34(3):J314-21.

10. Naldi L, Mercuri SR. Smoking and psoriasis: From epidemiology to pathomechanisms. J Invest Dermatol 2009; 129(12):2741-3.

11. Hojgaard P, Glintborg B, Hetland ML, et al. Association between tobacco smoking and response to tumour necrosis factor alpha inhibitor treatment in psoriatic arthritis: Results from the DANBIO registry. Ann Rheum Dis 2014. [epub ahead of print].

12. Kaan U, Ferda O. Evaluation of clinical activity and functional impairment in smokers with ankylosing spondylitis. Rheumatol Int 2005; 25(5):357-60.

13. Saevarsdottir S, Wedren S, Seddighzadeh M, et al. Patients with early rheumatoid arthritis who smoke are less likely to respond to treatment with methotrexate and tumor necrosis factor inhibitors: Observations from the epidemiological investigation of rheumatoid arthritis and the swedish rheumatology register cohorts. Arthritis Rheum 2011; 63(1):26-36.

14. Saevarsdottir S, Rezaei H, Geborek P, et al. Current smoking status is a strong predictor of radiographic progression in early rheumatoid arthritis: Results from the SWEFOT trial. Ann Rheum Dis 2014. [epub ahead of print].

15. Soderlin MK, Petersson IF, Bergman S, Svensson B, BARFOT study group. Smoking at onset of rheumatoid arthritis (RA) and its effect on disease activity and functional status: Experiences from BARFOT, a long-term observational study on early RA. Scand J Rheumatol 2011; 40(4):249-55.

16. Saeki Y, Matsui T, Kagawa K, et al. Smoking cessation significantly reduces failure of biologics (bio)-treatment in rheumatoid arthritis (RA): From the “NINJA” registry cohort of japanese patients (ABSTRACT SAT0074). Ann Rheum Dis 2014: 73.

17. Borland R, Partos TR, Yong HH, Cummings KM, Hyland A. How much unsuccessful quitting activity is going on among adult smokers? Data from the international tobacco control four country cohort survey. Addiction 2012; 107(3):673-82.

18. CAN-ADAPTT. Canadian smoking cessation clinical practical guideline. Toronto, Canada: Canadian Action Network for the Advancement, Dissemination and Adoption of Practice-informed Tobacco Treatment, Centre for Addiction and Mental Health. 2011.

19. Treating Tobacco Use and Dependence 2008 Update. U.S. Department of Health and Human Services, Public Health Service Report. 2008.

20. Stead, L.F., Perera, R., Bullen, C., Mant, D. & Lancaster, T. 2008, "Nicotine replacement therapy for smoking cessation", The Cochrane database of systematic reviews, vol. (1):CD000146. doi, no. 1, pp. CD000146.

21. Fucito LM, Bars MP, Forray A, et al. Addressing the evidence for FDA nicotine replacement therapy label changes: A policy statement of the association for the treatment of tobacco use and dependence and the society for research on nicotine and tobacco. Nicotine Tob Res 2014; 16(7):909-14.

22. U.S. Food and Drug Administration. Nicotine therapy replacement labels may change. FDA Consumer Health Information. 2013.

23. U.S Department of Health and Human Services. The Health Consequences of Smoking - 50 Years of Progress. A report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services. Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health. 2014.

Adam Ramzy, BHSc
UBC MD/PhD Student,
Laboratory of Dr. Timothy Kieffer
Diabetes Research Group,
University of British Columbia
Vancouver, British Columbia

Milan Khara, MBChB, CCFP, ABAM
Smoking Cessation Clinic
Vancouver General Hospital
Vancouver, British Columbia

Issue Skyscraper