Rheumatology
Rheumatoid Arthritis
Prioritizing Smoking Cessation During the Early Rheumatoid Arthritis Period
Overview
Clinical Study Title: Smoking Behavior Changes in the Early Rheumatoid Arthritis Period and Risk of Mortality During Thirty-Six Years of Prospective Followup
Clinical Study Abstract:
OBJECTIVE: To investigate whether rheumatoid arthritis (RA) diagnosis influences smoking behavior changes and whether these changes were associated with mortality.
METHODS: We identified an incident RA cohort in the Nurses’ Health Study (NHS; 1976-2012). Behavioral data were collected through biennial questionnaires. We created a comparison cohort, matching RA cases to women without RA by age and calendar year at the index date of RA diagnosis. To investigate smoking behavior changes in the early RA period, sustained cessation was defined as permanently quitting within 4 years of the RA/index date. We used Cox regression to obtain hazard ratios (HRs) for mortality, comparing sustained smoking cessation to continued smoking.
RESULTS: Among 121,700 women in the NHS, we identified 938 with incident RA matched to 8,951 non-RA comparators. Among current smokers, 40.0% with RA permanently quit smoking in the early RA period, compared to 36.1% of comparators (odds ratio for sustained cessation 1.18 [95% confidence interval (95% CI) 0.88, 1.58]). There were 313 deaths (33.4%) in the RA cohort and 2,042 (22.8%) among comparators. Compared to continued smoking, sustained cessation was associated with similarly decreased mortality in both the RA (HR 0.58 [95% CI 0.33, 1.01]) and comparison (HR 0.47 [95% CI 0.39, 0.58]) cohorts. Women with RA had higher mortality for >5 post-RA pack-years (HR 3.67 [95% CI 2.80, 4.81]) than comparators with >5 post-index pack-years (HR 1.88 [95% CI 1.62, 2.17]; P < 0.001 for interaction; reference: ever-smoker non-RA women with 0 post-index pack-years).
CONCLUSION: Sustained smoking cessation within 4 years of RA diagnosis reduced mortality risk, with a similar effect observed among non-RA comparators. Smoking >5 pack-years after RA diagnosis significantly increased mortality beyond the risk of non-RA comparators.
Reference: Sparks JA, Chang SC, Nguyen UDT, et al. Smoking behavior changes in the early rheumatoid arthritis period and risk of mortality during thirty-six years of prospective followup. Arthritis Care Res (Hoboken). 2018;70(1):19-29.
Expert Commentary
Leonard H. Calabrese, DO
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“Copious data support smoking cessation efforts by patients with RA, including those data showing reduced mortality.”
Sparks and colleagues recently reported long-term data from the Nurses’ Health Study, which was well equipped to analyze smoking behaviors before and after RA diagnosis. Repeated measures of smoking had been collected throughout the 36 years of prospective follow-up, and women who developed RA were compared with those who did not. Copious data support smoking cessation efforts by patients with RA, including those data showing reduced mortality.
Smoking cessation may prevent a large proportion of deaths, particularly among those with RA. Patients may be interested to learn that, in the analysis by Sparks and colleagues, permanent smoking cessation in the early RA period resulted in a 42% to 53% reduced mortality among women, compared with sustained smoking. Further, smoking >5 pack-years following RA diagnosis significantly increased mortality (by nearly 3-fold) beyond the risk of non-RA comparators.
Smoking is also associated with worse RA severity and outcomes, including the development of erosions and nodules, higher disease activity, and extraarticular manifestations such as interstitial lung disease. In consideration of RA-associated lung disease, one cannot ignore the role of smoking. While a patient can develop interstitial lung disease independently of smoking, smokers with RA have much more inflammation and significantly higher morbidity from multiple causes, especially from cardiovascular disease. What is more, England and colleagues reported data that link increased levels of circulating cytokines with mortality risk in a group of mostly male patients with RA who were heavy smokers, and it is likely that the mortality risk in RA from smoking exists, regardless of sex.
In conclusion, Sparks and colleagues found a modest, but not statistically significant, effect of RA diagnosis on sustained smoking cessation, which underscores the need for patient education and, perhaps, RA-specific smoking cessation programs.
References
England BR, Sokolove J, Robinson WH, et al. Associations of circulating cytokines and chemokines with cancer mortality in men with rheumatoid arthritis. Arthritis Rheumatol. 2016;68(10):23942402.
Joseph RM, Movahedi M, Dixon WG, Symmons DP. Smoking-related mortality in patients with early rheumatoid arthritis: a retrospective cohort study using the Clinical Practice Research Datalink. Arthritis Care Res (Hoboken). 2016;68(11):1598-1606.
Sparks JA, Chang SC, Nguyen UDT, et al. Smoking behavior changes in the early rheumatoid arthritis period and risk of mortality during thirty-six years of prospective followup. Arthritis Care Res (Hoboken). 2018;70(1):19-29.
