Smoking and rheumatoid arthritis

Dr Helen Harris investigated the awareness of a link between smoking and rheumatoid arthritis.

Rheumatoid arthritis: smoking has been shown to increase the risk of developing the condition (Photograph: SPL)
Rheumatoid arthritis: smoking has been shown to increase the risk of developing the condition (Photograph: SPL)

We are all familiar with the association between smoking and heart disease and lung cancer. However, the impact smoking has on the development of rheumatoid arthritis (RA) is less well known.

RA affects approximately 50,000 people in Scotland1 and data from the Fife Rheumatic Diseases Unit (FRDU) suggest that there are around 2,000 cases of RA in Fife alone.2

Worryingly, it is estimated that one million adults in Scotland3 and nearly one quarter of the population in Fife are smokers.4

What is the link between smoking and RA?
Cigarette smoking can cause citrullination (a post-translation modification of the amino acid arginine) of proteins in the body which results in the production of anticyclic citrullinated protein antibodies that are strongly associated with the development of RA.

Smoking more than 20 cigarettes a day for 20 years (20 pack-years) has been demonstrated to double the chances of developing RA.5

In addition, smoking can have a negative impact on the effect of RA treatments including anti-TNF agents and DMARDs.6-8 Consequently, patients with RA who smoke may find that certain medications do not have the benefits they may provide to a non-smoker.

Gauging awareness
A survey was developed and distributed by the National Rheumatoid Arthritis Society (NRAS) to a selection of patients.

Almost half of the respondents stated that they knew nothing about the link between RA and smoking and only a quarter indicated that they suspected their smoking was worsening their RA symptoms.

Before the launch of an awareness campaign, a survey of the attitudes and beliefs about cigarette smoking of 320 Fife seropositive RA patients was undertaken.

The results of the Fife RA smoking survey showed:

  • -Only 5% of respondents were aware of a link between RA and smoking and 4% knew that smoking could interfere with treatment of RA.
  • 32% of Fife RA patients had never smoked, 48% were ex-smokers and 20% were current smokers.
  • 55% of Fife RA ex-smokers stated that a major illness had been the motivation to quit smoking.
  • When giving up only 5% had used counselling sessions and 2.5% had used a smoking cessation group.
  • The majority of RA ex-smokers (65%) had used pharmacotherapy and had quit on their first attempt.
  • Of the current RA smokers, 57% were smoking more than 10 cigarettes per day.
  • 53% of current RA smokers were considering stopping.
  • RA smokers stated that some things they enjoyed about smoking were stress relief (32%), pleasure (22%) and habit (19%).
  • When asked what would help them stop, RA smokers stated medication (20%), a health scare (14%), less stress (13%), one-to-one support (13%) or partner giving up (13%).
  • RA smokers said that the most difficult things about giving up were craving cigarettes (80%), being tense or irritable (75%), losing the pleasure (60%) and gaining weight (55%).


Smoking more than 20 cigarettes a day for 20 years (20 pack-years) has been demonstrated to double the chances of developing RA

Conclusions of the survey

  • More than half of RA smokers are thinking about quitting.
  • The majority of RA ex-smokers used pharmacotherapy and quit after one attempt.
  • Both current and ex-smokers pointed to 'a health scare' as motivation to quit.
  • There is a 'golden moment' for doctors and other healthcare workers to give advice on smoking cessation at the time of RA diagnosis.
  • In order to use opportunities to advise on smoking cessation, doctors and other healthcare workers should be familiar with pharmacotherapy and smoking cessation advice, and should refer patients to local smoking cessation services.
  • Smoking interferes with RA treatment, so smoking cessation advice should be part of the treatment plan for all RA patients who smoke.

In September 2011, a disease awareness campaign was launched in Fife to raise awareness of the risks of smoking to the general public and among patients with RA.

The campaign aimed to educate RA patients and the public on the links between RA and smoking and how it may reduce the effectiveness of some RA treatments such as anti-TNF agents and DMARDs.1-3

Materials approved by NRAS volunteers were used to prepare the campaign posters, leaflets and flyers. In addition, all FRDU RA patients were posted a flyer summarising the campaign.

The smoking status of all patients attending the rheumatology department is ascertained. Members of the FRDU multidisciplinary team are currently being trained in delivering brief smoking cessation intervention.

We plan to deliver brief smoking cessation intervention to all smokers with the option to 'opt out' rather than 'opt in'. Smoking cessation advice is now part of the treatment plan for patients with seropositive RA in Fife.

  • Dr Harris is a consultant rheumatologist, NHS Fife.
  • The survey and awareness campaign were carried out in collaboration with the NRAS and Pfizer.

References
1. National Rheumatoid Arthritis Society (NRAS). Response to Better Health, Better Care. A Discussion Document. www.scotland.gov.uk/Resource/Doc/211243/0056281.pdf

2. Data from Fife Rheumatic Diseases Unit.

3. ASH Scotland. Quick Facts for the Media. www.ashscotland.org.uk/media

4. NHS Health Scotland, ISD Scotland and ASH Scotland 2007. An Atlas of Tobacco Smoking in Scotland. Edinburgh: NHS Health Scotland.

5. Sugiyama D, Nishmura 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: 70-81.

6. Westhoff G, Rau R, Zink A et al. Rheumatoid arthritis patients who smoke have a higher need for DMARDs and feel worse, but they do not have more joint damage than non-smokers of the same serological group. Rheumatology 2008; 47: 849-54.

7. 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: 26-36.

8. Abhishek A, Butt S, Gadsby K et al. Anti-TNF-(alpha) agents are less effective for the treatment of rheumatoid arthritis in current smokers. J Clin Rheum 2010; 16: 15-18.

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