PHILADELPHIA – Cigarette smoking leads to rheumatic disease and makes treatment less successful, according to research presented this week at the American College of Rheumatology Annual Scientific Meeting in Philadelphia, Pa.
Three recent studies show links between the development of rheumatoid arthritis, less successful treatment of rheumatoid arthritis and disease activity and damage in lupus – adding to the seemingly never-ending list of health risks related to cigarette smoking.
Two studies focused on the link between smoking and rheumatoid arthritis, which is a chronic disease that causes pain, stiffness, swelling, and limitation in the motion and function of multiple joints. Though joints are the principal body parts affected by RA, inflammation can develop in other organs as well. An estimated 1.3 million Americans have RA, and the disease typically affects women twice as often as men.
Previous studies have established that smoking is a risk factor for RA. Two independent research teams out of Sweden recently looked at the role smoking plays in the development of RA and in the response to treatment of the disease.
The first study focused on the development of RA involved 172 patients—primarily women with a mean age of 63 years old at the time of diagnosis—who were included in a community-based health survey that took place between 1991 and 1996. Participants of the self-administered survey provided information on lifestyle factors (such as smoking, diet and level of formal education) and provided blood samples.
Researchers found that those who were smoking at the time of the survey were at increased risk for RA when compared to those who were not. Anti-CCP antibodies, which are highly specific for RA, occurred years before disease onset, and were associated with former, but not current smoking. Even in the absence of those antibodies, smoking increased the risk of developing the disease. The researchers concluded that in addition to inducing the immune phenotype that predisposes to RA, smoking may also be involved in events that trigger the disease.
“The main strength of this study is the fact that smoking and other life style factors were measured before disease onset”, says Carl Turesson, associate professor, Malmö University Hospital, Malmö, Sweden, and lead investigator in the study. “Our data confirm that smoking is a risk factor for RA, and provide further insight on the impact of smoking on disease mechanisms.”
Another group of researchers focused on what happens when people with RA smoke while being treated for the disease.
Just as in the first study, this team of researchers pulled information from a Swedish population-based study. They looked at the information of 1,756 RA patients and noted whether each person had never smoked, smoked in his or her past or was a current smoker at diagnosis (and the total amount which is measured by how many years with one cigarette pack per day a person has smoked, called a pack-year).
They were specifically looking to see if a patient had no response to methotrexate or anti-TNF therapy—two common treatments for RA–and how that related to his or her smoking activity.
The researchers found that smoking was associated with non-response to both methotrexate and anti-TNF therapy at the three months follow-up visit, which is a common time-point for evaluating whether the treatment is effective. Forty percent of current smokers did not respond to methotrexate (as compared to 28 percent of those who had never smoked); there was no evidence that the total amount smoked impacted this. For those on anti-TNF therapy, 40 percent of current smokers did not respond (as compared to 25 percent of those who had never smoked). Unlike those taking methotrexate, the lack of response to anti-TNF therapy correlated to the total number of pack-years of cigarettes smoked. When reviewed as one to 15, 16 to 30, and over 30 pack-years, researchers noticed a 31, 40 and 43 percent lack of response, respectively.
“The findings indicate that RA patients who smoke have increased risk of not getting better on the standard first line treatment for RA, namely methotrexate,” explains Saedis Saevarsdottir, MD, PhD; rheumatology unit, Karolinska University Hospital, Stockholm, Sweden, and lead investigator in the study. “Moreover, those who needed the immunologically designed anti-TNF drugs, which are now the second-line treatment of choice for those who do not respond to methotrexate, also risked having poor effect of this expensive medication if they smoked. As this study includes RA patients from a large area in Sweden that are followed from the diagnosis in a quality register with respect to their medication and disease activity, it is likely to reflect the real-life setting.”
The third study looked at how smoking could be associated with more disease activity as well as organ damage in people with systemic lupus erythematosus. Disease activity is a measure of SLE symptoms, signs and laboratory evaluation for ongoing immunological response and injury; whereas disease damage reflects irreversible organ injury.
Systemic lupus erythematosus, also called SLE or lupus, is a chronic inflammatory disease that can affect the skin, joints, kidneys, lungs, nervous system, and/or other organs of the body. The most common symptoms include skin rashes and arthritis, often accompanied by fatigue and fever. Lupus occurs mostly in women, typically developing in individuals in their twenties and thirties – prime child-bearing age.
Researchers pulled information from a study on health-related quality of life in 216 patients with lupus who had been seen in the rheumatology clinic of a U.S. hospital between September 2006 and April 2008. These patients were predominately African American females in their early 40s.
Fifteen percent of the patients were smoking at the time of the study. Researchers noted that smokers had greater lupus disease activity and damage than non-smokers. Specific differences seen in diseases activity included a greater number of patients with swelling and pain in more than two joints, and lower complements—a marker of ongoing immunological response—among smokers. Smokers also had greater numbers of patients with irreversible skin related changes from lupus. These results led researchers to conclude that smokers do have higher disease activity and damage to organs.
“We are strongly encouraging physicians to actively enquire about smoking history, especially in patients with lupus, since smoking is strongly associated with how active or inactive their lupus is and development of irreversible skin damage,” explains Ravikumar Patel, MBBS; researcher, department of medicine, section of rheumatology at Rush University Medical Center in Chicago, and lead author in the study. “Besides the well-known adverse effects of smoking, we are presenting additional reasons for lupus patients to actively consider quitting smoking."
These three studies reconfirm or add to the growing number of health risks associated with cigarette smoking.
The ACR is an organization of and for physicians, health professionals, and scientists that advances rheumatology through programs of education, research, advocacy and practice support that foster excellence in the care of people with or at risk for arthritis and rheumatic and musculoskeletal diseases. For more information on the ACR’s annual meeting, see www.rheumatology.org/annual.
http://www.rheumatology.org/press/2009/2009_am_21.asp
And now, the end is near;
And so I face the final curtain.
My friend, I’ll say it clear,
I’ll state my case, of which I’m certain.
I’ve lived a life that’s full.
I’ve traveled each and every highway;
And more, much more than this,
I did it my way.
Regrets, I’ve had a few;
But then again, too few to mention.
I did what I had to do
And saw it through without exemption.