Smoking Behavior Changes in the Early Rheumatoid Arthritis Period and Risk of Mortality During Thirty‐Six Years of Prospective Followup

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.

Weight Change During the Early Rheumatoid Arthritis Period and Risk of Subsequent Mortality in Women With Rheumatoid Arthritis and Matched Comparators

“…The increased mortality risk for patients with rheumatoid arthritis (RA) compared to the general population may be attributable to altered immunity, medication side effects, systemic effects of inflammation, worsened physical function, accumulation of multimorbidities, and excessive unhealthy behaviors such as smoking . The contribution of metabolic and inflammatory factors (such as obesity) to RA etiology and outcomes has received increased attention recently .…”

Predictors of Smoking Cessation in Patients With Rheumatoid Arthritis in Two Cohorts: Most Predictive Health Care Factors

“…Instead, we found that health care factors, such as being new to rheumatology care and the health system, were more predictive of smoking cessation. The observed increased likelihood of quitting in patients new to rheumatology care may partially be due to cessation following a new RA diagnosis, a phenomenon previously reported in RA and other chronic diseases (8–10,14,25). Despite their worse RA prognosis, seropositive patients were 43% less likely to quit smoking (26,27).…”

“…Patients with RA who continue smoking for at least 5 years after RA diagnosis are at even greater risk of death than smokers without RA and patients with RA who quit smoking (8). While patients are more likely to quit smoking after diagnosis of a smoking‐related chronic disease, research shows that most will continue to smoke (8–10). Further, most patients with RA are not aware of the associations between smoking and RA development and complications (11), although such knowledge could influence cessation attempts.

Despite recognition of smoking as a risk factor for poor rheumatoid arthritis (RA) outcomes, little is known about what predicts smoking cessation among patients with RA. We found that health system factors were more predictive of smoking cessation than patient sociodemographic factors, highlighting the value of implementing health system interventions for smoking cessation. Patients new to rheumatology care were 60% more likely to quit smoking, while seropositive patients were 43% less likely to quit smoking.

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“…Continuing to smoke after being diagnosed with RA contributes to RA severity (4), treatment failure (5,6), and higher medication dose requirements (7). Patients with RA who continue smoking for at least 5 years after RA diagnosis are at even greater risk of death than smokers without RA and patients with RA who quit smoking (8). While patients are more likely to quit smoking after diagnosis of a smoking-related chronic disease, research shows that most will continue to smoke (8)(9)(10).…”

“…Patients with RA who continue smoking for at least 5 years after RA diagnosis are at even greater risk of death than smokers without RA and patients with RA who quit smoking (8). While patients are more likely to quit smoking after diagnosis of a smoking-related chronic disease, research shows that most will continue to smoke (8)(9)(10). Further, most patients with RA are not aware of the associations between smoking and RA development and complications (11), although such knowledge could influence cessation attempts.…”