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Smoking and RA

by Wendy McBrair, BSN, MS, CHES

It wasn’t long ago that smoking was considered sophisticated, a helpful source of energy, and good for weight control. Movies made in the 1940’s through the 1960’s habitually featured at least one character smoking and enjoying it. Kids smoked behind closed doors or in cars thinking it was “cool.” Parents smoked without worrying about secondhand smoke or whether they were being poor role models for their children. And smokers with rheumatoid arthritis (RA) likely never gave a thought to whether there was a connection between their condition and their habit.

We are all a lot wiser now. We know what smoking tobacco, and even being exposed to secondhand smoke, can do to our health. It is well established that smoking contributes to problems with the heart, blood vessels, and lungs and also raises the risk for some cancers, osteoporosis, and blindness. Furthermore — although this is not so widely known — smoking is now considered a risk factor for developing RA.

Because smoking’s role is not well known, people tend to focus on other risk factors for RA, such as having a close family member with the condition or being a woman (women are twice as likely as men to develop RA). But these are facts we can’t change. Being a smoker is something we can change. And quitting smoking offers a proven way to reduce the risk of developing RA and might also help reduce the impact of RA that has already developed. This article looks first at the evidence for a connection between RA and smoking, and then describes steps you can take to help yourself quit.

What do the studies reveal?

Multiple studies have come to the same conclusion: people who smoke are more likely to get RA, and their RA is more likely to be severe.

In a study published in 2005 in Clinical and Experimental Rheumatology, 287 people newly diagnosed with RA were followed for 10 years. The study found that those who smoked were diagnosed with RA at an earlier age, had more joints affected by RA, and had more active RA. They also had more joint damage as seen on x-rays than nonsmokers. The study concluded that people with RA who smoke are at higher risk for more active and severe RA. Other, more recent studies have come to similar conclusions. One study found that smokers with RA tend to use more disease-modifying antirheumatic drugs (DMARDs) and biologic drugs. According to the study’s authors, this might mean that smoking reduces the potency of these drugs, that the smokers’ RA is more active, or both.

Why does smoking increase RA risk? Research suggests that there is a genetic connection. In a Swedish study published in the October 2004 issue of Arthritis & Rheumatism, researchers tested the DNA of 858 people newly diagnosed with RA and 1,048 people who did not have RA. The participants included both smokers and people who had never smoked (never-smokers). The study focused on a gene linked to RA called the shared epitope (SE) HLA-DR gene. The researchers found that smokers who had two copies of the SE HLA-DR gene were 15.7 times more likely than never-smokers without the gene to have RA. Smokers with one copy of the gene were 7.5 times more likely to have RA. Never-smokers with the gene were only 2.8 times more likely to have RA. Smoking, according to this study, seemed to trigger a preexisting genetic disposition to RA.

Recently, researchers have begun looking into whether quitting smoking can reduce RA symptoms in people who already have RA. A study presented at the 2008 American College of Rheumatology Annual Scientific Meeting found that stopping smoking could help control the symptoms of RA. In the study, researchers at three major medical centers in New York State evaluated 14,847 people with RA. Of the 1,405 who were smokers when they entered the study, 21.1% were able to quit. At the end of the study, those who had stopped smoking had fewer swollen and tender joint counts and lower blood levels of C-reactive protein (a protein that is associated with inflammation) than those who continued smoking. However, there was no difference between the two groups in other measures, such as DMARD and biologic use. The evidence from the study is preliminary, but it suggests that quitting smoking may have a positive effect on RA symptoms.

Getting ready to quit

No matter what the state of your health, quitting smoking will help improve it. But even when you’re armed with this knowledge, stopping is far from easy. The good news is that there are proven methods to help you quit.

As with any major behavior change, quitting smoking requires that you first understand completely what needs to be changed. Smoking cigarettes is not only a habit; it can also be an addiction. Because they contain nicotine, cigarettes can be as addictive as cocaine and heroin. Nicotine enters the body through the lungs as smoke is inhaled, travels quickly through the bloodstream to most body parts, and there causes both a physical and mental dependence. Nicotine stays in your body for at least three to four days after your last smoke. Because it invades so much of your body and takes such a strong hold, stopping smoking often requires more than just a strong will.

When you start thinking about quitting, there’s no need to jump right in. Review the strategies described later in the article, such as using medicines and/or nicotine replacement and setting up a support team or program. Consider yourself, your likes and dislikes, and which strategies you would feel most comfortable with. Think about why you want to stop smoking. Your goal is to improve your health, of course, but you should take time to think about the barriers that might get in your way. You might be afraid you’ll gain weight or have less energy, or you might be worried about your reactions to stress or the effects that not smoking will have on your mood. These barriers to change need to be addressed and planned for as well. When you are ready, it will be time to take the next step.

Making a plan

Although a few people can quit by going “cold turkey,” most of us need help. Start with a written plan that includes a contract with yourself or someone else. This is an effective way to help you follow through. Your plan should include a “stop day” and a list of the strategies you think will help you quit. You should also plan to address symptoms of nicotine withdrawal.

Identifying a “stop day.” Choosing the day on which you stop smoking is important. Planning for that day puts the whole process in your control. It should be a day that isn’t filled with stress but is instead filled with fun and camaraderie with nonsmokers. Perhaps a workday is good for you, when you are very busy. Or perhaps you will want to take a relaxing walk on your stop day, go out to dinner at a smoke-free restaurant, or visit with the grandchildren. Make sure the activities you do on your stop day are not associated with smoking, and avoid any place you associate with smoking. The American Cancer Society (ACS) sponsors the Great American Smokeout day every year, usually on the third Thursday in November. You may find it helpful to quit on a day when you know thousands of others are quitting too. (Go to the ACS Web site to learn more about this day and find quitting resources.)

As the stop day draws near, make sure you throw away all your cigarettes and ashtrays. Stock up on oral substitutes such as coffee stirrers, sugarless gum, straws, or toothpicks. Drink lots of fluids and juice. And avoid negative self-talk such as “I just can’t do this so I’ll start next week” or “My father lived to 80 and he smoked.” Mark the date on the calendar and be prepared to stop on that day.

Gathering your support team. Before you quit, you may find it useful to enlist others to help you along the way. Clearly your physician should be part of your team. He or she can advise you on options such as nicotine replacement, medicines, and support programs in your area. In addition to your physician, a support team might also include phone, individual, or group counseling. The ACS Quitline, ACS Quit For Life, Nicotine Anonymous groups, or a local Stop Smoking Program near you can help provide this counseling. (Go to www.cancer.org or call 800-227-2345 for more information on counseling.) Make sure you investigate each option to see whether you think it will work for you. And don’t forget that your support team includes your family and friends. If family members smoke or you visit with people who smoke, your chances for success are lower. Surround yourself with people determined to help rather than undermine your efforts.

Nicotine replacement options. Nicotine replacement helps to reduce uncomfortable withdrawal symptoms and is usually used by people who smoke more than 10 cigarettes a day. Nicotine replacement comes in many forms, including patches, gum, nasal spray, inhalers, and lozenges. Some of the forms are prescription, some over-the-counter. There’s research suggesting that using the patch, which is long-acting, in combination with short-acting products might work better than a single product, but this hasn’t been proved, and it’s not clear what doses are safe and effective. Don’t use more than one product without talking to your doctor. Most replacement products are meant to be used for a limited time, from several weeks up to five months. Again, working with your doctor can help you choose the right replacement, take it properly, and decide when to taper down and finally stop.

Medicines. Doctors may also prescribe medicines that can help you stop smoking. These include bupropion (Zyban), varenicline (Chantix), nortriptyline (Aventyl, Pamelor), and clonidine (Catapres). Zyban is an antidepressant approved by the FDA to reduce nicotine withdrawal symptoms. It can be used with nicotine replacement and is best started one to two weeks before the predetermined stop day. Chantix is also FDA-approved to help with nicotine withdrawal as well as reduce the pleasurable feelings of nicotine. Some doctors prescribe the antidepressant nortriptyline or the blood-pressure-lowering medicine clonidine to help people trying to quit. Although these drugs are approved by the FDA for some uses, they are not approved for this use. Make sure you review all of your medicine options with your physician.

According to the ACS, only 4% to 7% of people who stop smoking without medicine will succeed on any given attempt. When medicine is used, success rates for stopping for six months or more are estimated to be between 25% and 33%. Adding support or other behavioral therapies further increases the success rate.

Self-care techniques

Taking care of yourself while you stop smoking is also essential. This is especially important when you are dealing with the effects of nicotine withdrawal. You should be careful that nicotine withdrawal symptoms do not promote a return to smoking. When you first quit smoking you can expect to experience irritability, headaches, fatigue, increased appetite, sleep disturbance, anxiety, depression, and even dizziness. Though most symptoms last for only two or three days, some may last for several weeks. Exercise, stress management, and healthy nutrition can all help you deal with these symptoms. Review your health concerns and plans for new health behaviors with your doctor. The doctor and possibly a physical therapist can help you develop an exercise program suitable for someone with RA. You might also want to see a counselor to learn stress-management techniques that can take the place of cigarette smoking. Or you might want to see a nutritionist to see how you can improve your daily diet and thwart the weight gain that sometimes occurs when people quit smoking.

The next challenge

Once you have stopped smoking, the next challenge is staying away from cigarettes permanently. This is the maintenance stage. The first few months after quitting are usually the toughest because that is when withdrawal symptoms are at their strongest. As you experience withdrawal symptoms, it is important to review the benefits of not smoking and congratulate yourself on doing a good job so far. This is called positive self-talk. If you are prepared when strong cravings come, you will be better able to resist them. These cravings become less pronounced the longer you are smoke-free, but they can still occur long after you have quit.

What happens if you do have a cigarette? The key is to act quickly to make sure your one-time “slip” does not become a full-blown relapse into old habits. Slips can be corrected if caught early. However, because a slip can so easily become a relapse, it's best to avoid them altogether. If you do go back to smoking, remind yourself that repeated attempts at quitting are often necessary. Don’t get discouraged, don’t give up, and always be ready to try again.

Last Reviewed on May 30, 2012

Wendy McBrair spent 30 years as a health-care professional in the fields of rheumatology and orthopedics, where she specialized in patient and community service, patient education, and advocacy.

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