Smoking and Rheumatoid Arthritis: 6 Things You Need to Know

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cigarette smokeSix take-aways in a short list below! But, first some surprising evidence.

Even light smoking contributes to Rheumatoid Arthritis risk

A recent Swedish study of 34,101 women reported “even light cigarette smoking is associated with increased risk of RA in women and that smoking cessation may reduce, though not remove, this risk.”[1] Although they found the risk of developing Rheumatoid Arthritis (RA) decreased over time after smoking cessation, the risk remained significantly higher than for “never smokers.”

How is Rheumatoid Arthritis diagnosis related to smoking?

Smoking has been shown to trigger immunity to citrullinated proteins, a key process in Rheumatoid Disease. For decades, smoking has been considered one risk factor that a person can influence. “The connection of smoking, anti-citrullinated antibodies and RA is unambiguously proven by several studies and reports. Consequently, it is essential to inform patients about the hazardous role of smoking in the development and progression of RA,”[2] Rheumatoid arthritis and smoking: putting the pieces together. Although I’ve seen a lot of dumb articles telling people how to decrease their risk of being diagnosed with RA, it appears that not smoking, and likely quitting smoking, is the only known risk factor people can control.

Genetic differences play a role

A study specifically in Americans of African ancestry showed that smoking risk affected both autoantibody-positive disease (Rheumatoid factor or anti-CCP positive) and autoantibody-negative disease[3] although most previous studies have linked smoking to being seropositive. The study, Associations of Cigarette Smoking with Rheumatoid Arthritis in African Americans, contradicted the Swedish results: they found the risk of RA attributable to smoking is limited to heavy smokers. The African American study did agree with previous studies that people with genetic risk (HLA–DRB1 positive) are more susceptible to RA risk from smoking.

Does smoking make RA more severe?

It is often said that RA patient-smokers suffer more severe disease and are less responsive to treatment, maybe because they are considered more likely to be seropositive. But, in the large QUEST-RA database (7307 PRD), smokers and non-smokers had similar clinical status. They reported in 2010: “RA patients who had ever smoked were more likely to have RF and nodules, but values for other clinical status measures were similar in all smoking categories (never smoked, current smokers and former smokers).”[4]

How many people with Rheumatoid Disease (PRD) smoke / have smoked?

Coincidentally, when the Swedish RA-smoking study was published, I was reading an article about cardiovascular disease in Rheumatoid and Lupus patients. Smoking, a common risk factor for cardiovascular disease, was discussed: “The frequency of patients with RA or SLE who smoke appears to be comparable with that in the general population.”[5]

The same number of PRD smoke as in the general population? I was surprised. So I dug a little deeper.

About one percent of the population worldwide is affected by RD, and according to the CDC, 19% of Americans smoke. The percentage is lower in people of Hispanic origin and much higher in Native American populations.[6] It varies quite a bit by geographic region and level of education.

But the Rheumatoid Disease process begins long before diagnosis, and past smoking is likely to matter as well as current smoking, as the new Swedish study seems to confirm. So, I explored EVER-smoking rates. In the U.S., 42.5% of people have EVER smoked, according to the CDC. [7] How does that compare with PRD populations?

EVER-smoking rates (the percentage who have ever smoked tobacco)

  • 42.5% – Total US population of 315 million
  • 46% – Swedish RA study of 34,000
  • 35% – QUEST-RA data of 7,300
  • 52% – African-American RA study of 605

SIX take-aways for people living with Rheumatoid Disease (PRD)

1) Tobacco smoking is a known trigger to complicated immune processes involved in RD.

2) Even light smoking can increase risk of Rheumatoid Disease.

3) Smoking cessation at any point may improve the health of PRD, but it is not guaranteed to improve clinical status.

4) More research is needed regarding other potential triggers. There is very little evidence of things people can do to avoid RD. Not smoking is the only behavioral advice that can be given.

5) Genetic factors significantly affect risk of RA, and may interact with environmental risks such as smoking. This complicates the interpretation of smoking impact.

6) Serous systemic effects of RD should not be broadly blamed on smoking status since significant percentages of NEVER-smoking PRD are seropositive and suffer from lung or cardiovascular (or other) disease as a result of RD.


PRD receive too much blame for how sick they are, and smoking is a sensitive topic. I have read articles that make the assumption that the lung or heart disease related to Rheumatoid Disease might not attributable to the disease, but is a result of behavior of patients such as smoking, inability to perform regular aerobic exercise, medication use, and improper diet. Such implications are inappropriate; RAW has previously discussed various evidence that the cardiovascular disease of RA is not the same as other CVD, and that traditional approaches to heart disease are not altogether adequate for the CVD of RD.

Image attributed to Robert Aleck,, used under Creative Commons.

Recommended reading

[1] Di Giuseppe D, Orsini N, Alfredsson L, Askling J, Wolk A. Cigarette smoking and smoking cessation in relation to risk of rheumatoid arthritis in women. Arthritis Res Ther [Internet]. 2013 [cited 2013 Jun 24];15:R56. Available from:

[2] Baka Z, Buzás E, Nagy G. Rheumatoid arthritis and smoking: putting the pieces together. Arthritis Res Ther [Internet]. 2009 Aug 3[cited Jun 22];11(4):238. Available from:

[3] Mikuls TR, Sayles H, Yu F, LeVan T, Gould KA, Thiele GM, Conn DL, Jonas BL, Callahan LF, Smith E, et al. Associations of cigarette smoking with rheumatoid arthritis in African Americans. Arthritis Rheum [Internet]. 2010 Dec [cited 2013 Jun 22];62(12):3560–3568 Available from:

[4] Naranjo A, Toloza S, Guimaraes da Silveira I, Lazovskis J, Hetland ML, Hamoud H, Peets T, Mäkinen H, Gossec L, Herborn G, et al. Smokers and non smokers with rheumatoid arthritis have similar clinical status: data from the multinational QUEST-RA database [abstract]. Clin Exp Rheumatol [Internet]. 2010 Nov-Dec [cited 2013 Jun 24];28(6):820-7. Available from:

[5] Hall FC and Dalbeth N. Disease modification and cardiovascular risk reduction: two sides of the same coin? (Oxford) Rheumatology [Internet]. 2005 Dec [cited 2013 Jun 24];44(12):1473-1482. Available from:

[6] Centers for Disease Control and Prevention. Adult Cigarette Smoking in the United States: Current Estimate. 2013 Jun 3 [cited 2013 Jun 24]. Available from:

[7] Wikipedia contributors. Prevalence of tobacco consumption [Internet]. Wikipedia, The Free Encyclopedia; 2013 May 29 [cited 2013 Jun 24]. Available from:

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Kelly Young. All rights reserved.

This entry was posted on Monday, June 24th, 2013 at 2:45 pm and is filed under RA Research, Resources, and Rheumatology. You can follow any responses to this entry through the RSS 2.0 feed. You can leave a response, or trackback from your own site.


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