Smoking and Rheumatoid Arthritis: 6 Things You Need to Know | Rheumatoid Arthritis Warrior

Smoking and Rheumatoid Arthritis: 6 Things You Need to Know

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:

Kelly O'Neill

Kelly O'Neill (formerly Kelly Young) has worked about 12 years as an advocate helping patients to be better informed and have a greater voice in their healthcare. She is the author of the best-selling book Rheumatoid Arthritis Unmasked: 10 Dangers of Rheumatoid Disease. Kelly received national acknowledgement with the 2011 WebMD Health Hero award. She is the president of the Rheumatoid Patient Foundation. Through her writing and speaking, she builds a more accurate awareness of rheumatoid disease (RD) aka rheumatoid arthritis (RA) geared toward the public and medical community; creates ways to empower patients to advocate for improved diagnosis and treatment; and brings recognition and visibility to the RA patient journey. In addition to RA Warrior, she writes periodically for newsletters, magazines, and websites. There are over 60,000 connections of her highly interactive Facebook page. You can also connect with Kelly on Twitter or YouTube, or LinkedIn. She created the hashtag: #rheum. Kelly is a mother of five, longtime home-schooler, NASA enthusiast, and NFL fan. She has lived over fourteen years with unrelenting RD. See also https:/

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30 thoughts on “Smoking and Rheumatoid Arthritis: 6 Things You Need to Know

  • June 24, 2013 at 3:06 pm

    Does the same hold true for exposure to second-hand smoke?

    • June 24, 2013 at 6:28 pm

      Interesting question! I have never smoked, but my parents were heavy smokers when I was growing up. My latest rheumatologist (my old rheumatologist retired) thinks I may not have RA, in spite of three strongly positive anti-ccp tests (60-72). He thinks that heavy exposure to second hand smoke may have confounded the results.

      I’m not sure how strongly he believes that though, because he ordered a anti-ccp test from a different hospital’s lab. It also came back strongly positive at 69, so I’ll see what he says at my next appointment.

      • June 24, 2013 at 7:06 pm

        Hi Sandra,
        anti-CCP tests should be repeated if negative & you have definite reason to believe it should be positive – your doctor was right. We’ve seen errors with them in our hospital too, varying over 218 points within 2 weeks.
        Do you know why he’s repeating the test though? It usually stays positive and does not change with treatment.

        • June 24, 2013 at 8:27 pm

          I think the doctor was looking for “classic” RA, and I do not have that. My symptoms are non-specific: pain, weakness, and fatigue that gets better and worse, and muscle and joint pain that moves around my body.

          He’s right to be skeptical. Even with *4* positive anti-ccp tests in slightly more than two years, my rheumatoid factor has always been negative, and more than a dozen ESR and CRP tests were normal. My metacarpal and metatarsal joints are puffy and tender with nodules, but my joints are not visibly arthritic. My x-rays do not show erosions. DMARDS did not cause remission.

          I wear wrist, ankle, knee, and/or neck braces when my joints feel weak, tingly, or painful, and I worked with two physical therapists to learn stretches that I do to maintain range of motion. When I can, I do water yoga, tai-chi, and bicycle on a crank-forward bike. I am obese, but I “pay to play.” (Thanks for that, BTW!)

          The rheumatologist can see parotid gland enlargement, my repeated neck/face scans, and negative PET scan (except for the thyroid uptake because of Hashimoto’s but that’s another story), and two blood tests that were positive for SSA antibodies, so he agrees I have Sjogren’s. Ironically, my ANA results have always been negative.

          So, do positive anti-ccp tests mean I have RA with secondary Sjogren’s, primary Sjogren’s which may develop into RA, or are the anti-ccp tests only positive because of early exposure to second-hand smoke, as the doctor suggested?

          • June 25, 2013 at 8:38 am

            The symptoms & medication response you describe sound like a large percent of rheum dz. patients I’ve heard from. I’m not sure if it’s possible to know whether left alone this would eventually become more like what you called “classic RA,” or show itself to be another rheumatic disease. Diagnosis between these similar labels is almost always a judgement call.
            As far as the smoking and the anti-ccp testing – I’ll ask a dr friend about it, but I did not think that was a dichotomy. As far as I understood, a trigger (like smoking) or another illness/event can trigger the process of excess citrullination & antibodies to citrullinated proteins & that is part of the disease process. It does not progress at the same rate from there in each person, and does not express itself the same way. I do believe we will one day be able to divide what we now call RA into different categories, but I’m not sure whether that will be based on different genes or different “strains” of the disease. Here’s a post where the uniqueness is discussed:
            Anyway, good luck with finding the right treatment for you – that’s what matters!

  • June 24, 2013 at 6:35 pm

    This is interesting. I wonder how second hand smoke effects the disease? I was exposed to a lot of second hand smoke growing up.

  • June 24, 2013 at 6:53 pm

    I know this is obviously not fully fleshed yet, but I wonder about the effects of second hand smoke as well. For those that have not smoked, personally, but have been around it on a semi regular or regular basis.

    Always something new to think about. Thank you Kelly!


    • June 24, 2013 at 6:59 pm

      Yes, it seems to be something a lot of us wonder about Jennifer. That is a fairly muddy area – I have some ideas about how we can research it, but it’s not as precise to measure as asking packs/ day, so you can see why it would be difficult.

  • June 25, 2013 at 10:08 am

    Count my vote for wondering about secondhand smoke. My parents smoked when I was growing up, my first husband smoked like a chimney, and my present husband smokes (but he’s moved mostly to an e-cigarette). He had to stop smoking around me after a particularly vicious bout of bronchitis in 2001, when the doctor told him if he can’t quit, he had to quit smoking in the same room as I was. I personally have never smoked cigarettes.


  • June 25, 2013 at 11:02 am

    I have never smoked either, but like you, grew up in a smoking household. Considering the amount of and the nature of the chemicals in secondhand smoke, the corolation wouldn’t surprise me a bit. It’s not far-fetched to think they would impact the immune system so severely.

  • June 26, 2013 at 8:10 am

    I have to admit, these scientific studies usually make me dizzy. Thanks for sorting out the “science-speak.”

  • June 26, 2013 at 11:07 am

    I was a light smoker, 3-4 cigs a day for about 15 years. I quit in 1997. Started having symptoms of RD in 2006 and was diagnosed in 2009. I have the HLA gene risk and am anticcp and RF positive. I’ve always wondered if the smoking was part of the trigger, but I know high stress and multiple surgeries were also to blame, living on a highway for 9 years and working around garden chemicals possibly too. It seems I had all the environmental risks as well as genetic.

  • June 26, 2013 at 11:08 am

    I am a smoker and have been for 35+ years. My parents were smokers also. In fact most of my family (aunts, uncles, grandparents..) smoked. I also have a lot of family members that have RA. My RA is not as severe (yet) as I’ve read on here, or even as some of my family. Yes I believe that smoking does cause some health issues, but I don’t believe that had I never started smoking, or around so much secondhand smoke, that I would not have RA at this time. I think I was doomed to have RA because of my family history with it. My grandfather lived with severe RA for years and had quit smoking for 50 years before he passed away. Yes, I believe that smoking can cause flareups and such.. but to say that I have RA because I’ve smoked all these years, I disagree with.

  • June 26, 2013 at 1:50 pm

    There are documents from 1500 B.C. that describe a condition like Rheumatoid Arthritis. It was also found to be prevalent in Egyptian mummies upon examination. It is written about in Indian historical documents. It has a long history with varied success in treatment. Some of the treatments were Barbaric.
    I wonder if they smoked?

  • June 26, 2013 at 1:55 pm

    I too am a smoker, I have smoked on and off for 20 years, but stated to smoke more four years ago after my Mom died. I have done lots of my own research, and smoking is a real and serious factor in being the trigger for RD. I am so ashamed for smoking, because there is a real possibility this was my trigger, maybe one day we will know for sure. I was diagnosed with RD about two years ago,am on Humira, yet I have pain and fatigue most days. I have also learnt that smoking can diminish the good effects of RD medication, and that smoking can actually prevent the brain from signally the response to produce the bodies own natural antii-inflammory something or other, yet I still smoke. It is a terrible addiction and I am struggling to give up. I get fearful when the pain is really bad and then smoke more even though I feel confident that giving up would help me.

    • June 26, 2013 at 4:35 pm


      I am 60 years old. I’ve had severe RA for at least 25 of those years. I have smoked pretty regularly for 42. I was diagnosed in 1994 but joint symptoms had presented in the late 80’s. I’ve been on the dole since 1998 because I can’t do anything substantial for any length of time. I have been treated with a variety of medications.

      I understand the shame your talking about. It’s the reason I no longer have any medical providers. My relationships with them deteriorated because I couldn’t quit smoking and I couldn’t deal with their contempt anymore.

      I really hope for your sake that you can find it in your will to quit. It isn’t easy and I’ve never been able to do it but I can tell you from experience living like this isn’t much fun either.

      As for whether smoking is a trigger or not or whether it causes worse response to therapy or worse symptoms for you and I; it really doesn’t make much difference but quitting might help you so I encourage you to do it.

      • June 26, 2013 at 5:04 pm

        Tom thank you very much for your kind response. I too pray that my will, will change if that makes sense. The shame that I mat have brought this on myself and my family is hard to take. My stopping smoking can not reverse this ugly RD, which almost makes me defiant and smoke, but that is ridiculous behaviour. Thank you again

        • June 26, 2013 at 7:19 pm

          Your welcome and I hope your successful!

        • June 27, 2013 at 1:19 pm


          I refrained from saying anything about this earlier but I am going to go ahead anyway: perhaps at my peril.

          That shame that we’re feeling? That’s by design. It’s the desired effect of the campaign against tobacco users.

          I am a defiant smoker too. I avoid people when I smoke and that isolation is by design. The isolation I feel from providers of medical treatment is the same.

          The idea is for us to blame ourselves.

          A few months back I was going to post my whole story here but decided that it wouldn’t be appropriate because I am a smoker.

          The campaign is effective.

          The first study done in the United States attempting to show a link to smoking and disease was done in 1950.

          There were much earlier studies done in Germany. They were used as the basis moving forward in the campaign against tobacco companies, use and now users here.

          The study Kelly uses, I believe, is the Swedish study published in 2003 and extrapolated for data several times since.

          The first study I know of attempting to establish a link between smoking and RA was an English study published in 1987.

          While I think the questions presented here are valid and appear to be: If you could do something that could prevent the activation of RA would you? and Is there a link to smoking and RA and if there is would you do something about it? I am not sure that will be the end result. Look at how many of the responses here jump to the question of whether second smoke could be a cause of their RA?

          There was a smoking essay written in 2004 by Joe Jackson. He is from the UK. He lived in the U.S. at the time but is now living in Berlin. I don’t know if you know of the essay but he points out some interesting information and has done a lot of research. I encourage you to read it. It presents both sides of the issue.

          Not sure this will get posted but don’t know how else to get in touch.

          Take care

          • June 27, 2013 at 3:06 pm


            Just a brief correction about my sources: the Swedish study I quoted was published within the past month. That’s why I said in the post that it’s “recent” news.

            I’m sorry if this post offended you & I don’t know how long you’ve been reading so I want to make sure we are on the same page. In the past 4.5 years, I’ve written 800 articles on RA, and this is the first time I’ve ever written one about smoking, so I spent over 8 hours of research on it. (There are dozens of studies on this topic). Based on my work, it would not seem that this post is part of any “campaign.”

            The final paragraph on this page actually says it’s wrong to blame people, and anyone who reads regularly would know my position on respecting differences. One of the 6 summary points of this post is that more research is needed on other triggers.

            There are multiple likely triggers for rheumatoid disease, and the latest research shows it begins in the airways. It is not a matter of conjecture that smoking is one of the triggers for anti-bodies and excess citrullination – it’s been observed in the laboratory.

            Research showing the disease may begin in the lungs:

            And the mouth / periodontal disease:

            Other triggers we have discussed on this blog include medications (, and pollution, hair dye, insecticides, and microbes in the digestive tract.

            And, all non-spam comments are posted, although it’s not the case on many blogs, as I know by experience. I suppose that would be at the discretion of the site’s owner. The comment policy for this site is on the disclaimer page (link in footer).

  • June 27, 2013 at 4:33 pm


    I was not offended by your post and I was not referring to it as a campaign in and of itself. It was reasoned and informative as are the posts referenced in your reply.

    The campaign I was speaking of is the one that’s been going on in the general public for the past decade and ironically the one that we smokers pay for through taxation.

    I apologize if I offended you.

  • June 28, 2013 at 3:58 am

    I am not sure what to say here but will try. I was in no way whatsoever responding to the initial article because I thought this was just some anti -smoking campaign out to put blame on smokers. I love rA warrior and am deeply grateful for Kelly for giving so much, and for all the other people who share their stories. On the days I am in terrible pain I spend a lot of time reading and re-reading many posts and they bring me both comfort and joy.
    I appreciate Kelly posting the information on smoking, as I said before I have done my own research also about smoking and it confirms what I already know.

    My initial response was to acknowledge the report, and just to say I agree with the report and how crazy am I am to still be smoking.
    It is entirely my own shame and I know there are some people who really can not or struggle to give up, even knowing that smoking has many serious consequences.
    My Mom died ages 62,10 days after a lobectomy, on the third day after the surgery she told me she needed a cigarette. My Dad died on the 1st May this year, he had kidney cancer which spread to his lungs, he was still smoking. The horror for me is that you would think I would never have another cigarette.
    I personally take full accountability for my smoking, I have to stop.I feel the addiction is so complex and great that sometimes smokers become defensive.

    I do not think the others who responded, with regard to second hand smoke were in anyway climbing on the anti-smoking bandwagon, but were rightly questioning whether this could be a trigger. If I was not a smoker I would do the same. I think many people with RA do question a lot “why do I have this” as I do, and what I was trying to originally say was “I agree and I am sad that more than likely i could have triggered this myself by smoking, and even if I did not, that stopping smoking, could help reduce the inflammation.
    Tom, I am sorry you have been ostracised by the medical profession for continuing to smoke but I must point out that I wrote for the first time on this site, knowing that I would not be judged. I truly feel that there were no other responses to my post simply because there were no other smokers, and that my post did not apply to them.
    Tom thank you for your concern I wish you well. Kelly thank you for putting everything you find out there to help all of us.

  • July 4, 2013 at 3:27 am

    In my family there are four women diagnosed with RD (3), and one with lupus, lung involvement. The lupus woman has a mother, who smoked heavily with RD, she also smokes at times. But the most affected of us all, wheelchair bounded, never smoked and wasn’t around it much. My parents and most of my siblings did. too My 30year married ex remains a heavy smoker to this day. I did quit many years ago but, probably too little too late. But this is excellent news to tell my smoking adult children, who are constantly trying to quit. Maybe I finally have the information to turn them into quitters. Thank you Kelly.

  • August 23, 2013 at 3:18 pm

    I too was a smoker for about 8 years. Ironically, when I decided to quit -and I was doing pretty well for 3 months- that’s when RA hit me. Maybe it was the shock of the sudden withdrawal or RA was waiting for me around the corner, who knows. Of course I went back on it after the diagnosis… Was of course adviced to quit, which I did after about a year on prednisone (despite smoking I put on some weight, mostly fat, especially on my knees! which I am still trying to get rid of). Now I am smoke-free for a year and I don’t miss it. If you can’t quit cold turkey, you should try tapering it and eventually stop it completely.

  • September 22, 2013 at 10:59 pm

    well I smoked for a long time and I have RA. I since stopped and it is in remission. Don’t know if that had any bearing on it or it is just the medication combination.

  • April 4, 2014 at 2:18 am

    Hi Kelly. Yes, I was one of those people who smoked quite heavily leading up to my illness and then stopped when I got ill (several years ago).
    As foolish as I feel and as much as I wished I had NEVER smoked, there is nothing that I can do now but to manage where I am now.

    I encourage anyone out there PLEASE do not smoke and if you have RA and still smoke, please consider quitting.

    Much love and warmest wishes,

  • June 1, 2014 at 11:07 pm

    I would like to know how many people with RA also have hashimotoes or thyroid problems.

  • June 6, 2015 at 3:30 pm

    All I know is I was diagnosed at age 28 I’m now 52
    Pain is unbearable
    I’m on methotrexate and I take pain meds and every 2 months I have Remicaid infusions
    This pain is horrible but I have to work to pay my bills I woke up in pain my hands and hip
    I can’t take it no more pain is so bad I have RA and fibromyalgia Help

  • December 18, 2017 at 11:27 am

    I have RA. It got really bad after a car accident. Trouble getting out of chairs, constantly swollen hands, my RA factor went from 140 to 358 in one year based on my blood work . Thing is I also took up smoking again a year and a half ago. Have been hitting prednisone 10 mg twice a day and Tramadol in between just to kill the pain a little. Well I’ve quit smoking for two weeks now and I just had to say something, difference is unreal, I’m taking 10 mg once a day now, in nowhere near the pain and don’t need the pain meds at all. It’s not the nicotine , I still have that going in via patches, gum . But there is something else in those damn things that’s a real RA trigger. I’ll never smoke again, guess the best way to get me off them was constant torcher and the best way to stay off is remembering it. Odd thing is the results came so fast after quitting. I know it was the smokes because that’s the ONLY change I’ve made.


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