Background There is a clear causal relationship between tobacco smoking and rheumatoid arthritis (RA), supported by observational studies and systematic reviews (1); however, the effect of smoking on disease activity and the development of joint surface erosions has not been clearly established. Current data are conflicting, with some studies reporting an increased activity and progression (2,3) of erosions and others showing an opposite relationship (4).
Objectives To summarize through a systematic review and meta-analysis of available data in the literature about cigarette smoking and RA, regarding its effect on disease activity and radiographic progression.
Methods The systematic search was done following PRISMA guidelines in the Medline, EMBASE databases up to August 2012 and databases alerts until November 2012. Additional studies were identified from the EULAR and ACR congresses from 2000 to 2012 and article references. Search terms included “smoking”, “tobacco”, “smoke”, “cigarette” and “rheumatoid arthritis”. Any type of study done with RA cases, defined by accepted classification criteria and having information about the relationship between cigarette smoking and DAS28 or erosion score was considered for inclusion. A common effect size was calculated based on a random effects model.
Results Out of a total of 2215 articles retrieved, 43 articles met inclusion. Of these, 27 were included in the meta-analysis. Twelve contained information about DAS28 and 17 about radiographic progression. There was a negative association between smoking and EULAR response (OR: 0.72; 95% CI:0.57-0.91; p-value:0.005) and DAS28 remission (OR:0.78; 95%CI:0.63-0.96; p-value:0.023). DAS28 was significantly higher in current smokers (MD:0.29; 95% CI:0.12-0.44;p-value:<0.001) as well as erosive score (SMD:0.38;95% CI:0.04-0.72; p-value:0.028). Data was ambiguous for erosion progression during follow-up (OR: 0.93; 95% CI: 0.72-1,2; p-value:0.59). A sensitivity analysis confirmed that the results were not sensitive to restrictions on the data included. Publication bias was trivial.
Conclusions Cigarette smoking is associated with a diminished response to treatment (by the EULAR criteria) and an increased erosion score. However, an increased rate of radiographic progression was not demonstrated in smokers. Prospective studies are warranted for this topic.
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Disclosure of Interest None Declared
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