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Smoking is a major preventable risk factor for rheumatoid arthritis: estimations of risks after various exposures to cigarette smoke
  1. Henrik Källberg1,
  2. Bo Ding1,
  3. Leonid Padyukov2,
  4. Camilla Bengtsson1,
  5. Johan Rönnelid3,
  6. Lars Klareskog2,
  7. Lars Alfredsson1,4,
  8. EIRA Study Group
  1. 1Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
  2. 2Department of Medicine, Rheumatology Unit, Karolinska Institutet/Karolinska Hospital, Stockholm, Sweden
  3. 3Unit of Clinical Immunology, Uppsala University/Akademiska Sjukhuset, Uppsala, Sweden
  4. 4Karolinska Institutet School of Public Health, Stockholm, Sweden
  1. Correspondence to Dr Henrik Källberg, Institute of Environmental Medicine, Box 210, Karolinska Institutet, 171 77 Stockholm, Sweden; henrik.kallberg{at}


Background Earlier studies have demonstrated that smoking and genetic risk factors interact in providing an increased risk of rheumatoid arthritis (RA). Less is known on how smoking contributes to RA in the context of genetic variability, and what proportion of RA may be caused by smoking.

Objectives To determine the association between the amount of smoking and risk of RA in the context of different HLA-DRB1 shared epitope (SE) alleles, and to estimate proportions of RA cases attributed to smoking.

Design, Setting and Participants Data from the Swedish Epidemiological Investigation of Rheumatoid Arthritis (EIRA) case–control study encompassing 1204 cases and 871 controls were analysed.

Main Outcome Measure Estimated OR to develop RA and excess fraction of cases attributable to smoking according to the amount of smoking and genotype.

Results Smoking was estimated to be responsible for 35% of anticitrullinated protein/peptide antibody (ACPA)-positive cases. For each HLA-DRB1 SE genotype, smoking was dose-dependently associated with an increased risk of ACPA-positive RA (p trend <0.001). In individuals carrying two copies of the HLA-DRB1 SE, 55% of ACPA-positive RA was attributable to smoking.

Conclusions Smoking is a preventable risk factor for RA. The increased risk due to smoking is dependent on the amount of smoking and genotype.

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  • Funding The EIRA study was supported by grants from the Swedish Medical Research Council, from the Swedish Council for Working Life and Social Research, from King Gustaf V's 80-year Foundation, from the Swedish Rheumatism Foundation, from Stockholm County Council, from the insurance company AFA, from the EU-supported AutoCure project, FAMRI (Flight Attendant Medical Research Institute), NIH (P60 AR047782), and from the COMBINE (Controlling Chronic Inflammatory Diseases with Combined Efforts) project.

  • Competing interest None.

  • Patient consent Obtained.

  • Ethics approval This study was conducted with the approval of the relevant ethical committees and all the participants consented to contribute to the study on a voluntary basis.

  • Provenance and peer review Not commissioned; externally peer reviewed.