Objectives To investigate the association of smoking with various clinical, functional and imaging outcomes in patients with early axial spondyloarthritis (SpA).

Methods 647 patients with early inflammatory back pain (IBP) fulfilling at least one of the internationally accepted SpA criteria and with available smoking data were included in the analyses. Clinical, demographic and imaging parameters were compared between smokers and non-smokers at a cross-sectional level. Variables with significant differences in univariate analyses were used as dependent variables in multivariate linear and logistic regression models adjusted for potential confounding/contributing factors.

Results Multivariate analysis showed that smoking was associated with an earlier onset of IBP (regression coefficient (B)=(−1.46), p=0.04), higher disease activity (ankylosing spondylitis disease activity score B=0.20, p=0.03; Bath ankylosing spondylitis disease activity index B=0.50, p=0.003), worse functional status (Bath ankylosing spondylitis functional index B=0.38, p=0.02), more frequent MRI inflammation of the sacroiliac joints (OR 1.57, p=0.02) and the spine (OR 2.33, p<0.001), more frequent MRI structural lesions of the sacroiliac joints (OR 1.54, p=0.03) and the spine (OR 2.02, p=0.01), and higher modified Stoke ankylosing spondylitis spine score (B=0.54, p=0.03) reflecting radiographic structural damage of the spine. Smoking was also associated with poorer quality of life (Euro-quality of life questionnaire B=1.38, p<0.001, short form 36 physical B=(−4.89), p<0.001, and mental component score B=(−5.90), p<0.001).

Conclusion In early axial SpA patients, smoking was independently associated with earlier onset of IBP, higher disease activity, increased axial inflammation on MRI, increased axial structural damage on MRI and radiographs, poorer functional status and poorer quality of life.