Do cigarettes exacerbate Inflammatory Bowel Disease (IBD)?

From the Guidelines

Cigarette smoking is not recommended for managing inflammatory bowel disease (IBD) and patients who currently smoke should be strongly encouraged to quit. While some studies have paradoxically shown that smoking may have a protective effect in ulcerative colitis, it significantly worsens Crohn's disease symptoms and outcomes 1. The risks of smoking—including increased cancer risk, cardiovascular disease, and respiratory problems—far outweigh any potential benefits for IBD management. Instead, patients with IBD should focus on evidence-based treatments such as anti-inflammatory medications (mesalamine, corticosteroids), immunomodulators (azathioprine, methotrexate), biologics (infliximab, adalimumab), and in some cases, surgery. The apparent protective effect in ulcerative colitis is likely due to nicotine's anti-inflammatory properties and effects on gut motility, but these benefits can be better achieved through safer medical treatments without the harmful effects of tobacco.

Key Points to Consider

• Smoking cessation improves overall health outcomes and, for those with Crohn's disease, can significantly reduce disease flares and complications 1.
• Patients with IBD should be counseled to stop smoking and also be advised to remain up to date with their disease- and therapy-related monitoring labs 1.
• The British Society of Gastroenterology recommends that smokers with Crohn’s disease should be encouraged to stop, as smokers have a higher risk of disease flare, a higher incidence of surgery and a higher risk of postoperative recurrent disease 1.
• Ulcerative colitis patients who continue to smoke cigarettes should be encouraged to stop, with awareness of the potential increased risk of flare after stopping 1.

Recommendations for Patients with IBD

• Quit smoking to improve overall health outcomes and reduce disease flares and complications.
• Focus on evidence-based treatments for IBD management.
• Remain up to date with disease- and therapy-related monitoring labs.
• Consider alternative therapies, such as cognitive behavioral therapy, hypnotherapy, and mindfulness meditation, to improve symptom control and quality of life 1.

From the Research

Cigarettes and Inflammatory Bowel Disease (IBD)

• There is evidence to suggest that nicotine, a component of cigarettes, may have an adverse effect on the course of Crohn's disease and is not recommended 2.
• However, nicotine has been shown to produce greater symptomatic improvement in active ulcerative colitis compared to placebo 2.
• It is essential to note that not all studies have found a positive effect of nicotine on IBD, and its relationship to the disease has been known for many years, but its usefulness as a therapeutic agent requires further exploration 2.

Treatment of IBD

• Mesalamine has demonstrated clinical effectiveness as a therapeutic agent in the treatment of active ulcerative colitis and inactive Crohn's disease 2.
• Other medications, including aminosalicylates, corticosteroids, immune modifiers, and biologic treatment, are also used to control inflammatory activity in IBD 3.
• Combination therapy of anti-TNFα and thiopurines, such as azathioprine, is associated with greater efficacy and lower immunogenicity in IBD patients 4, 5.

Management of IBD

• The management of IBD requires a wide differential diagnosis to define the pathophysiologic mechanisms in individual patients 3.
• It is essential to tailor therapies according to presumed etiologies, and antidiarrheal agents are not recommended in extremely ill patients or those with known hypersensitivity or evidence of obstruction or colonic dilation, fever, or abdominal tenderness 3.
• Evidence-based clinical practice guidelines for IBD have been developed to provide recommendations for the diagnosis, treatment, and management of the disease 6.