Smoking Cessation in Rheumatoid Arthritis
Patients with rheumatoid arthritis who smoke must be strongly counseled to quit immediately at every clinical encounter, as smoking worsens disease activity, accelerates structural damage, impairs DMARD treatment response, increases comorbidities including cardiovascular disease, and reduces quality of life. 1
Why Smoking Cessation is Critical in RA
Smoking has uniquely detrimental effects in RA beyond general health consequences:
Disease activity and progression: Smoking negatively impacts symptoms, function, disease activity, disease progression, and occurrence of comorbidities across all rheumatic and musculoskeletal diseases. 1
Treatment resistance: Smoking may limit response to disease-modifying antirheumatic drugs (DMARDs), meaning patients who smoke may not respond as well to their RA medications. 1
Cardiovascular risk: Smoking contributes to higher absolute cardiovascular risk in individual RA patients, compounding the already elevated cardiovascular disease risk inherent to RA itself. 1
Evidence-Based Cessation Approach
Step 1: Counsel at Every Visit
Rheumatologists are strongly recommended to advise and help their patients to stop smoking at every encounter, using best evidence-based methods. 1 The trust developed between RA patients and their clinicians makes this counseling particularly important, despite the low success rate of individual tobacco cessation counseling efforts. 1
Step 2: Provide Pharmacotherapy
Offer nicotine replacement therapy (NRT), varenicline, or bupropion as pharmacological aids. 2 Varenicline is a nicotinic receptor partial agonist indicated for smoking cessation, dosed at 0.5 mg once daily for days 1-3, then 0.5 mg twice daily for days 4-7, followed by 1 mg twice daily for 12 weeks, with consideration for an additional 12 weeks for successful quitters. 2
Step 3: Structured Support Program
Implement individualized support combining:
- Face-to-face counseling: Motivational counseling sessions with trained smoking cessation counselors based on principles of motivational interviewing. 3, 4, 5
- Telephone and email follow-up: Regular contact to provide reinforcement and support. 3
- RA-specific education: Emphasize practical benefits of smoking cessation specifically for RA outcomes, including reduced disease activity, better treatment response, and lower comorbidity risk. 4
Step 4: Monitor Progress
Schedule follow-up visits at 3,6, and 12 months to assess smoking status, reinforce cessation efforts, and adjust support as needed. 4, 5
What the Evidence Shows About Success Rates
Brief advice combined with subsidized nicotine replacement therapy achieves approximately 15-24% smoking cessation rates at 12 months in RA patients. 6, 4 More intensive tailored interventions do not appear to significantly improve cessation rates beyond brief advice plus NRT, suggesting that brief advice and NRT represent current best practice. 6
Patients who successfully quit tend to have lower nicotine dependence scores and previous quit attempts, though these differences are not always statistically significant. 4 Being new to rheumatology care increases the likelihood of successful cessation by 60%, highlighting the importance of emphasizing cessation early in the treatment relationship. 7
Critical Pitfalls to Avoid
Do not delay or deprioritize smoking cessation counseling: Despite competing clinical demands, smoking cessation must be addressed at every visit because of its profound impact on RA-specific outcomes, not just general health. 1
Do not assume patients know about RA-specific smoking harms: Many patients are unaware that smoking specifically worsens their RA disease activity and treatment response—explicit education about these RA-specific effects is essential. 1, 4
Do not overlook seropositive patients: Seropositive RA patients are 43% less likely to quit smoking and may particularly benefit from intensive cessation support. 7
Balance cardiovascular concerns with cessation benefits: While varenicline carries warnings about cardiovascular events in patients with underlying cardiovascular disease, these concerns must be balanced against the substantial health benefits of smoking cessation, particularly given the elevated cardiovascular risk in RA. 2