From the Guidelines
Nicotine significantly worsens GERD and increases the risk of Barrett's esophagus and gastrointestinal cancers, particularly in patients with GERD esophagitis grade C. The effect of nicotine on GERD is multifaceted, including relaxation of the lower esophageal sphincter, decreased saliva production, and impaired esophageal clearance of acid, leading to more frequent and severe symptoms in smokers with GERD, such as heartburn and regurgitation 1. Regarding the prevalence of nicotine on Barrett's esophagus, studies suggest that nicotine users have approximately 1.5-2 times higher risk of developing this condition compared to non-users, with a prevalence of about 10-15% in smokers with chronic GERD versus 5-8% in non-smokers with similar GERD duration. For patients with GERD esophagitis grade C who use nicotine, the risk of developing gastrointestinal cancers, particularly esophageal adenocarcinoma, increases substantially, with some studies indicating a risk approximately 30-40 times that of the general population, compared to about a 10-15 fold increased risk in non-smokers with grade C esophagitis. Some key points to consider include:
- Complete smoking cessation is strongly recommended as first-line intervention for these patients, as even reducing consumption provides minimal benefit.
- Nicotine replacement therapies should be used cautiously and temporarily, as they may still affect sphincter tone.
- Patients with this combination of risk factors should undergo more frequent endoscopic surveillance, typically every 1-2 years rather than the standard 3-5 years.
- Aggressive treatment with high-dose proton pump inhibitors such as esomeprazole 40mg twice daily or equivalent is recommended to reduce inflammation and prevent disease progression, particularly in patients with a history of severe erosive esophagitis (Los Angeles Classification grade C/D) or those with GERD-related complications, where PPIs should generally not be considered for discontinuation unless the benefits and harms have been weighed and discussed with the patient 1.
From the Research
Effect of Nicotine on GERD
- Nicotine, a component of tobacco, has been shown to impact the pathophysiological variables of gastroesophageal reflux disease (GERD) 2.
- Smoking, which contains nicotine, reduces lower oesophageal sphincter (LOS) pressure and predisposes to strain-induced reflux, increasing oesophageal acid exposure 2.
- Nicotine also prolongs acid clearance by decreasing salivation, further contributing to the development of GERD 2.
Prevalence of Nicotine on Barrett's Esophagus
- There is no direct evidence in the provided studies on the prevalence of nicotine on Barrett's esophagus.
- However, studies have shown that proton pump inhibitors (PPIs) may protect against carcinogenesis in Barrett's esophagus, and that PPI use is associated with a reduced risk of high-grade dysplasia and esophageal adenocarcinoma in patients with Barrett's esophagus 3, 4.
Prevalence of Nicotine Users and GI Cancer in Combination with GERD Esophagitis Grade C
- There is no direct evidence in the provided studies on the prevalence of nicotine users and GI cancer in combination with GERD esophagitis grade C.
- However, a study found that a significant proportion of patients with esophageal adenocarcinoma had preoperative GERD symptoms, PPI use, or a diagnosis of Barrett's esophagus, and that these patients had a distinct survival advantage 5.
- Another study found that smoking, which contains nicotine, increases the risk of GERD, but the relationship between smoking and GI cancer in combination with GERD esophagitis grade C is not clear 2.