Risks of Smoking With Rheumatoid Arthritis

Smoking contributes to RA development, more severe disease, and more

Smoking and RA

 Patcharanan Worrapatchareeroj/Getty Images

Smoking can contribute to the development and progression of rheumatoid arthritis (RA). But most people with this condition aren’t aware of the effect smoking has on their disease. The connections between RA and smoking are vast and it is important to be aware of those if you have RA or if the condition runs in your family.

Rheumatoid arthritis is a chronic inflammatory disease that affects more than just your joints. RA is a systemic disease, causing inflammation throughout the body that can affect the skin, eyes, heart, and lungs. Left unchecked, that all-over inflammation can lead to progressive joint and organ damage, loss of mobility, and disability.

Here is what you need to know about the effects of smoking on RA development, disease severity, and the potential for disease complications.

The RA and Smoking Connection

Smoking is linked to the development of RA and people who smoke have an increased risk for more severe disease. Also, people with RA who smoke who less likely to experience remission (inactive disease).

Smoking also decreases the effectiveness of medications for treating RA. It may also increase your risk for complications, including those that affect the heart and the lungs. Smoking with RA has also been associated with a higher death rate.

Exact reasons for why smoking affects RA in the way that it does are unknown. Still, researchers suspect smoking affects the way the immune system functions, especially in people who have risk factors for RA.

Development of RA

Exact causes of RA are unknown, but researchers believe several genetic and environmental factors are to blame. One of those environmental factors is cigarette smoking, and numerous studies have shown smoking is a risk factor for the development of RA.

The risk relates to the number of cigarettes smoked daily and the number of years a person has smoked. The risk applies to both current and past smoking history. Development of RA is twice as high for smokers than for non-smokers. Risk is the highest for heavy smokers, but even people who are light smokers still have an increased risk of developing RA.

While people who previously smoked are still at risk for RA, the risk decreases over time once they quit smoking. This is because cigarette smoking is linked to rheumatoid factor (RF) and anti-citrullinated protein (anti-CCP) antibodies specific to the development of RA.

Rheumatoid factor and anti-CCPs are responsible for causing the inflammation RA is known for. When smoking boosts these proteins, inflammation becomes out of control, and the immune system starts to attack its own healthy tissues by mistake.

With RA, inflammation attacks the synovium—the membranes that line the joints. Inflammation can also affect organs and tissues throughout the body.

Rheumatoid factor and anti-CCP antibodies are found in the bloodwork of 70% to 80% of people with RA, according to a 2020 report in journal Cells. The risk for the development of RA can continue up to 20 years after quitting smoking in people who have anti-CCP antibodies.

Secondhand smoking can also contribute to the development of RA. In fact, research shows people exposed to secondhand smoke during childhood have an increased susceptibility for developing RA. However, researchers do not know how expansive childhood exposure to secondhand smoke would have to be to increase the risk for RA.

More Severe Disease

Smoking is associated with more severe RA, including more active disease, more joint damage and deformity, loss of function, disability, and RA complications, such as rheumatoid nodules, blood vessel inflammation (vasculitis), and rheumatoid lung disease. This is because smoking increases inflammatory proteins causing more aggressive symptoms.

A study reported in 2018 in the journal Arthritis Research & Therapy found people with early RA who had a history of smoking, RF and anti-CCP activity, early erosion, high disease activity, and active disease at one year have an increased risk for rapid radiographic progression (RRP), especially in the hands and feet.

Additionally, a history of smoking increased the risk for RRP for up five years, along with continued high disease activity, swollen count joints, and pain. 

Research also shows smoking with RA can actually predispose you to severe joint damage. In fact, according to a study reported in 2015 by the Annals of the Rheumatic Diseases, smoking is a strong independent risk factor for radiologic progression in the early stages of RA.

Decreases Medication Effects

Evidence shows smokers are less likely to respond to first-line and second-line treatments like methotrexate and tumor necrosis factor (TNF) inhibitors. Researchers think this is because smoking weakens the effectiveness of anti-rheumatic drugs and biologic drugs designed to treat RA.

A study reported in 2012 by the Scandinavian Journal of Rheumatology looked at patients on a voluntary rheumatology biologic drug register in Southern Sweden. Participants on the registry were given a questionnaire that included questions about smoking habits.

Of the study participants, 23% were current smokers at the start of their anti-TNF therapy. The researchers determined heavy smokers had the poorest drug survival. Drug survival is the time from the start of therapy using a biologic drug to its discontinuation.

Researchers of the Swedish study concluded that current smoking while taking an anti-TNF biologic drug was predictive of a poor response to treatment for a period of up to 12 months.

Reduced Odds for Remission

People with RA who smoke are less likely to go into remission compared to non-smokers. Remission in RA means the disease is no longer active. It may mean your symptoms are completely gone, or that you have occasional joint pain and morning stiffness.

In a study reported at the 2018 American College of Rheumatology/Association of Rheumatology Health Professionals (ACR/ARHP) Annual Meeting, researchers focused on 1,628 adults with active RA who were followed from 2007–2016. At the one-year mark, 44% of the women participants and 36% of the men still had active disease and not gone into remission.

For the women in the study, being overweight doubled their risk for not achieving remission over a 12-month period. But for men, smoking was the biggest barrier. The researchers determined current smokers—regardless of gender—had a 3.5 greater chance of not achieving RA remission.

Complications of Smoking with RA

Extra-articular manifestations (EAMs) of RA—that is symptoms and conditions not directly related to the musculoskeletal system—are often reported in people with RA who smoke.

EAMs are a result of higher disease activity in RA and may include rheumatoid nodules, rheumatoid vasculitis, pleuritis, interstitial lung disease, pericarditis (inflammation of the protective sac that encloses the heart), eye inflammation, and secondary Sjogren’s syndrome.

In a study reported in 2012 in the Brazilian journal Revista Brasileira de Reumatologia, Brazilian researchers reviewed the medical charts of 262 people with RA. During the course of the disease, 120 of the people with RA developed EAMs of RA, specifically pulmonary disease, rheumatoid nodules, and Sjogren’s syndrome.

The 120 participants with EAMs tested positive for RF and had high levels of anti-CCPs in their bloodwork. The researchers confirmed that smoking was linked to the presence of EAMs and the current smokers had the highest risk for the development of EAMs.

High Death Rate

People with RA who smoke have an almost double risk for death than non-smokers, according to a study reported in 2016 by the journal Arthritis Care & Research. The study consisted of 5,677 people with RA of which 34% were former smokers and 26% were current smokers.

Compared to the never smokers, current smokers had an increased risk for all-cause mortality (all causes of death) and death due to cardiovascular disease and lung cancer. The researchers also confirmed that after quitting smoking, each year of smoking cessation decreased the risk of all-cause mortality in people with RA.

People with RA have an almost twice as likely risk for cardiovascular disease than others without the condition and smoking further adds to that risk. Having RA makes it more likely that you will experience a heart attack or stroke. Further, the presence of rheumatoid lung disease and rheumatoid vasculitis increases the likelihood of a cardiovascular event or death.

Barriers to Quitting Smoking in RA

Clearly, with all the evidence above, quitting smoking is one of the best things you can do to improve your health, reduce your risk for RA related complications and disability, and to improve treatment outcomes.

The hardest part, however, is to decide that you want to quit and can quit. Unfortunately, research shows RA disease-related issues can hinder the ability to quit smoking.

According to a qualitative mixed-methods study reported in 2016 by the journal Arthritis Care & Research, there are five key barriers to smoking cessation faced by RA patients.

Barriers included:

  • Unawareness of the relationship between RA and smoking was common.
  • Smoking was a distraction from pain.
  • Exercising was too hard with RA pain and, therefore, could not be used as a distraction from pain.
  • Smoking was a coping mechanism for dealing with the challenges of RA.
  • The participants felt unsupported and isolated.

The researchers concluded through understanding the perceptions of people living with RA, there can be opportunities to plan effective intervention to increase the potential to quit smoking in order to reduce disease progression and complications.

A Word From Verywell

If you have RA and smoke, you will want to quit. Quitting will help improve your RA symptoms, reduce the risk of disease complications, and improve your quality of life.

Quitting smoking will not just improve RA, it will also improve your life. And if one plan for quitting doesn’t work, try another option. You may struggle and relapse before you quit for good. But that is OK. Quitting cigarettes is an emotional process and you will need lots of support.

Talk to your doctor about the different options for quitting smoking. Fortunately, there is a lot of information and support available to help you quit when you are ready.

Was this page helpful?
Article Sources
Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read our editorial process to learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.
  1. Chang K, Yang SM, Kim SH, et al. Smoking and rheumatoid arthritis. Int J Mol Sci. 2014;15(12):22279-22295. doi:10.3390/ijms151222279

  2. Ishikawa Y, Terao C. The impact of cigarette smoking on risk of rheumatoid arthritis: A narrative review. Cells. 2020;9(2):475. doi:10.3390/cells9020475

  3. Rydell E, Forslind K, Nilsson J, et al. Smoking, body mass index, disease activity, and the risk of rapid radiographic progression in patients with early rheumatoid arthritis. Arthritis Res Ther. 2018;20,82. doi:10.1186/s13075-018-1575-2

  4. Saevarsdottir S, Rezaei H, Geborek P, et al. Current smoking status is a strong predictor of radiographic progression in early rheumatoid arthritis: results from the SWEFOT trial. Ann Rheum Dis. 2015;74(8):1509-1514. doi:10.1136/annrheumdis-2013-204601

  5. Saevarsdottir S, Wedrén S, Seddighzadeh M, et al. Patients with early rheumatoid arthritis who smoke are less likely to respond to treatment with methotrexate and tumor necrosis factor inhibitors: Observations from the Epidemiological Investigation of Rheumatoid Arthritis and the Swedish Rheumatology Register cohorts. Arthritis Rheum. 2011;63(1):26-36. doi:10.1002/art.27758

  6. Söderlin MK, Petersson IF, Geborek P. The effect of smoking on response and drug survival in rheumatoid arthritis patients treated with their first anti-TNF drug. Scand J Rheumatol. 2012;41(1):1-9. doi:10.3109/03009742.2011.599073

  7. Carrascosa JM, Notario J. Drug survival in biologic therapy. Do we know what it means? Can we calculate it?. Actas Dermosifiliogr. 2014;105(8):729-733. doi:10.1016/j.ad.2014.04.004

  8. Mack ME, Hsia E, Aletaha D. Comparative assessment of the different American College of Rheumatology/European League Against Rheumatism remission definitions for rheumatoid arthritis for their use as clinical trial end points. Arthritis Rheumatol. 2017;69(3):518-528. doi:10.1002/art.39945

  9. Bartlett SJ, Schieir O, Valois MF, et al. Lifestyle and MTX use are the strongest predictors of not achieving remission in the first year of rheumatoid arthritis: results from the Canadian Early Arthritis Cohort (CATCH) [abstract]. Arthritis Rheumatol. 2018;70 (suppl 10). 

  10. Das S, Padhan P. An overview of the extraarticular involvement in rheumatoid arthritis and its management. J Pharmacol Pharmacother. 2017;8(3):81-86. doi:10.4103/jpp.JPP_194_16

  11. Moura MC, Zakszewski PT, Silva MB, et al. Epidemiological profile of patients with extra-articular manifestations of rheumatoid arthritis from the city of Curitiba, south of Brazil. Rev Bras Reumatol. 2012;52(5):679-694.

  12. Joseph RM, Movahedi M, Dixon WG, et al. Smoking-related mortality in patients with early rheumatoid arthritis: a retrospective cohort study using the clinical practice research datalink. Arthritis Care Res (Hoboken). 2016;68(11):1598-1606. doi:10.1002/acr.22882

  13. Wright K, Crowson CS, Gabriel SE. Cardiovascular comorbidity in rheumatic diseases: a focus on heart failure. Heart Fail Clin. 2014;10(2):339-352. doi:10.1016/j.hfc.2013.10.003

  14. Aimer P, Stamp L, Stebbings S, et al. Identifying barriers to smoking cessation in rheumatoid arthritis. Arthritis Care Res (Hoboken). 2015;67(5):607-615. doi:10.1002/acr.22503