The role of smoking in cancer, lung diseases and cardiovascular diseases is now widely recognised. The fact that smoking also affects the immune system is less well known. In fact, smoking has wide ranging and severe impacts on the immune system: it increases the risk of a number of allergic conditions, increases the incidence of autoimmune diseases, decreases innate and acquired immunity and increases infection rates.1 The 2014 US Surgeon General’s report concluded that components of cigarette smoke have both immune activating and immune-suppressive effects. Smoking compromises the immune system and immune homeostasis, which relates to a heightened risk for pulmonary infections and several disorders with an underlying immune predisposition.2
Cigarette smoke triggers a systemic inflammatory response, through the release and inhibition of pro-inflammatory and anti-inflammatory molecules. These molecules are often referred to as cytokines or mediators or immunomodulating agents. For example, cigarette smoke induces the release of inflammatory cytokines such as TNF-α, interleukin (IL)-1, IL-6, IL-8 and granulocyte-macrophage colony-stimulating factor (GM-CSF). It increases production of endotoxin, one of the most potent inflammatory agents. It increases polymorphonuclear neutrophils (PMNs) with consequential adverse effects on the respiratory passage.1 A review of evidence about possible molecular pathways for smoking's impact on inflammation concluded that activation of the nuclear factor kappa B (NF-kB) family is the main mechanism.2
3.17.1 Rheumatoid arthritis
Rheumatoid arthritis is a systemic autoimmune disease characterised by disabling and painful destruction of the joints, and sometimes inflammation of the lungs and other organs. The incidence is about three-fold higher in women than men. A large proportion of patients (but not all) have the rheumatoid factor (RF) antibody.
Smoking causes rheumatoid arthritis.2 The risk is most markedly elevated in men who are RF-positive (RF is a type of antibody).4 There have been suggestions that smoking only increases susceptibility to rheumatoid arthritis in individuals who have specific genetic profiles.5
A number of studies have reported a poorer response to drug treatments in patients with rheumatoid arthritis who continue to smoke.6 Smoking reduces the effectiveness of tumour necrosis factor-alpha (TNF-a) inhibitors, a type of immunomodulatory drug that is currently used to treat rheumatoid arthritis.2 Rheumatoid arthritis sufferers have a higher mortality rate than the general population. Recent cohort studies have found this excess mortality confined to patients who are RF-positive.7,8 It has therefore been suggested that this excess mortality could be due to smoking.8
3.17.2 Anal abscess and fistula
Anal abscess is an inflammatory, fistulising cutaneous disease. A small case-control study in the US of 74 patients with anal abscess/fistula found that smoking within the previous year doubled the risk of this condition.9
3.17.3 Graves' opthamology
(See Eye 3.10.3)
3.17.4 Psoriasis
(See Skin 3.14.4)
3.17.5 Lupus erythematosus
(See Skin 3.14.5)
3.17.6 Other inflammatory conditions
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(Last updated May 2019)
References
1. Arnson Y, Shoenfeld Y and Amital H. Effects of tobacco smoke on immunity, inflammation and autoimmunity. Journal of Autoimmunity 2010;34(3):j258-65. Available from: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=20042314
2. US Department of Health and Human Services. The health consequences of smoking - 50 years of progress. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014. Available from: http://www.surgeongeneral.gov/library/reports/50-years-of-progress
3. Goncalves R, Coletta R, Silverio K, Benevides L, Casati M, da Silva J, et al. Impact of smoking on inflammation: overview of molecular mechanisms. Inflammation Research 2011;[Epub ahead of print] Available from: http://www.ncbi.nlm.nih.gov/pubmed/21298317
4. Sugiyama D, Nishimura K, Tamaki K, Tsuji G, Nakazawa T, Morinobu A, et al. Impact of smoking as a risk factor for developing rheumatoid arthritis: a meta-analysis of observational studies Annals of the Rheumatic Diseases 2010;69(1):70–81. Available from: http://ard.bmj.com/cgi/rapidpdf/ard.2008.096487v2
5. Bang S, Lee K, Cho S, Lee H, Lee K and Bae S. Smoking increases rheumatoid arthritis susceptibility in individuals carrying the HLA-DRB1 shared epitope, regardless of rheumatoid factor or anti-cyclic citrullinated peptide antibody status. Arthritis & Rheumatism 2010;62(2):369–77. Available from: http://www3.interscience.wiley.com/user/accessdenied?ID=123235521&Act=2138&Code=4719&Page=/cgi-bin/fulltext/123235521/HTMLSTART
6. Saevarsdottir S, Wedren S, Seddighzadeh M, Bengtsson C, Wesley A, Lindblad S, et al. Patients with early rheumatoid arthritis who smoke are less likely to respond to treatment with methotrexate and TNF inhibitors. Observations from the EIRA cohort and the Swedish Rheumatology Register. Arthritis & Rheumatism 2010; 63(1):26-36. Available from: http://onlinelibrary.wiley.com/doi/10.1002/art.27758/pdf
7. Gonzalez A, Icen M, Kremers HM, Crowson CS, Davis JM, 3rd, Therneau TM, et al. Mortality trends in rheumatoid arthritis: the role of rheumatoid factor. Journal of Rheumatology 2008;35(6):1009–14. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18412312
8. Goodson NJ, Farragher TM and Symmons DPM. Rheumatoid factor, smoking, and disease severity: associations with mortality in rheumatoid arthritis. Journal of Rheumatology 2008;35(6):945–9. Available from: http://www.jrheum.com/subscribers/08/06/945.html
9. Devaraj B, Khabassi S and Cosman B. Recent smoking is a risk factor for anal abscess and fistula. Diseases of the Colon and Rectum 2011;54(6):681–5. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21552051