|Year : 2019 | Volume
| Issue : 2 | Page : 70-73
Effect of smoking in patients with ankylosing spondylitis: A cross-sectional study in state of Madhya Pradesh, India
Akshat Pandey1, Ved Prakash2, Mimansha Pandey3
1 Division of Rheumatology, Apollo Hospitals, Indore, Madhya Pradesh, India
2 Division of Medicine, Mahatma Gandhi Memorial Medical College, Indore, Madhya Pradesh, India
3 Consultant Oral Medicine and Radiologist, My Dentist Indore Clinic, Indore, Madhya Pradesh, India
|Date of Submission||19-Jan-2019|
|Date of Acceptance||29-Apr-2019|
|Date of Web Publication||19-Jun-2019|
Division of Rheumatology, Apollo Hospitals, Indore - 452 010, Madhya Pradesh
Source of Support: None, Conflict of Interest: None
Aim: Understanding the impact of smoking on the development and severity of ankylosing spondylitis (AS) is pivotal, as it affects the management of the disease. This study investigated the effect of smoking in patients with AS and its outcome on the disease. Methods: This was a cross-sectional study from September 1, 2018, to November 30, 2018, in a rheumatology outpatient department enrolled patients aged >18 years diagnosed with AS and divided into two groups according to their smoking status. Demographic details and hematological and biochemical parameters were noted. Modified Schober's test, chest expansion, and duration of disease measurements were performed. Disease activity and functional state were evaluated using the Bath AS Disease Activity Index (BASDAI) and Bath AS Functional Index (BASFI). Results: A total of 48 patients were enrolled (smoker, n = 20; nonsmoker, n = 28). The mean age in smoker and nonsmoker groups was 39.40 years and 26.18 years, respectively, and male preponderance was observed; the mean duration of disease was 42.90 months and 43.14 months, respectively. BASDAI and BASFI scores were significantly higher in the smoker group (5.08 and 4.51, respectively) as compared to nonsmoker group (3.40 and 2.34, respectively) (P < 0.001). The modified Schober's test showed a significant decrease in the range of spinal mobility in the smoker group (2.67 cm) than in the nonsmoker group (4.40 cm) (P < 0.001). A significant decrease in the mean chest expansion was seen in the smoker group than the nonsmoker group (3.08 vs. 5.68 cm; P < 0.001). Conclusion: Results demonstrate the negative effect of smoking on disease and functional activity in patients with AS.
Keywords: Disease, functional activity, modified Schober's test, smoking
|How to cite this article:|
Pandey A, Prakash V, Pandey M. Effect of smoking in patients with ankylosing spondylitis: A cross-sectional study in state of Madhya Pradesh, India. Apollo Med 2019;16:70-3
|How to cite this URL:|
Pandey A, Prakash V, Pandey M. Effect of smoking in patients with ankylosing spondylitis: A cross-sectional study in state of Madhya Pradesh, India. Apollo Med [serial online] 2019 [cited 2019 Sep 17];16:70-3. Available from: http://www.apollomedicine.org/text.asp?2019/16/2/70/260687
| Introduction|| |
Smoking is a well-established environmental risk factor for many severe and chronic diseases including cancer, cardiovascular diseases, and lung diseases. Cigarette smoke contains many toxic chemicals, which may severely affect many systems and organs, including the most affected musculoskeletal system.,
Ankylosing spondylitis (AS) is a chronic inflammatory condition of the axial joints and bilateral sacroiliac joints with variable frequency and severity of extra-articular manifestations and comorbidities. Patients with AS experience progressive limitation of the spinal mobility, loss of functional ability, and impaired quality of life. Environmental and genetic factors play a crucial role in the development and progression of this chronic inflammatory disease.
Previous studies have demonstrated the association of smoking with increased disease activity and radiographic severity in established AS.,,, A recent report by Sakellariou et al. showed that current but not previous smoking or smoking intensity can be a major risk factor for incident AS, which depicts smoking as a causal factor in the development of AS. As the addiction of smoking adversely affects the severity of disease and management of disease in patients who smoke is more difficult than nonsmokers, smoking becomes a major hurdle in the treatment of AS.
Until now, only one study has attempted to assess the correlation between smoking and disease outcome in Indian AS patients undergoing antitumor necrosis factor therapy. To our knowledge, this study is the first Indian study to directly assess the effect of smoking in AS patients in the state of Madhya Pradesh, India, and its outcome on the disease.
| Methods|| |
This was a cross-sectional single-center study conducted at a rheumatology clinic in Central India, city Indore, from September 1, 2018, to November 30, 2018. The study protocol was approved by the Local Ethics Committee, and written informed consent was obtained from all study participants. The study was conducted in accordance with ethical principles that have their origin in the Declaration of Helsinki. Patients aged >18 years diagnosed with AS were enrolled. For the diagnosis of AS, modified AS Assessment Study group criteria was used, and 48 consecutive patients were enrolled in the study.
Demographic characteristics (age, gender, and disease duration) were documented for each patient. In laboratory assessments, hemoglobin (Hb), white blood cell (WBC) count, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), blood urea, and serum creatinine were estimated. For determining the range of motion assessment of lumbar flexion in patients, modified Schober's test was performed. Further, chest expansion and duration of disease were measured. The disease activity was evaluated using Bath AS Disease Activity Index (BASDAI), whereas functional state was assessed by Bath AS Functional Index (BASFI). The ophthalmological and routine dental checkups were done in all patients.
Information regarding smoking status (current and never) was collected at the time of enrollment, and pack-years of smoking served as the measure of cumulative exposure. Never smoking was defined as having smoked fewer than 100 cigarettes in the patient's lifetime.
Statistical analysis was done using online statistical software, GraphPad. Association between two nonparametric variables was assessed using Pearson's Chi-square test (for qualitative data). The mean comparisons of study parameters between the groups were done using unpaired t-test (for quantitative data). Proportional comparisons were performed using the Z-test for two sample proportions, and correlation analysis was performed using Pearson's correlation coefficient. P < 0.05 was considered statistically significant.
| Results|| |
A total of 48 patients were enrolled in the study and were divided into two groups: smoker group (n = 20) and nonsmoker group (n = 28) based on smoking status. Demographic parameters were comparable between the study groups [Table 1]. A male preponderance was observed in both the groups with 19 (95.0%) males in the smoker group and 22 (78.6%) males in the nonsmoker group. The mean (standard deviation [SD]) age in the smoker and nonsmoker groups was 39.40 (9.0) years and 26.18 (8.9) years, respectively; and the mean (SD) duration of the disease was 42.90 (34.9) months and 43.14 (46.3) months, respectively.
[Table 2] shows a comparative analysis of laboratory and clinical parameters between smoker and nonsmoker groups. In laboratory estimations, no significant difference was seen in any of the hematological (Hb, WBC count, and ESR) or biochemical parameters (CRP, blood urea, and serum creatinine) (P > 0.05).
The mean BASDAI and BASFI scores were significantly higher in the smoker (5.08 and 4.51, respectively) than the nonsmoker groups (3.40 and 2.34, respectively) (P < 0.001). The modified Schober's test significantly (P < 0.001) decreased the mean range of motion assessment of lumbar flexion in the smoker group (2.67 cm) than the nonsmoker group (4.40 cm). Similarly, the mean chest expansion significantly (P < 0.001) reduced in the smoker group (3.08 cm) than the nonsmoker group (5.68 cm). After ophthalmological examination, uveitis was ruled out in all the study patients.
In the smoker group, two (10%) patients had a duration of smoking between 1 and 5 years, 5 (25%) patients each had between 5–10 years, 11–15 years, and 16–20 years, and three (15.0%) patients had >20 years. The majority of patients had a smoking history (duration of smoking) of >10 years.
Correlation of duration of smoking with BASDAI, BASFI, modified Schober's test, and chest expansion are presented in [Table 3]; however, there was no significant correlation between these parameters.
|Table 3: Correlation of smoking duration with Bath Ankylosing Spondylitis Disease Activity Index, Bath Ankylosing Spondylitis Functional Index, modified Schober's test, and chest expansion (n=20)|
Click here to view
| Discussion|| |
This cross-sectional study showed that the disease activity (BASDAI) and functional state (BASFI) scores were significantly higher in the smoker group than the nonsmoker group (P < 0.001). Compared to the nonsmoker group, the smoker group had significantly decreased the range of spinal mobility as well as chest expansion (P < 0.001). The duration of disease and age of patients were comparable in both the study groups, and no significant association of smoking duration with BASDAI, BASFI, modified Schober's test, and chest expansion was observed.
The present study showed male preponderance with 95% and 78.6% of males in the smoker and nonsmoker groups, respectively. These results were consistent with a previous study by Zhang et al. Demographic parameters (mean duration of disease and age) did not show a significant difference between both the study groups. Results of the study done by Chen et al. were quite similar with these findings.
To evaluate the impact of smoking on inflammatory markers, the present study compared the ESR and CRP levels between the two study groups. Although ESR and CRP levels were higher in the smoker group than the nonsmoker group, the difference in the present study was not significant (P > 0.05). These observations correlate with the previous cohort study by Ward who reported higher ESR (P = 0.09) and CRP levels (P = 0.08) in the smoker group than the nonsmoker group. Roseman et al. reported significantly higher CRP (P = 0.04) and ESR (P = 0.02) in current smokers compared to nonsmokers, and smoking had a significant impact on both CRP (P = 0.008) and ESR (P = 0.037). In 2013, Chen et al. reported similar results for ESR and CRP levels. In smoking AS patients, significantly higher ESR levels and insignificantly higher CRP levels were reported than nonsmoking patients.
In the present study, BASDAI and BASFI scores were significantly higher in the smoker group than the nonsmoker group (P < 0.001), which suggested higher disease activity and impaired functional status, respectively. A recent Egyptian study by Wafaa et al. reported that AS patients who smoke had a higher disease activity index (BASDAI) (P = 0.03) and physical activity index (BASFI) (P > 0.05). Similar results were also reported by other studies, but the difference was not significant.,, Further, observations from studies conducted by Mattey et al. and Kaan and Ferda demonstrated a significantly higher disease activity with higher BASDAI in the smoker group., However, Dincer et al.'s study contradicted the current study results of disease activity, which showed no difference in disease activity between smoking and nonsmoking AS patients. The present study of functional status assessment through BASFI is similar to the results of Chen et al. who found higher BASFI scores in smokers, but the difference was not statistically significant. The results of Mattey et al. showed that smokers had a functional impairment with significantly higher BASFI score regardless of their current smoking status.
Several possible mechanisms have been proposed, through which smoking may result in decreased functional activity. One of the causal factors for decreased physical activity in smokers is an increase in comorbidity. Smoking in AS patients can severely affect poor lung function, which ultimately leads to a further decrease in their functional ability. Further, smoking has been strongly correlated with inflammation and may cause increased inflammation in joints, thereby reducing physical mobility. Therefore, the present study depicts the adverse impact of smoking on the disease as well as functional activity in AS patients.
The modified Schober's test was performed to evaluate the range of spinal mobility in AS patients. The present study revealed a significant reduction in the spinal mobility in the smoker group as compared to the nonsmoker group (P < 0.001). Chest expansion was also significantly reduced in the smoker group (P < 0.001). These observations were parallel to the observations of Chen et al. who found adverse smoking effects on the modified Schober's test and chest expansion. Averns et al. have concluded that cigarette smoking is associated with a worse clinical, functional, and radiological outcome in AS. They reported significant differences in the outcome between smokers and nonsmokers for Schober's test (P < 0.01) and total spinal movement (P < 0.001).
The present study further assessed the association of smoking duration with disease activity (BASDAI), functional activity (BASFI), the range of spinal mobility (modified Schober's test), and chest expansion. No significant correlation was observed between any of these study parameters. However, these results are partially discordant with the observations of a study by Chen et al. who reported a significant positive correlation of smoking duration with BASFI (r = 0.409, P = 0.018) and no association with BASDAI, modified Schober's test, and chest expansion. Due to the cross-sectional study design and small sample size, the present study could have failed to show any significant association between these parameters.
| Conclusion|| |
The observations from the present study depict the adverse impact of smoking on various disease outcomes such as spinal mobility, chest expansion, disease activity as well as the functional state in AS patients from the state of Madhya Pradesh, India. Therefore, it is important to consider smoking as a negative factor in the treatment of AS, and for a better prognosis, doctors should strongly recommend these patients to stop smoking cigarette.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Sparks JA, Chen CY, Hiraki LT, Malspeis S, Costenbader KH, Karlson EW. Contributions of familial rheumatoid arthritis or lupus and environmental factors to risk of rheumatoid arthritis in women: A prospective cohort study. Arthritis Care Res (Hoboken) 2014;66:1438-46.
Bang SY, Lee KH, Cho SK, Lee HS, Lee KW, Bae SC. 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 Rheum 2010;62:369-77.
Carlens C, Hergens MP, Grunewald J, Ekbom A, Eklund A, Höglund CO, et al.
Smoking, use of moist snuff, and risk of chronic inflammatory diseases. Am J Respir Crit Care Med 2010;181:1217-22.
Chung HY, Machado P, van der Heijde D, D'Agostino MA, Dougados M. Smokers in early axial spondyloarthritis have earlier disease onset, more disease activity, inflammation and damage, and poorer function and health-related quality of life: Results from the DESIR cohort. Ann Rheum Dis 2012;71:809-16.
Chen CH, Chen HA, Lu CL, Liao HT, Liu CH, Tsai CY, et al.
Association of cigarette smoking with Chinese ankylosing spondylitis patients in Taiwan: A poor disease outcome in systemic inflammation, functional ability, and physical mobility. Clin Rheumatol 2013;32:659-63.
Mattey DL, Dawson SR, Healey EL, Packham JC. Relationship between smoking and patient-reported measures of disease outcome in ankylosing spondylitis. J Rheumatol 2011;38:2608-15.
Wafaa G, Ahmed H, Ihab I, Zeinab N. Impact of smoking on disease outcome in ankylosing spondylitis patients. Egypt Rheumatol 2015;37:185-9.
Sakellariou GT, Anastasilakis AD, Kenanidis E, Potoupnis M, Tsiridis E, Savvidis M, et al.
The effect of smoking on clinical and radiographic variables, and acute phase reactants in patients with ankylosing spondylitis. Rheumatol Int 2015;35:2109-14.
Das P, Moorthy A, Samanta A. THU0222 Anti TNF therapy in ankylosing spondylitis – An observational study assessing the impact of smoking in white British and Indian population. Ann Rheum Dis 2015;74 Suppl 2:276-7.
Akgul O, Ozgocmen S. Classification criteria for spondyloarthropathies. World J Orthop 2011;2:107-15.
Garrett S, Jenkinson T, Kennedy LG, Whitelock H, Gaisford P, Calin A, et al.
Anew approach to defining disease status in ankylosing spondylitis: The bath ankylosing spondylitis disease activity index. J Rheumatol 1994;21:2286-91.
Calin A, Garrett S, Whitelock H, Kennedy LG, O'Hea J, Mallorie P, et al.
Anew approach to defining functional ability in ankylosing spondylitis: The development of the bath ankylosing spondylitis functional index. J Rheumatol 1994;21:2281-5.
Zhang S, Li Y, Xu X, Feng X, Yang D, Lin G. Effect of cigarette smoking and alcohol consumption on disease activity and physical functioning in ankylosing spondylitis: A cross-sectional study. Int J Clin Exp Med 2015;8:13919-27.
Ward MM. Predictors of the progression of functional disability in patients with ankylosing spondylitis. J Rheumatol 2002;29:1420-5.
Roseman C, Truedsson L, Kapetanovic MC. The effect of smoking and alcohol consumption on markers of systemic inflammation, immunoglobulin levels and immune response following pneumococcal vaccination in patients with arthritis. Arthritis Res Ther 2012;14:R170.
Kaan U, Ferda O. Evaluation of clinical activity and functional impairment in smokers with ankylosing spondylitis. Rheumatol Int 2005;25:357-60.
Dincer U, Cakar E, Kiralp MZ, Bozkanat E, Kilac H, Dursun H. The pulmonary involvement in rheumatic diseases: Pulmonary effects of ankylosing spondylitis and its impact on functionality and quality of life. Tohoku J Exp Med 2007;212:423-30.
Averns HL, Oxtoby J, Taylor HG, Jones PW, Dziedzic K, Dawes PT. Smoking and outcome in ankylosing spondylitis. Scand J Rheumatol 1996;25:138-42.
[Table 1], [Table 2], [Table 3]