Smoking behaviour and knowledge of the health effects of smoking in patients with inflammatory bowel disease

Results of the Eighth Scientific Workshop of ECCO: Prevention and Treatment of Postoperative Recurrence in Patients With Crohn's Disease Undergoing an Ileocolonic Resection With Ileocolonic Anastomosis

Despite the introduction of biological therapies, an ileocolonic resection is often required in patients with Crohn's disease [CD]. Unfortunately, surgery is not curative, as many patients will develop postoperative recurrence [POR], eventually leading to further bowel damage and a decreased quality of life. The 8th Scientific Workshop of ECCO reviewed the available scientific data on both prevention and treatment of POR in patients with CD undergoing an ileocolonic resection, dealing with conventional and biological therapies, as well as non-medical interventions, including endoscopic and surgical approaches in case of POR. Based on the available data, an algorithm for the postoperative management in daily clinical practice was developed.

Risk perception of non-communicable diseases: A systematic review on its assessment and associated factors

BACKGROUND

The burden of non-communicable diseases (NCDs) is increasing. Risk perception of NCDs is an important factor towards the uptake of preventive health interventions. There are various questionnaires assessing risk perception of NCDs, but no internationally standardized questionnaire has been available. Identification of factors associated with risk perception of NCDs may facilitate the development of targeted interventions. This systematic review aims to identify available questionnaire assessing risk perception of NCDs and the factors associated with risk perception of NCDs.

METHODS

The reporting of this systematic review is in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We carried out a literature search through three databases (Scopus, PubMed, Web of Science) and targeted original article published in English between 2012 and 2021. Quality appraisal of the eligible articles was conducted using the Mixed Methods Appraisal Tool. Findings were synthesized using content analysis.

RESULTS

A total of 86 studies were included. We found a variety of questionnaires assessing risk perception of NCDs, with many differences in their development, domains, items and validity. We also identified several personal, sociopsychological and structural factors associated with risk perception of NCDs.

LIMITATIONS

Most of the included studies were of cross-sectional design, and therefore the quality of evidence was considered low and exhibit a high risk of bias. The role of publication bias within this systematic review should be acknowledged as we did not include grey literature. Additionally, language bias must be considered as we only included English-language publications.

CONCLUSION

Further development and testing of available questionnaire is warranted to ensure their robustness and validity in measuring risk perception of NCDs. All the identified factors deserve further exploration in longitudinal and experimental studies.

Effectiveness of a Telephone-Based Motivational Intervention for Smoking Cessation in Patients With Crohn Disease: A Randomized, Open-Label, Controlled Clinical Trial

A randomized, open-label, controlled clinical trial was designed to assess the effectiveness of a motivational intervention based on the 5 R's model (relevance, risks, rewards, roadblocks, and repetition) delivered by specialized inflammatory bowel disease nurses every 3 months over a 1-year period as compared with patients who were followed regularly. Patients diagnosed with Crohn disease, aged 18 years or older, who reported being active smokers with Internet access at home and an e-mail address were eligible. A total of 144 patients (72 per group) were included (50% women, median age 40 years). They smoked a median of 10 cigarettes per day (range = 1-40) and had been smoking for a median of 22 years (range = 1-51). Motivation to quit (Richmond test) was low in 73 patients, moderate in 39 patients, and high in 32 patients. Statistically significant differences between the study groups in the predisposition to change, motivation to quit, and tobacco withdrawal were not found. However, 14 patients (20.9%) in the intervention group and 9 patients (13.2%) among controls stopped smoking at the end of the study. These findings support a higher trend toward smoking cessation associated with the motivational intervention 5 R's. This behavioral strategy can aid patients with Crohn disease to quit smoking.

Opening a Window on Attention: Adjuvant Therapies for Inflammatory Bowel Disease

Inflammatory bowel disease (IBD), most commonly known as Crohn's disease (CD) and ulcerative disease (UC), is a chronic and relapsing intestinal disease which cannot be cured completely. The prevalence of IBD in Europe and in North America has increased over the past 20 years. As most IBD patients are young at onset, their quality of life (QOL) can be influenced to varying degrees. Thus, current treatment goals are typically focused on preventing complications, including maintaining clinical remission and improving the QOL. Adjuvant therapies have been widely concerned as an effective treatment in alleviating IBD symptoms, including dietary intervention, traditional Chinese medicine, smoking, alcohol, and physical activities. This review focuses on different ancillary therapies for IBD treatments, in particular the mechanism of reducing inflammation based on the actual data from research studies. Moreover, comparing the latest data, this review also presented potential future prospect for adjuvant therapies.

British Society of Gastroenterology consensus guidelines on the management of inflammatory bowel disease in adults

Ulcerative colitis and Crohn's disease are the principal forms of inflammatory bowel disease. Both represent chronic inflammation of the gastrointestinal tract, which displays heterogeneity in inflammatory and symptomatic burden between patients and within individuals over time. Optimal management relies on understanding and tailoring evidence-based interventions by clinicians in partnership with patients. This guideline for management of inflammatory bowel disease in adults over 16 years of age was developed by Stakeholders representing UK physicians (British Society of Gastroenterology), surgeons (Association of Coloproctology of Great Britain and Ireland), specialist nurses (Royal College of Nursing), paediatricians (British Society of Paediatric Gastroenterology, Hepatology and Nutrition), dietitians (British Dietetic Association), radiologists (British Society of Gastrointestinal and Abdominal Radiology), general practitioners (Primary Care Society for Gastroenterology) and patients (Crohn's and Colitis UK). A systematic review of 88 247 publications and a Delphi consensus process involving 81 multidisciplinary clinicians and patients was undertaken to develop 168 evidence- and expert opinion-based recommendations for pharmacological, non-pharmacological and surgical interventions, as well as optimal service delivery in the management of both ulcerative colitis and Crohn's disease. Comprehensive up-to-date guidance is provided regarding indications for, initiation and monitoring of immunosuppressive therapies, nutrition interventions, pre-, peri- and postoperative management, as well as structure and function of the multidisciplinary team and integration between primary and secondary care. Twenty research priorities to inform future clinical management are presented, alongside objective measurement of priority importance, determined by 2379 electronic survey responses from individuals living with ulcerative colitis and Crohn's disease, including patients, their families and friends.

British Society of Gastroenterology consensus guidelines on the management of inflammatory bowel disease in adults

Ulcerative colitis and Crohn's disease are the principal forms of inflammatory bowel disease. Both represent chronic inflammation of the gastrointestinal tract, which displays heterogeneity in inflammatory and symptomatic burden between patients and within individuals over time. Optimal management relies on understanding and tailoring evidence-based interventions by clinicians in partnership with patients. This guideline for management of inflammatory bowel disease in adults over 16 years of age was developed by Stakeholders representing UK physicians (British Society of Gastroenterology), surgeons (Association of Coloproctology of Great Britain and Ireland), specialist nurses (Royal College of Nursing), paediatricians (British Society of Paediatric Gastroenterology, Hepatology and Nutrition), dietitians (British Dietetic Association), radiologists (British Society of Gastrointestinal and Abdominal Radiology), general practitioners (Primary Care Society for Gastroenterology) and patients (Crohn's and Colitis UK). A systematic review of 88 247 publications and a Delphi consensus process involving 81 multidisciplinary clinicians and patients was undertaken to develop 168 evidence- and expert opinion-based recommendations for pharmacological, non-pharmacological and surgical interventions, as well as optimal service delivery in the management of both ulcerative colitis and Crohn's disease. Comprehensive up-to-date guidance is provided regarding indications for, initiation and monitoring of immunosuppressive therapies, nutrition interventions, pre-, peri- and postoperative management, as well as structure and function of the multidisciplinary team and integration between primary and secondary care. Twenty research priorities to inform future clinical management are presented, alongside objective measurement of priority importance, determined by 2379 electronic survey responses from individuals living with ulcerative colitis and Crohn's disease, including patients, their families and friends.

The impact of smoking and smoking cessation on disease outcomes in ulcerative colitis: a nationwide population-based study

BACKGROUND

Smokers are less likely to develop ulcerative colitis (UC) but the impact of smoking and subsequent cessation on clinical outcomes in UC is unclear.

AIM

To evaluate the effect of smoking status and smoking cessation on disease outcomes.

METHODS

Using a nationally representative clinical research database, we identified incident cases of UC during 2005-2016. Patients were grouped as never-smokers, ex-smokers and smokers based on smoking status recorded in the 2 years preceding UC diagnosis. We defined subgroups of persistent smokers and smokers who quit within 2 years after diagnosis. We compared the rates of overall corticosteroid use, corticosteroid-requiring flares, corticosteroid dependency, thiopurine use, hospitalisation and colectomy between these groups.

RESULTS

We identified 6754 patients with a new diagnosis of UC over the study period with data on smoking status, of whom 878 were smokers at diagnosis. Smokers had a similar risk of corticosteroid-requiring flares (OR 1.16, 95% CI 0.92-1.25), thiopurine use (HR 0.84, 95% CI 0.62-1.14), corticosteroid dependency (HR 0.85, 95% CI 0.60-1.11), hospitalisation (HR 0.92, 95% CI 0.72-1.18) and colectomy (HR 0.78, 95% CI 0.50-1.21) in comparison with never-smokers. Rates of flares, thiopurine use, corticosteroid dependency, hospitalisation and colectomy were not significantly different between persistent smokers and those who quit smoking after a diagnosis of UC.

CONCLUSIONS

Smokers and never-smokers with UC have similar outcomes with respect to flares, thiopurine use, corticosteroid dependency, hospitalisation and colectomy. Smoking cessation was not associated with worse disease course. The risks associated with smoking outweigh any benefits. UC patients should be counselled against smoking.

Smoking Status at Diagnosis and Subsequent Smoking Cessation: Associations With Corticosteroid Use and Intestinal Resection in Crohn's Disease

BACKGROUND

The impact of smoking at diagnosis and subsequent smoking cessation on clinical outcomes in Crohn's disease (CD) has not been evaluated in a population-based cohort.

METHODS

Using a nationally representative clinical research database, we identified incident cases of CD between 2005 and 2014. We compared the following outcomes: overall corticosteroid (CS) use; flares requiring CS; CS dependency and intestinal surgery between smokers and non-smokers at time of CD diagnosis. Differences in these outcomes were also compared between persistent smokers and smokers who quit within 2 years of diagnosis.

RESULTS

We identified 3553 patients with a new CD diagnosis over the study period of whom 1121 (32%) were smokers. Smokers at CD diagnosis had significantly higher CS-use (56 versus 47%, p < 0.0001), proportionally more CS flares (>1 CS flare/year: 9 versus 6%, p < 0.0001), and higher CS dependency (27 versus 21%, p < 0.0001) than non-smokers. Regression analysis identified smoking at diagnosis to be associated with a higher risk of intestinal surgery (HR 1.64, 95% CI 1.16-2.52). There was a significantly higher proportion of 'quitters' who remained steroid-free through follow-up in comparison to 'persistent smokers' (45.4 versus 37.5%, respectively, p = 0.02). 'Quitters' also had lower rates of CS dependency compared to 'persistent smokers' (24 versus 33%, p = 0.008).

CONCLUSIONS

Smokers at CD diagnosis have higher CS-use, CS dependency and higher risk of intestinal surgery. Quitting smoking appears to have beneficial effects on disease related outcomes, including reducing CS dependency highlighting the importance of offering early smoking cessation support.

Practices, attitudes, and knowledge about Crohn's disease and smoking cessation among gastroenterologists

OBJECTIVE

Cigarette smoking is one of the most important, modifiable environmental factors in Crohn's disease (CD) and screening for tobacco use is an official recommendation and quality measure in the care of CD patients. The objective of this study was to learn more about gastroenterologists' practices, opinions, and knowledge in this area.

PATIENTS AND METHODS

A 15 question survey was sent through email to two national gastroenterology distribution lists. Questions were written in multiple choice formats and were designed to collect information about gastroenterologists' practices, attitudes, and knowledge regarding smoking cessation in CD patients. Responses were stratified by practice setting, experience, and inflammatory bowel disease-focus. Responses were anonymous and were collected in a secure, online database.

RESULTS

A total of 141 respondents completed the survey. Overall, 89% of participants screened their CD patients for smoking more than 75% of the time. In all, 62% provided smoking cessation counseling more than 75% of the time. Overall, 94% of respondents felt comfortable discussing the benefits of smoking cessation with their patients. In all, 56% felt comfortable discussing smoking cessation strategies with their patients. Overall, 88% of respondents agreed that gastroenterologists should provide smoking cessation counseling; however, 43 and 11% agreed that the gastroenterologist should be the primary counselor and primary prescriber of cessation-related pharmacotherapy, respectively.

CONCLUSION

Surveyed gastroenterologists agree that smoking cessation is an important part of the care of CD patients and this is reflected in their screening practices. Counseling occurs irregularly and many gastroenterologists do not feel comfortable discussing cessation strategies. Future guidelines should provide further guidance on the gastroenterologist's role in smoking cessation counseling for CD patients.

Use of azathioprine and corticosteroids during pregnancy and birth outcome in women diagnosed with inflammatory bowel disease

BACKGROUND

The aim of this study was to describe prescription patterns for azathioprine and corticosteroids for pregnant women with inflammatory bowel diseases (IBD) before, during, and after pregnancy and to describe pregnancy outcomes.

METHODS

A cohort composed of all singleton pregnancies in Danish registries from 1996 to 2009 was divided by maternal IBD status: Crohn's disease (CD, n = 827), ulcerative colitis (UC, N = 1361), or no IBD diagnosis (background population, n = 814,231). The number of women with a prescription for azathioprine, local and systemic steroids within a 3-month period was computed for each of the pregnancy trimesters and the year before and after pregnancy. Outcomes of interest were stillbirth, perinatal mortality, low birth weight (LBW), preterm birth, and small for gestational age (SGA).

RESULTS

Number of prescriptions for azathioprine decreased just before and during pregnancy and increased after birth. Number of prescriptions for local and systemic corticosteroids decreased approximately 30% compared with before pregnancy and increased in the second trimester. There was an increased risk among mothers with IBD of LBW (adjusted odds ratio [adjOR]: CD: 2.25 [95% confidence interval {CI}, 1.74-2.91], UC: 1.81 [95% CI, 1.42-2.30]), preterm birth (adjOR: CD: 2.54 [95% CI, 2.04-3.15], UC: 1.86 [95% CI, 1.52-2.27]), and SGA (adjOR: CD: 1.99 [95% CI, 1.26-3.15], UC: 1.80 [95% CI, 1.18-2.75]).

CONCLUSION

Use of azathioprine and corticosteroids was often reduced or discontinued before or during early pregnancy followed by an increased use of corticosteroids later in pregnancy. Women diagnosed with IBD and with prescriptions for azathioprine and/or corticosteroids, have an increased risk of LBW, pre-term birth, and SGA. Birth Defects Research (Part A) 106:494-499, 2016. © 2016 Wiley Periodicals, Inc.

Communication of alcohol and smoking lifestyle advice to the gastroenterological patient

Effective communication between healthcare staff and patients is central to development of the patient-professional relationship. Many barriers influence this communication, often resulting in patients' lack of understanding and retention of information, particularly affecting advice regarding lifestyle habits, such as alcohol consumption and smoking. Alcohol and smoking misuse are potentially modifiable risk factors known to adversely affect a variety of gastroenterological conditions and improvements in communication with patients regarding this is an important management component. This review discusses the clinical impact of these factors and how healthcare professionals can improve communication. We discuss how enhancing verbal communication skills through medical training leads to greater outcomes in patient satisfaction and adherence to treatment and advice. In addition, with the rapid digitalisation of society, platforms such as social media and smartphone applications may be considered as adjuncts to traditional forms of communication.

Smoking is Associated with Higher Disease-related Costs and Lower Health-related Quality of Life in Inflammatory Bowel Disease

BACKGROUND AND AIMS

Smoking affects the course of inflammatory bowel disease [IBD]. We aimed to study the impact of smoking on IBD-specific costs and health-related quality-of-life [HrQoL] among adults with Crohn's disease [CD] and ulcerative colitis [UC].

METHODS

A large cohort of IBD patients was prospectively followed during 1 year using 3-monthly questionnaires on smoking status, health resources, disease activity and HrQoL. Costs were calculated by multiplying used resources with corresponding unit prices. Healthcare costs, patient costs, productivity losses, disease course items and HrQoL were compared between smokers, never-smokers and ex-smokers, adjusted for potential confounders.

RESULTS

In total, 3030 patients [1558 CD, 1054 UC, 418 IBD-unknown] were enrolled; 16% smoked at baseline. In CD, disease course was more severe among smokers. Smoking was associated with > 30% higher annual societal costs in IBD (€7,905 [95% confidence interval €6,234 - €9,864] vs €6,017 [€5,186 - €6,946] in never-smokers and €5,710 [€4,687 - €6,878] in ex-smokers, p = 0.06 and p = 0.04, respectively). In CD, smoking patients generated the highest societal costs, primarily driven by the use of anti-tumour necrosis factor compounds. In UC, societal costs of smoking patients were comparable to those of non-smokers. Societal costs of IBD patients who quitted smoking > 5 years before inclusion were lower than in patients who quitted within the past 5 years (€ 5,135 [95% CI €4,122 - €6,303] vs €9,342 [€6,010 - €12,788], p = 0.01). In both CD and UC, smoking was associated with a lower HrQoL.

CONCLUSIONS

Smoking is associated with higher societal costs and lower HrQoL in IBD patients. Smoking cessation may result in considerably lower societal costs.

Outcome of inflammatory bowel disease patients treated with TNF-α inhibitors: two-year follow-up

BACKGROUND

Biological medications, particularly TNF-α inhibitors, are used increasingly for active inflammatory bowel disease (IBD). Even though they are superior to many older medications in achieving remission and mucosal healing, primary nonresponse and loss of response remain significant problems, and a remarkable proportion of patients still need surgery at some point.

OBJECTIVE

To study the outcome of IBD patients treated with TNF-α inhibitors, either infliximab or adalimumab, with a two-year follow-up.

PATIENTS AND METHODS

Patient data from the hospital electronic patient documents of IBD patients treated with TNF-α inhibitors were studied. The main targets of interest were treatment response, the remission rate and the number of patients operated, as well as reasons for the discontinuation of treatment. Remission was defined both endoscopically and by faecal calprotectin.

RESULTS

Altogether 100 patients were included. Only 29% of the patients achieved remission during the two-year follow-up. 26% of the Crohn's disease patients and 36% of the ulcerative colitis patients underwent surgery during the follow-up. A significant proportion of patients experienced side effects of the medication (21%) or discontinued the therapy for other reasons (altogether 63%).

CONCLUSIONS

In this single centre study of 100 IBD patients treated with TNF-α inhibitors, less than one-third of the patients achieved remission, and a significant proportion had side effects and needed surgery during the two-year follow-up. There is an obvious need for more effective therapies with less side effects for IBD patients.

Total and cancer mortality in a cohort of ulcerative colitis and Crohn's disease patients: The Florence inflammatory bowel disease study, 1978-2010

BACKGROUND

There is no consensus on the leading causes of death among inflammatory bowel diseases (IBD) patients.

AIM

We present the results of an extended follow-up of the population-based Florence IBD cohort, including 689 ulcerative colitis and 231 Crohn's disease patients.

METHODS

The causes of death of cohort members were determined through linkage with the local mortality registry. We calculated standardized mortality ratios (SMR) and 95% confidence intervals (95%CI) by applying gender-, age- and calendar time-death rates to person-years at risk.

RESULTS

Ulcerative colitis patients had overall mortality comparable to the general population (SMR 0.99, 95%CI 0.85-1.14), though being at increased risk of dying from Hodgkin's disease (SMR 11.74, 95%CI 2.94-46.94), rectal cancer (SMR 3.69, 95%CI 1.66-8.22) and Alzheimer's disease (2.40, 95%CI 1.00-5.76). Crohn's disease patients had an increased overall mortality (SMR 1.79, 95%CI 1.39-2.27) and were at higher risk of dying from cancer (SMR 2.57, 95%CI 1.28-5.13) and non-cancer diseases of the respiratory system (SMR 2.51, 95%CI 1.05-6.04), brain cancer (SMR 6.26, 95%CI 1.57-25.02) and non-cancer diseases of the genitourinary system (SMR 4.38, 95%CI 1.10-17.52).

CONCLUSIONS

IBD patients should be offered counselling on risk reduction strategies, as much of their mortality excess is potentially avoidable.

Systematic review with meta-analysis: the effect of tobacco smoking on the natural history of ulcerative colitis

BACKGROUND

Tobacco smoking is associated with a reduced risk of developing ulcerative colitis (UC). A high proportion of UC patients perceive a benefit in disease outcomes secondary to smoking. However, the effects of smoking on the natural history of UC are uncertain.

AIM

To conduct a systematic review and meta-analysis of the effects of tobacco smoking on the natural history of UC.

METHODS

A search of MEDLINE, EMBASE and EMBASE classic was carried out (up to December 2015) to identify observational studies reporting data on smoking and rates of colectomy, flare of disease activity, proximal disease extension, and development of pouchitis following panproctocolectomy and ileal pouch-anal anastomosis in patients with UC. Dichotomous data were pooled to obtain odds ratios (ORs), with 95% confidence intervals (CIs).

RESULTS

The search identified 16 eligible studies: five (2615 patients) studying colectomy; four (620 patients) reporting on flare of disease activity; four (687 patients) examining proximal disease extension and three (355 patients) assessing development of pouchitis. Compared with nonsmokers, the odds of colectomy (OR = 0.89; 95% CI 0.62-1.26), flare of disease activity (OR = 1.26; 95% CI 0.65-2.44), proximal extension of disease (OR = 0.57; 95% CI 0.20-1.66) or the development of pouchitis (OR = 0.57; 95% CI 0.21-1.53) were not significantly lower in smokers.

CONCLUSIONS

Smoking may not improve the natural history of ulcerative colitis. Given the health benefits of smoking cessation and the lack of clear benefit in ulcerative colitis, smoking cessation advice should be incorporated into guidance on the management of ulcerative colitis.

Smoking Cessation for Crohn's Disease: Clearing the Haze

The TABACROHN Study Group conducted a multicenter prospective cohort study, demonstrating that smoking cessation improved the prognosis of Crohn's disease. Patients who continued to smoke were 50% more likely to relapse compared with non-smokers. Smoking cessation reduced the risk of flaring, regardless of exposure to anti-tumor necrosis factor agents. Despite the evidence that smoking cessation is beneficial, many patients do not quit smoking after their diagnosis of Crohn's disease. Lack of awareness, physical addiction, and social context of smoking inhibit smoking cessation. In spite of this, comprehensive smoking cessation programs have been shown to be effective and reduce costs.

Systematic review with meta-analysis: the adverse effects of tobacco smoking on the natural history of Crohn's disease

BACKGROUND

Tobacco smoking is a well-established risk factor for the development of Crohn's disease, and this may lead to a more complicated disease course. However, recent evidence suggests that many patients with Crohn's disease are unaware of this fact.

AIM

To perform a systematic review and meta-analysis of the effects of smoking on disease course in Crohn's disease.

METHODS

A search of MEDLINE, EMBASE and EMBASE classic was carried out (up to July 2015) to identify observational studies reporting data on smoking and rates of surgery or flares of disease activity in patients with Crohn's disease. Dichotomous data were pooled to obtain odds ratios (ORs) for flares of disease activity or need for surgery, with 95% confidence intervals (CIs).

RESULTS

The search identified 33 eligible studies. Compared with nonsmokers, smokers had increased odds of flare of disease activity (OR, 1.56; 95% CI, 1.21-2.01), flare after surgery (OR, 1.97; 95% CI, 1.36-2.85), need for first surgery (OR, 1.68; 95% CI, 1.33-2.12) and need for second surgery (OR, 2.17; 95% CI, 1.63-2.89). The odds of these outcomes among ex-smokers diminished upon smoking cessation, with ORs comparable to those among nonsmokers and, in the case of flare or second surgery, significantly lower than smokers.

CONCLUSIONS

Smokers with Crohn's disease have a more complicated disease course than nonsmokers, and quitting smoking may ameliorate this. Patients should be reminded of the detrimental effects of smoking on the course of their disease, and smoking cessation advice should be provided to reduce disease burden and costs in these patients.