Attitudes toward smoking and smoking behaviors of patients with Crohn's disease

Residential treatment exclusively for smoking cessation in patients with Crohn’s disease: Results from a pilot study

INTRODUCTION

Cigarette smoking is a risk factor for the induction and severity of the course of Crohn’s disease (CD). Hospital admission may be required for treatment of the disease but is generally not available solely for smoking cessation. Outpatient group therapy is readily available, however long-term quit rates are limited. Residential treatment for smoking cessation may offer a more intense contact between patient and therapist, and may result in higher abstinence rates in a sensitive group of patients. The objective of this pilot study is to evaluate the feasibility of implementing a residential program with hospital admission, exclusively for smoking cessation for patients suffering from CD.

METHODS

Twelve eligible smokers suffering from CD were recruited for a 9-day inpatient smoking cessation treatment. Treatment consisted of single and group behavioral therapy together with supportive measures such as exercise therapy, relaxation techniques or nutritional counselling. Nicotine replacement therapy or prescription medication was offered according to the Fagerström test for nicotine dependence (FTND) score and treatment guidelines. Quit rates were assessed by CO-testing during hospital treatment and by follow-up calls 6 months after discharge.

RESULTS

All recruited participants arrived on time for treatment and collectively stopped smoking on the 2nd day after admission. All participants completed the therapy process without relapse and left the hospital smoke-free (100% quit rate on discharge, CO monitored). Self-reported abstinence rates after 6 months were 72.7% for continuous abstinence and 81.8% for 7-day point prevalence abstinence.

CONCLUSIONS

Residential treatment exclusively for smoking cessation is feasible and efficient and may be a valuable treatment option for patients suffering from CD.

Patients' perspectives on smoking and inflammatory bowel disease: An online survey in collaboration with European Federation of Crohn's and Ulcerative Colitis Associations

BACKGROUND

Smoking has detrimental effects on Crohn’s disease (CD) activity while data on ulcerative colitis (UC) are conflicting. Little is known about the use and impact of alternative smoking products in inflammatory bowel diseases (IBD).

AIM

To understand the patients’ perceptions of the impact of smoking on their IBD and to assess differences between CD and UC patients.

METHODS

The questionnaire was developed by Philip Morris Products SA in cooperation with European Federation of Crohn's and Ulcerative Colitis Associations. The final survey questionnaire consisted of 41 questions divided in 8 categories: (1) Subject screener; (2) Smoking history; (3) Background information; (4) IBD disease background; (5) Current disease status; (6) Current therapeutics and medications; and (7) Current nicotine/cigarettes use and awareness of the impacts of smoking on IBD. The questionnaire was submitted online from 4^th November 2019 to 11th March 2020 through the European Federation of Crohn's and Ulcerative Colitis Associations website to IBD patients who were current smokers or had a history of smoking.

RESULTS

In total 1050 IBD patients speaking nine languages participated to the survey. Among them, 807 (76.9%) patients declared to have ever smoked or consumed an alternative smoking product, with a higher proportion of current cigarette smokers among CD patients (CD: 63.1% vs UC: 54.1%, P = 0.012). About two-thirds of the participants declared to have ever stopped cigarette smoking and restarted (67.0%), with a significantly higher proportion among UC patients compared to CD patients (73.1% vs 62.0%, P = 0.001). We also found significant differences between CD and UC patients in the awareness of the health consequences of smoking in their disease and in the perceived impact of smoking on disease activity, for both cigarettes and alternative smoking products.

CONCLUSION

This survey found significant differences between CD and UC patients in both awareness and perception of the impact of smoking on their disease. Further efforts should be done to encourage smoking cessation for all IBD patients, including UC patients.

The effect of a multidisciplinary approach for smoking cessation in patients with Crohn's disease: Results from an observational cohort study

INTRODUCTION

Cigarette smoking is the most important risk factor for Crohn’s disease (CD). The effectiveness of smoking cessation programs (SCPs) in patients with CD is still poorly understood.

METHODS

This was a retrospective, observational, single-centre, cohort study of 136 active smokers with mean age 55 years (SD=11), 58% males, including 27 (19.8%) patients with CD who entered the multidisciplinary SCP of the Luigi Sacco University Hospital of Milan from January 2017 through January 2019. A pulmonologist was responsible for the clinical and pharmacological management, while a psychiatrist and a psychologist conducted the counselling and assessed the motivation to quit, anxiety and depression using the Brief Psychiatric Rating Scale (BPRS) and the nicotine dependence with the Fagerström test. Patients were defined as quitters after 12 months.

RESULTS

Demographic and clinical characteristics, and Fagerström score, did not differ in patients with and without CD. At baseline, patients with CD had a higher BPRS (median: 27, IQR: 22–32; vs 25 and 22–28.5; p=0.03), and a lower motivation to quit score (median: 10, IQR: 9–13; vs 14 and 12–15; p<0.001). After 12 months, the quitting rate of smokers with CD was significantly lower (14.8% vs 36.7%; p<0.022) and the chance of quitting was negatively associated with the baseline BPRS (r=-0.256; p<0.003). Varenicline and nicotine replacement therapy tended to be less effective in patients with CD.

CONCLUSIONS

The lower efficacy of SCPs in patients with CD might be secondary to a higher prevalence of anxiety and depression. Psychological issue recognition and support should be enhanced to increase SCP effectiveness in CD.

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.

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

BACKGROUND

The detrimental effect of smoking on development and progression of Crohn's disease (CD) is generally accepted.

AIM

To evaluate the awareness of smoking risks in a Belgian inflammatory bowel disease (IBD) population.

METHODS

In the out-patient clinic of a tertiary referral centre, 625 consecutive patients with CD, 238 patients with ulcerative colitis (UC) and 289 non-IBD controls, filled out a simple questionnaire. This questionnaire included data on smoking behaviour and awareness of smoking-related health effects, including effects on IBD.

RESULTS

At diagnosis, more CD patients were active smokers compared to UC (40% vs. 17%, P < 0.001). Remarkably, smoking cessation rates after diagnosis were similar for CD and UC (both 56%, P = 0.997). The great majority recognised a detrimental influence of smoking on general health (98-99%), lung cancer (95-97%), myocardial infarction (89-92%) and stroke (78-87%). Although CD patients more frequently acknowledged risks of smoking on their disease, only 37% were aware of a link with CD development, 30% of increased surgical rates and 27% of increased post-operative CD recurrence. Active smokers more frequently denied an increased risk of surgery and higher post-operative CD recurrence. Intriguingly, within the active smokers with CD, those not willing to quit smoking most often denied a potential bad influence of smoking. Taking into account disease duration, previous surgery, education level, working status and nicotine dependence, we were unable to define specific subgroups of patients requiring extra education.

CONCLUSION

Although patients with Crohn's disease were better informed on the detrimental effects of smoking, the awareness rate was still low.

Beliefs and behaviour about smoking among inflammatory bowel disease patients

BACKGROUND AND AIMS

We investigated the beliefs and behaviours about tobacco among inflammatory bowel disease (IBD) patients.

MATERIALS AND METHODS

A questionnaire of 18 items was developed and administered to all consecutive patients followed for IBD at Nancy University Hospital from October 2012 to March 2013.

RESULTS

Two hundred and thirty-one patients participated in the survey [Crohn's disease (CD)=171, ulcerative colitis (UC)=60]. Among IBD patients who were smokers at diagnosis, 10.5% of CD patients versus 14.3% of UC patients believed that tobacco could have triggered their IBD; about half the CD smokers at diagnosis were not aware that smoking might promote their disease. Three quarters of smokers after diagnosis knew that tobacco was not beneficial for their CD, whereas all UC were aware that smoking had a beneficial effect on their disease course. About half of the CD patients had stopped smoking during a flare-up. Four former smokers with UC (21.1%) resumed smoking during a relapse. Nearly 90% of IBD current smokers wished to quit smoking. About half the IBD patients were aware of the relation between smoking and IBD, and the Internet was a source for 24.3% of these patients.

CONCLUSION

The majority of IBD patients are unaware of the effects of tobacco on their disease. Better information through a therapeutic education programme should be systematically recommended in IBD.

Delivering optimal care for inflammatory bowel disease patients in Scotland in 2014

The inflammatory bowel diseases (IBDs), Crohn's disease and ulcerative colitis, present an ever increasing burden to the healthcare systems in the Western world. Scotland in particular has seen a significant increase in both diseases, particularly Crohn's disease. It is thus of paramount importance that secondary care services within Scotland are equipped to cope with this increased demand at a time when the treatment options are broadening, patients expectations are increasing and healthcare budgets face major restriction. This article outlines some aspects of optimal delivery of an IBD service in secondary care.

High smoking cessation rate in Crohn's disease patients after physician advice--the TABACROHN Study

INTRODUCTION

Tobacco smoking has a significant impact on the development of Crohn's disease (CD) and its clinical course, making smoking cessation one of the main goals in CD therapeutic strategy.

AIMS

To evaluate the effectiveness of an advice-based smoking cessation strategy among CD patients.

METHODS

We have performed a prospective multicenter study which enrolled 408 CD smokers. At inclusion all patients were instructed about the risks of smoking and subsequently followed every 3 months. Each center used additional smoking cessation strategies based on available resources. Urinary cotinine and exhaled carbon monoxide levels were evaluated in a subgroup of patients.

RESULTS

Median study follow up was 18 months. 31% of the patients achieved complete smoking cessation and 23% were smoking-free at the end of their follow up with 8% of smoking relapse. Most patients not achieving smoking cessation did not change their smoking habit with only 5% presenting a decrease in tobacco load. 63% of patients willing to quit smoking received help from another specialist, most frequently the pulmonologist (47%). Surprisingly, most patients (88%) tried to quit smoking with no pharmacological therapy and bupropion, varenicline and nicotine replacement treatment were used in few patients. Urinary cotinine and exhaled CO levels tested in a subgroup of patients proved to have a good correlation with the self-reported smoking habit. No predictors of successful smoking cessation were identified.

CONCLUSION

Our results underline that an anti-tobacco strategy mostly based on CD patients's education and counseling is feasible and effective in helping patients reach complete abstinence.

Assessment of variables associated with smoking cessation in Crohn's disease

BACKGROUND

Patients with Crohn's disease (CD) who smoke have a more complicated disease course.

AIMS

Our primary objective was to assess smoking related variables that were associated with smoking cessation versus continued smoking in patients with CD.

METHODS

A multi-center study identified CD patients who were seen at the University of Chicago and University of Calgary IBD clinics. Patients were categorized into three subgroups: lifetime non-smokers, current smokers, or ex-smokers. Participants completed questionnaires assessing their cigarette smoking behavior. Current smokers were prospectively followed for 6 months to assess smoking status and attempts to quit. Logistic regression analysis was performed to identify factors associated with smoking cessation.

RESULTS

Three hundred patients were enrolled with 148 identifying themselves as lifetime non-smokers, 70 as current smokers, and 82 as ex-smokers. Patients who reported their first cigarette within 5 min of waking were more likely to be current smokers (OR = 21; 95% CI 3.94-107.3) as compared to patients who waited greater than 60 min. Current smokers were more likely to have one or more household members who smoked compared to ex-smokers (P < 0.05). Nearly half (49%) of the current smokers were in the precontemplation stage of change (i.e. no intention to quit smoking). At the 6-month follow-up, only 11% reported they quit smoking.

CONCLUSIONS

Patients who report a short time to first cigarette in the morning may have more difficulty in smoking cessation. Current smokers were more likely to have another smoker in the household compared to ex-smokers. Current smokers had low levels of motivation to quit smoking and consequently with no intervention, very few quit 6 months after the baseline assessment.

Management of Crohn's disease in smokers: is an alternative approach necessary?

Inflammatory bowel disease is a chronic condition with a pathogenic background that involves both genetic and environmental factors. Although important progress has been made regarding the former in the last decade, scarce knowledge is available for the latter. In this sense, smoking remains the most important environmental factor in IBD. Active smoking increases the risk of developing Crohn's disease (CD). Moreover, CD patients who start or continue smoking after disease diagnosis are at risk for poorer outcomes such as higher therapeutic requirements and disease-related complications, as compared to those patients who quit smoking or who never smoked. However, the harmful effect of active smoking is not uniform in all patients or in all clinical scenarios. Interventions designed to facilitate smoking cessation may impact the course of the disease. In this article, the available evidence of the deleterious effects of smoking on CD is reviewed in detail, and alternative therapeutic approaches to CD in smokers are proposed.

Smoking cessation strategies in Crohn's disease

Although smoking cessation is one of the most effective interventions in patients with Crohn's disease, the prevalence of smoking in these patients is higher than in the general population, and much higher than in patients with other smoking-related diseases. There is a lack of awareness of the benefits of cessation among patients and general practitioners, and a lack of engagement in smoking cessation by specialists. This article discusses the strategies that practitioners can use to motivate patients to quit and how the success of a quitting attempt can be maximised.

Tobacco dependence and awareness of health risks of smoking in patients with inflammatory bowel disease

BACKGROUND AND AIM

Smoking is a risk factor for developing Crohn's disease (CD) and worsens its outcome. Conversely, in ulcerative colitis (UC), the onset may be triggered by the smoking cessation and smoking may be beneficial. To help to ascertain whether patients with inflammatory bowel disease (IBD) would benefit from attending a smoking cessation clinic, we assessed: first, the prevalence of smoking; second, patients' awareness of the effects of smoking, and finally nicotine dependence in IBD patients compared with the healthy and disease-matched controls.

METHODS

A total of 246 consecutive IBD outpatients (173 patients with CD, 73 patients with UC) completed a questionnaire on smoking habits and its effect on IBD. Smokers were assessed for dependence using the Fagerstrom test for nicotine dependence (FTND) score and their results were compared with those of age, sex, and ethnicity-matched healthy (five controls for each IBD patient) and asthma controls (one control for each IBD patient) attending a smoking cessation clinic.

RESULTS

Thirty five out of 173 patients (20%) with CD and nine out of 73 patients (12%) with UC were current smokers, with 52 out of 173 patients (30%) with CD and 28 out of 73 patients (38%) with UC being ex-smokers. Ninety out of 173 patients (52%) with CD knew that smoking worsens CD, whereas only 15 out of 73 patients (21%) with UC knew of the beneficial effects of smoking on their disease (P=0.032). Knowledge was unrelated to smoking status. In patients with CD, the median (range) FTND score was 3 (0-8) compared with 7 (2-10) in healthy (P<0.001) and 6 (2-9) in asthma controls (P<0.0001). Only seven of the 35 (20%) smoking patients with CD were highly dependent (FTND score ≥6). Similarly, in the patients with UC, the FTND score was 1 (0-4), lower than in healthy, [6 (2-10)], and asthma controls, [7 (4-10); (P<0.004 for both groups)].

CONCLUSION

Patients with CD were better informed about the effects of smoking on their own disease than the patients with UC. Nicotine dependence in IBD patients is lower than in smokers' clinic clients and comparable with that of the general population. Their low nicotine dependence suggests that most IBD patients could be weaned off the smoking habit successfully in the IBD clinic and referral to a smoking cessation clinic was offered to the highly dependent minority and others expressing interest in attending.

The impact of smoking in Crohn's disease: no smoke without fire

Smoking habit is the most widely accepted environmental factor affecting the incidence and disease progression in the inflammatory bowel diseases. The contrasting effects in Crohn's disease (CD) and ulcerative colitis are unexplained. The purpose of this review is to summarise the existing data on the effects of smoking in CD on disease history, recurrence after surgery, effects on drug responses and to review available evidence that carriage of some of the known susceptibility genes may be disproportionate in smokers with CD. The review also highlights potential mechanisms involved and factors that might affect patients' smoking habits. The clinical and scientific implications of the data are discussed.

Active and passive smoking behaviour and cessation plans of patients with Crohn's disease and ulcerative colitis

BACKGROUND

Smoking is a remarkable risk factor in inflammatory bowel disease (IBD), with negative effects on Crohn's disease (CD) and positive effects on ulcerative colitis (UC). This makes different changes in smoking behaviour after diagnosis between CD and UC likely. Changes in active smoking, cessation plans and passive smoking were studied in IBD patients.

METHODS

820 IBD patients were sent a questionnaire on active and passive smoking, and cessation plans. A total of 675 (82%) patients (380 CD and 295 UC) responded.

RESULTS

More ever smoking UC patients stopped smoking before diagnosis than CD patients (63% vs 22%; p<0.001), resulting in 30% former smokers at diagnosis in UC and 13% in CD (p<0.001). The smoking cessation rates at and after diagnosis are equal between CD and UC. Half of the CD patients stopped smoking after diagnosis leading to less present smokers in CD than in a control population (26% (95% confidence interval: 21.1%-29.9%) vs 33%). For both CD (22% vs 35%; p=0.044) and UC (24% vs 53%; p=0.024) continuing smokers after diagnosis were less often higher educated than quitters. Cessation plans (89%), passive smoking in childhood and present passive smoking were not different between CD and UC patients.

CONCLUSION

There are no differences in changes in smoking behaviour at and after diagnosis between CD and UC patients, suggesting a lack of knowledge in these patients about the link between their disease and smoking behaviour. However, CD patients seem less refractory to smoking cessation than the general population. Therefore it is worthwhile putting energy in helping CD patients stop smoking.

Is the personality characteristic "impulsive sensation seeking" correlated to differences in current smoking between ulcerative colitis and Crohn's disease patients?

BACKGROUND

Crohn's disease (CD) is associated with smoking, while ulcerative colitis (UC) is largely a disease of nonsmokers. We aimed to test whether the smoking-linked personality characteristic "impulsive sensation seeking" (ImpSS) is correlated to the differences in smoking in inflammatory bowel disease (IBD).

METHODS

In 185 IBD patients, the General Health Questionnaire and the Zuckerman-Kuhlman Personality Questionnaire (ZKPQ) were administered. The Fagerstrom Test for Nicotine Dependence was used to assess smokers' nicotine dependence.

RESULTS

CD patients were twice as likely to be active smokers than UC patients. CD patients presented higher ImpSS scores than UC patients, but the differences became nonsignificant after adjustment for age, gender, education and psychological distress. Multivariate analyses, however, showed that the relationship of ImpSS with current smoking was stronger in CD patients. Moderator analysis showed that the relationship of ImpSS with nicotine dependence was also greater in smokers with CD than in those with UC. No other ZKPQ subscale was correlated to disease type, current smoking or nicotine dependence.

CONCLUSION

ImpSS is associated with current smoking and nicotine dependence in IBD, and these associations are stronger in CD. These findings might be relevant to more effective interventions aiming at smoking cessation in CD patients.

Smoking and inflammatory bowel disease: a meta-analysis

OBJECTIVE

To assess whether there is a true effect of smoking on the 2 most prevalent forms of inflammatory bowel disease (IBD): Crohn disease (CD) and ulcerative colitis (UC).

METHODS

For this meta-analysis, we searched multiple health care databases, including MEDLINE and EMBASE (January 1980 to January 2006), to examine the relationship between smoking and IBD. Keywords searched included smoking, Inflammatory bowel disease, Crohn's disease, and ulcerative colitis. Data were abstracted using predefined inclusion and exclusion criteria. An odds ratio (OR) was recalculated for each study using the random-effects model, and a combined OR was calculated.

RESULTS

A total of 245 articles were obtained through an electronic search of health care databases. Thirteen studies examined the relationship between UC and smoking, whereas 9 examined the relationship between CD and smoking. We found evidence of an association between current smoking and CD (OR, 1.76; 95% confidence interval [CI], 1.40-2.22) and former smoking and UC (OR, 1.79; 95% CI, 1.37-2.34). Current smoking had a protective effect on the development of UC when compared with controls (OR, 0.58; 95% CI, 0.45-0.75).

CONCLUSION

This is the first meta-analysis, to our knowledge, to evaluate the relationship between smoking and IBD using accepted quality standards for meta-analysis reporting. Our meta-analyses confirm that smoking is an important environmental factor in IBD with differing effects in UC and CD. By using predefined inclusion criteria and testing for homogeneity, the current analysis provides an estimate of the effect of smoking on both these forms of IBD.

Inflammatory bowel disease and smoking: a review of epidemiology, pathophysiology, and therapeutic implications

The relationship between smoking behavior and inflammatory bowel disease (IBD) is complex. While Crohn's disease (CD) is associated with smoking and smoking has detrimental effects on the clinical course of the disease, ulcerative colitis (UC) is largely a disease of nonsmokers and former smokers. Furthermore, cigarette smoking may even result in a beneficial influence on the course of ulcerative colitis. The potential mechanisms involved in this dual relationship include changes in humoral and cellular immunity, cytokine and eicosanoid levels, gut motility, permeability, and blood flow, colonic mucus, and oxygen free radicals. Nicotine is assumed to be the active moiety. The differential therapeutic consequences comprise the cessation of smoking in CD and, so far, clinical trials using nicotine in different forms of application for UC. In this article, we review the relationship between cigarette smoking and IBD, considering epidemiological, pathogenetic, and clinical aspects.

Tobacco and IBD: relevance in the understanding of disease mechanisms and clinical practice

Current smoking protects against ulcerative colitis and, after onset of the disease, improves its course, decreasing the need for colectomy. However, smoking increases the risk of developing Crohn's disease and worsens its course, increasing the need for steroids, immunosuppressants and reoperations. Smoking cessation aggravates ulcerative colitis and improves Crohn's disease. The effects of smoking are the sum of contradictory effects of various substances, including nicotine and carbon monoxide, and are modulated by gender, genetic background, disease location and activity, cigarette dose and nicotine concentration. Smokers with ulcerative colitis should not be discouraged from stopping smoking but encouraged to stop, to reduce their risk of cardiopulmonary tobacco-related diseases. In Crohn's disease, smoking cessation has become a major therapeutic goal, particularly in young women and in patients with ileal involvement. A large amount of supportive information, use of nicotine-replacement therapies and antidepressants, and individual counselling might aid the patient in quitting.