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

https://doi.org/10.1016/j.bpg.2003.12.003Get rights and content

Abstract

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.

Section snippets

Risk of developing ulcerative colitis

Ulcerative colitis affects predominantly non-smokers and former smokers.3 The percentage of current smokers (smoking more than seven cigarettes per week) in a group of patients with UC is about 10–15%.4., 5., 6. These percentages are significantly lower than those observed in a control population matched for sex and age (25–40%). The meta-analysis by Calkins3 yielded a pooled odds ratio of 0.41 (0.34–0.48) for current smokers compared with lifetime non-smokers. The effect of smoking is only

Sex-based differences

The effect of smoking shows some differences between male and female patients. In CD, women are more affected by smoking. The study by Sutherland et al.32 first reported a doubled proportion of early postoperative recurrences in female smokers compared to female non-smokers, whereas there was no significant differences between male smokers and non-smokers. In Crohn's colitis, smoking is clearly harmful in women, whereas colitis of men is not affected by smoking.4 In UC, Motley et al.37 noticed

Ulcerative colitis

Stopping smoking increases the risk of developing UC when compared to never-smokers. This increased risk—about 1.64 (1.36–1.98)3—persists during the 2 to 3 years following smoking cessation.37 A link between smoking habit and UC course in intermittent smokers has also been reported. Many patients note symptom exacerbation when they stop smoking, followed by symptom relief when they smoke again.37 Moreover, smokers with UC who quit experience an increase in disease activity, hospital admissions

Smoking and the disease mechanisms

The reasons why smoking has an opposite effect in CD and UC remain obscure. The understanding of this duality is complicated by the variability of the effects according to the populations studied, the absence of an appropriate animal model and the complexity of tobacco smoke, which contains hundreds of different substances including nicotine, free radicals and carbon monoxide.

Therapeutic implications

From a therapeutic point of view, the relationship between smoking and IBD leads to a discussion on the therapeutic value of nicotine and the modalities of smoking cessation in UC and CD, respectively.

Summary and conclusion

Smoking modifies the risk of developing IBD, increasing the risk of CD and decreasing that of UC. In an individual genetically at risk for IBD, smoking might be the main factor determining the phenotype of the disease, either UC or CD. In addition, smoking exerts a considerable effect on the course of the disease, improving UC and worsening CD, and smoking cessation is followed rapidly by reversal of the effect. Nicotine, carbon monoxide and possibly other substances of tobacco smoke exert

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