Knowing "How" and "Why" to Quit Leads to Smoking Cessation


A new study published online ahead of print in Arthritis Care & Research sheds light on the barriers rheumatology patients face with regards to smoking cessation while describing individual reactions to cessation protocols and identifying patient centered outcomes after improvements in care.



A new study published online ahead of print inArthritis Care & Researchsheds light on the barriers rheumatology patients face with regards to smoking cessation while describing individual reactions to cessation protocols and identifying patient centered outcomes after improvements in care.

It is well known that smoking is a leading risk factor for cardiovascular disease (CVD) as well as increased disease activity in rheumatic disease. The European League Against Rheumatism (EULAR) strongly recommends smoking cessation care for all rheumatology patients.

Even though strong recommendations exist, only 10 percent of rheumatology visits with patients who smoke included documentation of cessation counseling or follow-up advice. 

Dr. Christine Bartels, M.D., and colleagues in Wisconsin and Iowa point out that,

“Both the central role of rheumatology clinics and the increased risk of CVD among patients with rheumatologic disease highlight the critical need to address smoking within rheumatology encounters to reduce smoking- related morbidity and mortality.“

Prior research has shown that patients with SLE who have ever smoked have higher disease activity and higher chronic damage index scores than those without a history of smoking. Further, Patients with RA who smoke require more disease-modifying anti-rheumatic drugs (DMARDs) and are less likely to respond to methotrexate and tumor necrosis factor inhibitors than those who previously or never smoked.

Based on these facts and since smoking is well known to increase the risk of CVD in rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE) patients, the authors chose to focus on these populations in this study.


The authors recruited 19 adult patients (12 with RA and 7 with SLE) in 2016 from two health systems to participate in one of three focus groups about smoking cessation. Inclusion criteria included having a diagnosis of RA or SLE, seeing a rheumatologist within one of the two health systems, and having a recent history of daily smoking.

Two experienced focus group facilitators led one-hour focus groups using a semi- structured interview guide that addressed three main topics.

1) Part one explored patients’ experiences of barriers and facilitators within conversations.
2)  Part two elicited feedback on a short video demonstrating the new Quit Connect protocol, where the rheumatology nurse or medical assistant (MA) asks about the patient’s readiness to quit and offers an electronic referral to the state tobacco quitline.
3) Part three identified and prioritized patient-centered outcomes that might occur as a result of the protocol.

Psychological barriers to smoking cessation included the desire to maintain a sense of control, the use of smoking as a coping mechanism, and a history of addiction to tobacco and other substances.

The authors found that “Many viewed smoking as “a crutch,” “a comfort,” and “the one thing I still have control over” while dealing with the burden of rheumatic disease, social and economic strain, and other stressors.”

One prominent facilitator for cessation was the way in which visible negative health effects of smoking could provide motivation to quit. Less common facilitators to cessation included a desire to minimize the costs of cigarettes, social stigma, and the smell of smoke.

Patients who received counseling, most appreciated information on the rheumatology- specific negative health effects of smoking. Most participants felt that rheumatology staff should find a balance between talking about smoking cessation and providing a non-judgmental place to discuss it.

Patients liked the Quit Connect protocol, which affirmed readiness to quit, discussed smoking risk in rheumatic disease, and offered resources to quit. As for desired outcomes nearly all participants rated cutting down or quitting smoking as an important outcome, and nearly all wanted to quit eventually.

Beyond smoking cessation itself, the two new outcomes that participants reported as most valuable were:
1) Knowing that smoking can exacerbate rheumatic diseases and reduce medication efficacy.
2) Knowing how to find resources to make changes to smoking behavior.


Smoking cessation represents the quintessential modifiable risk factor/ lifestyle modification for clinicians. Very few such factors have a greater impact on the health and wellbeing of rheumatology patients and the general population as a whole.

Here the authors uncover barriers and effective strategies directly from the patients themselves aimed at increasing the likelihood of successful cessation. What patients want is information as motivation to quit.

Clinicians should provide point-of-care advice in rheumatology clinics on smoking cessation strategies while connecting patients to recourses like quitlines. Finally, the authors suggest that,

“Emphasizing the rheumatology-specific why and the resource-specific how of smoking cessation is important when designing and evaluating smoking cessation interventions for use in rheumatology clinics. “


Gregory M. Weiss, M.D., is a cardiothoracic anesthesiologist practicing in Virginia. He is a frequent contributor to Rheumatology Network.


Wattiaux, A. , Bettendorf, B. , Block, L. , et al. Patient Perspectives on Smoking Cessation and Interventions in Rheumatology Clinics. Arthritis Care Research. (2019), Accepted Author Manuscript. doi:10.1002/acr.2385

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