3.18 Other conditions with possible links to smoking

Last updated: March 2015
Suggested citation: Hurley, S, Greenhalgh, EM & Winstanley, MH. 3.18 Other conditions with possible links to smoking. In Scollo, MM and Winstanley, MH [editors]. Tobacco in Australia: Facts and issues. Melbourne: Cancer Council Victoria; 2015. Available from http://www.tobaccoinaustralia.org.au/3-18-other-conditions-with-possible-links-to-smoking


This section provides information about the many other conditions (in addition to those discussed in Sections 3.1 to 3.17) that have been linked to smoking. The list of conditions discussed in this section is comprehensive but not exhaustive; because cigarette smoke can adversely affect most, if not all, organs of the body, the list of diseases that may be caused by tobacco is still growing.

Generally, causality between smoking and the conditions discussed in this section has not been definitively established. Before a causal link is confirmed by expert bodies such as the US Surgeon General's office, a plausible biological mechanism and multiple studies reporting the association (with large numbers of subjects, unbiased design and confounding controlled) are needed.

3.18.1 Mental illnesses

People with mood disorders or mental illness have a higher prevalence of smoking than the general population, and account for a large proportion of smokers.1 More than 32% of current smokers report some sort of mental health problem in the last 12 months, compared to about 18% of ex-smokers and 16% of people who have never smoked.2

Smokers often report that smoking allays anxiety and has an antidepressant effect, but many studies suggest the reverse association, i.e. that smoking leads to anxiety,3 bruxism (teeth clenching and grinding),4 panic attacks,5, 6 depression,3, 7 suicide attempts,3, 8 and schizophrenia.9 The difficulties involved in establishing the causal direction of the association between mental disorders and smoking have been well summarised (specifically for depression) by Munafò and Araya,10 who comment:

Depression may cause people to smoke (perhaps to self-medicate their symptoms), or smoking may cause increased risk of depression (via alterations to neurotransmitter pathways following chronic exposure). The relationship may even be bidirectional (acute or infrequent tobacco use may reduce negative affect, but chronic use may exacerbate it), or be caused by shared risk factors (possibly genetic) so that the relationship is not causal at all.

Large longitudinal studies of smoking and mental health in Norway,3 New Zealand,11 Copenhagen7 and Finland8 have enabled researchers to account for previous mental illness in their analyses. These studies support the claim that smoking increases the risk of anxiety, depression and suicidality, especially in nicotine-dependent (i.e. heavy) smokers. Munafò and Araya point out that this creates a paradox, namely, that smoking may cause depression, but smokers say they smoke to alleviate depression.10 Munafò and Araya suggest that because of nicotine's short half-life, and the consequential speed with which withdrawal symptoms appear in heavy smokers who stop smoking, acute abstinence is associated with anxiety. Smoking alleviates this anxiety. There is evidence that after a few weeks of smoking cessation the withdrawal syndrome ends and mood elevates above that reached when the individual was smoking.10

The association between smoking and schizophrenia is different from the link between smoking and mood disorders. A meta-analysis of studies from 20 countries found consistent evidence that schizophrenia patients have a biological predisposition to smoke; genetic factors increase the risk of both becoming a smoker and developing schizophrenia. Schizophrenia is also associated with greater frequencies of heavy smoking and high nicotine dependence.9

3.18.2 Neurological diseases

Smoking may be a precipitating factor for migraine12, 13 and smokers may be at increased risk of developing cranial autonomic symptoms (for example, facial sweating) during an attack.14

An association between smoking and hearing loss has been suggested. A case–control study in the US, which included more than 3 000 cases, found only a very small, marginally statistically significant increase in risk associated with smoking.15

An analysis of the Nurses Health Study II in the US reported an increased risk of seizures associated with smoking.16

Amyotrophic lateral sclerosis (ALS) is a progressive neurodegenerative condition; it is a type of motor neurone disease. A 2010 meta-analysis of 15 case–control and five cohort studies found that smoking increases the risk of ALS in women, but not in men.17 However a 2011 pooled analysis of data from more than half a million men and more than half a million women enrolled in five prospective cohort studies in the US found that smoking increases the risk of ALS by about 40% for both men and women.18 This large study therefore strongly supports the existence of a link between smoking and ALS. The risk in smokers increased with decreasing age at smoking initiation. Smoking has also been reported to decrease survival rates in female smokers.19

Multiple sclerosis (MS) is a disease in which the myelin sheaths surrounding nerves in the brain and spinal cord become damaged and are eventually destroyed through an autoimmune process. A 2011 meta-analysis investigating the possible link between smoking and MS pooled data on more than 3 000 cases from 14 studies.20 The study found that smoking increases the risk of MS by about 50%. Smoking has also been reported to accelerate the clinical progression of MS, and the progression of the typical disease lesions visible on magnetic resonance images.21-24 However, a review article in 2011 looking at smoking and the onset and progression of MS found that while most of the studies on onset supported a positive association, the evidence on progression was more limited and mixed.25  The meta-analysis also analysed four studies that addressed this issue. Smoking did appear to increase the risk of progression from relapsing-remitting MS to secondary progressive disease, but the magnitude of the effect varied between studies and the pooled result was not statistically significant.20 Evidence on a potential mechanism is also limited.25

3.18.3 Kidney disease

Smoking has physiological effects on the kidney. It has been reported to increase the glomerular filtration rate,26, 27 possibly by relaxing renal arteries.26 There is evidence that smoking increases the risk of developing chronic kidney disease. For example, a 10-year follow-up study of more than 100 000 Japanese people found that smoking increased the risk of developing proteinuria and renal dysfunction.28 A case–control study in Syria found that smokers had a higher risk of hypertensive nephropathy and diabetic nephropathy, but the risk of kidney disease with other aetiologies was not increased by smoking.29

3.18.4 Other conditions

Recent studies have suggested that smoking may worsen quality of life for patients with hepatitis C30 and increase the risk of moderate to severe hepatic lesions, which in turn hastens progression to cirrhosis.31 Impaired liver metabolism of nicotine and smoking-induced hypoxia are possible mechanisms.31

Cystic fibrosis (CF) is a heritable disorder that severely affects the lungs and digestive system. Studies have shown that smoking worsens CF, and predisposes people with CF to infection. Children with CF exposed to secondhand smoke experience higher rates of hospital admissions and increased use of antibiotics. The mechanism underlying these associations is likely the suppression of antimicrobial host defenses, which is compromised already in people with CF.32

Recent news and research

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12. Lopez-Mesonero L, Marquez S, Parra P, Gamez-Leyva G, Munoz P and Pascual J. Smoking as a precipitating factor for migraine: a survey in medical students. Journal of Headache and Pain 2009;10(2):101-3. Available from: http://www.springerlink.com/content/m7321n0664672p45/

13. Straube A, Pfaffenrath V, Ladwig K, Meisinger C, Hoffmann W, Fendrich K, et al. Prevalence of chronic migraine and medication overuse headache in Germany-the German DMKG headache study. Cephalalgia 2010;30(2):207-13. Available from: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=19489879

14. Hershey A and Lipton R. Lifestyles of the young and migrainous. Neurology 2010;75(8):680–1. Available from: http://www.neurology.org/cgi/content/full/75/8/680

15. Shargorodsky J, Curhan S, Eavey R and Curhan G. A prospective study of cardiovascular risk factors and incident hearing loss in men. Laryngoscope 2010;120(9):1887–91. Available from: http://onlinelibrary.wiley.com/doi/10.1002/lary.21039/pdf

16. Dworetzky B, Bromfield E, Townsend M and Kang J. A prospective study of smoking, caffeine, and alcohol as risk factors for seizures or epilepsy in young adult women: data from the Nurses' Health Study II. Epilepsia 2010;51(2):198-220. Available from: http://www3.interscience.wiley.com/cgi-bin/fulltext/122563552/HTMLSTART

17. Alonso A, Logroscino G and Hernan M. Smoking and the risk of amyotrophic lateral sclerosis: a systematic review and meta-analysis. Journal of Neurology, Neurosurgery & Psychiatry 2010;81(11):1249–5. Available from: http://jnnp.bmj.com.ezp.lib.unimelb.edu.au/content/81/11/1249.full.pdf

18. Wang H, O'Reilly E, Weisskopf M, Logroscino G, McCullough M, Thun M, et al. Smoking and risk of amyotrophic lateral sclerosis: a pooled analysis of 5 prospective cohorts. Archives of Neurology 2011;68(2):207–13. Available from: http://archneur.ama-assn.org/cgi/content/full/68/2/207

19. Alonso A, Logroscino G, Jick S and Hernan M. Association of smoking with amyotrophic lateral sclerosis risk and survival in men and women: a prospective study. BMC Neurology 2010;10(1):6. Available from: http://www.biomedcentral.com/content/pdf/1471-2377-10-6.pdf

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22. Healy BC, Ali EN, Guttmann CR, Chitnis T, Glanz BI, Buckle G, et al. Smoking and disease progression in multiple sclerosis. Archives of Neurology 2009;66(7):858–64. Available from: http://archneur.ama-assn.org/cgi/content/full/66/7/858?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=Smoking+and+disease+progression+in+multiple+sclerosis&searchid=1&FIRSTINDEX=0&resourcetype=HWCIT

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24. Zivadinov R, Weinstock-Guttman B, Hashmi K, Abdelrahman N, Stosic M, Dwyer M, et al. Smoking is associated with increased lesion volumes and brain atrophy in multiple sclerosis. Neurology 2009;73(7):504–10. Available from: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=19687451

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32. U.S. Department of Health and Human Services. The Health Consequences of Smoking: 50 Years of Progress. A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014. Available from: http://www.surgeongeneral.gov/library/reports/50-years-of-progress/full-report.pdf

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