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Evaluation of Smoking as a Modifying Factor in Chronic Rhinosinusitis

Educational Objective
To determine whether active smoking represents a risk factor for CRS development and/or whether smokers experience an increased symptom burden compared with nonsmokers.
1 Credit CME
Key Points

Question  Is smoking a risk factor for chronic rhinosinusitis (CRS), and is it associated with disease-specific quality of life?

Findings  This case-control study found no difference in active smoking prevalence by CRS disease (CRS without nasal polyps and CRS with nasal polyps) vs controls. However, symptom burden was associated with smoking, with worse Sino-nasal Outcome Test scores in the smoking cohort by a mean magnitude of 10 points.

Meaning  Cigarette smoking has a negative association with the quality of life and symptom burden of patients with CRS, and clinicians should encourage smoking cessation alongside general CRS medical management.


Importance  The negative association of smoking with the respiratory tract is well known; however, the association between smoking and chronic rhinosinusitis (CRS) has not been well characterized.

Objective  To analyze whether active smoking was a risk factor for CRS development, smoking was associated with disease-specific quality of life, and smokers experience an increased symptom burden than nonsmokers.

Design, Setting, and Participants  This subanalysis of the Chronic Rhinosinusitis Epidemiology Study (CRES), a prospective, questionnaire-based case-control study conducted between October 2007 and September 2013 was conducted across 30 UK tertiary/secondary care sites. Participants were identified at ear, nose, and throat outpatient clinics and classified into CRS phenotypes as per European Position Paper on Rhinosinusitis and Nasal Polyps 2012 criteria. The overall response rate of those identified to take part in the study was 66%. A total of 1535 questionnaires were returned, with 1470 considered eligible for inclusion. Data analysis was conducted in January 2020.

Main Outcomes and Measures  The CRES was designed to distinguish differences in socioeconomic status, geography, medical comorbidities, lifestyle, and quality of life between patients with CRS and healthy controls.

Results  A total of 1450 patients completed the smoking question, comprising 219 controls (15.1%; mean [SD] age, 47.3 [14.9] years; 143 women [68%]), 546 participants with CRS (37.7%; mean [SD] age, 51.8 [15.3] years; 259 women [53%]) without nasal polyps (CRSsNPs), and 685 participants (47.2%; mean [SD] age, 56.0 [14.5] years; 204 women [33%]) with CRS and nasal polyps/allergic fungal rhinosinusitis (CRSwNPs+). The mean age was similar, with a greater female preponderance in the control group and male in the CRSwNP group. The greatest number of active smokers was found among control participants (33 [15%]), with a lower rate of smokers in the patients with CRSwNPs+ (9.9%) and CRSsNPs (13.9%), respectively. We found a clinically significant difference in the mean difference in Sino-nasal Outcome Test (SNOT-22) scores between active smokers and nonsmokers for both CRS phenotypes (4.49, 12.25). In both CRS subgroups active smokers had significantly worse SNOT-22 scores than nonsmokers by a mean (SD) magnitude of 10 (18.99, 24.14) points. Nonsmokers also demonstrated a higher percentage of surgical procedures (1 or more), although this was not clinically or statistically different (0.34, 1.10).

Conclusions and Relevance  This questionnaire-based case-control study demonstrated a clinically significant symptom burden associated with active cigarette smoking, with worse SNOT-22 scores in the smoking cohort by a mean magnitude of 10 points. We could find no demonstrable evidence that smoking increases the likelihood of need for revision sinus surgery. Clinicians should encourage smoking cessation alongside general CRS medical management.

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CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.

Article Information

Accepted for Publication: October 16, 2020.

Published Online: December 10, 2020. doi:10.1001/jamaoto.2020.4354

Corresponding Author: Kristian Hutson, MD, James Paget University Hospital, Lowestoft Rd, Gorleston NR316LA, England (kristian.hutson@doctors.net.uk).

Author Contributions: Prof Philpott and Dr Hutson had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Hutson, Clark, Philpott.

Acquisition, analysis, or interpretation of data: Hopkins, Ahmed, Kumar, Carrie, Erskine, Sunkaraneni, Philpott.

Drafting of the manuscript: Hutson, Philpott.

Critical revision of the manuscript for important intellectual content: Clark, Hopkins, Ahmed, Kumar, Carrie, Erskine, Sunkaraneni, Philpott.

Statistical analysis: Hutson, Clark.

Obtained funding: Philpott.

Administrative, technical, or material support: Erskine, Philpott.

Supervision: Hopkins, Ahmed, Kumar, Sunkaraneni, Philpott.

CRES Group Members: Carl Philpott (chief investigator), James Paget University Hospital; Claire Hopkins, Guys & St Thomas’ Hospital; Nirmal Kumar, Wrightington, Wigan & Leigh NHS Foundation Trust ; Alasdair Robertson, Southern General Hospital, Glasgow; Amir Farboud, Wrexham Maelor Hospital, Wales; Shahzada Ahmed, University Hospitals Birmingham; Shahram Anari, Heart of England NHS Foundation Trust; Russell Cathcart, Cumberland Infirmary; Hisham Khalil, Derriford Hospital; Paul Jervis, Northampton General Hospital; Sean Carrie, Freeman Hospital, Newcastle; Naveed Kara, Sunderland Royal Infirmary; Peter Prinsley, Norfolk & Norwich University Hospital; Robert Almeyda, Oxford University Hospitals; Nicolas Mansell, Royal Berkshire NHS Foundation Trust; Mahmoud Salam, The Ipswich Hospital; Jaydip Ray, Sheffield Teaching Hospitals; Jaan Panesaar, Luton & Dunstable Hospital; Jonathan Hobson, Warrington and Halton Hospitals NHS Foundation Trust; Vishnu Sunkaraneni, Royal Surrey County Hospital, Guildford; and Allan Clark, Norwich Medical School, University of East Anglia.

Conflict of Interest Disclosures: Dr Philpott reported grants from the National Institute for Health Research and Rosetrees, and personal fees from Sanofi-Genzyme outside the submitted work. No other disclosures were reported.

Funding/Support: The study was funded by the Anthony Long Trust (postage costs) and the Bernice Bibby Trust (research nurse time).

Role of the Funder/Sponsor: The funding organizations had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Information: This study has been reported in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology statement guidelines for the reporting of observational studies.

Additional Contributions: We thank the CRES group of otorhinolaryngologists who recruited patients to the study and Jane Woods, RN, James Paget University Hospital, for her dedication to the study. None of these individuals received compensation for their contributions.

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