Evaluation of Smoking as a Modifying Factor in Chronic Rhinosinusitis

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.