Associations between smoking and extra-axial manifestations and disease severity in axial spondyloarthritis: results from the BSR Biologics Register for Ankylosing Spondylitis (BSRBR-AS)

Sizheng Zhao, Gareth T Jones, Gary J Macfarlane, David M Hughes, Linda E Dean, Robert J Moots, Nicola J Goodson (Corresponding Author)

Research output: Contribution to journalArticlepeer-review

23 Citations (Scopus)
28 Downloads (Pure)


Objective: The effects of smoking on disease manifestations in axial SpA are inadequately described. Utilizing a large and well-characterized cohort, we investigated the association between smoking and extra-axial manifestations, and smoking and disease severity measures.

Methods: Baseline data from the British Society for Rheumatology Biologics Register for Ankylosing Spondylitis were explored. Our analyses focused on extra-axial manifestations and other disease severity measures, including scales for fatigue, sleep, anxiety and depression. Logistic and linear models were used to quantify associations between disease characteristics according to smoking status (current/ex/never) and quantity (heavy/light), adjusting for age, gender, BMI, education, deprivation, comorbidities, symptom duration and alcohol status.

Results: A total of 2031 participants were eligible for the current analysis (68% male, mean age 49 years). Of these, 24% were current and 32% ex-smokers. When compared with non-smokers, current smokers had lower odds of uveitis [OR 0.7, 95% CI 0.5-0.9] and higher odds of psoriasis (ORadj 1.6, 95% CI 1.1-2.3). Ex- and current smokers had incrementally more severe disease than never smokers, with higher BASDAI (β = 0.3, 95% CI 0.1-0.6; β = 0.9, 95% CI 0.6-1.2) and BASFI (β = 0.5, 95% CI 0.2-0.8; β = 1.3, 95% CI 1.0-1.6); similar associations were observed for fatigue, sleep, anxiety and depression.

Conclusion: In this large cross-sectional study, we observed that smoking is independently associated with an adverse disease profile in axial SpA, including worse fatigue, sleep, anxiety and depression, and higher odds of psoriasis. The paradoxical association between current smoking and reduced odds of uveitis is interesting and warrants further investigation.

Original languageEnglish
Pages (from-to)811-819
Number of pages9
Issue number5
Early online date14 Dec 2018
Publication statusPublished - May 2019

Bibliographical note

We are grateful to the staff of the BSRBR-AS register, who are currently Claudia Zabke, Elizabeth Ferguson-Jones, Maureen Heddle, Nafeesa Nazlee and Barry Morris, and to the recruiting staff at the clinical centres, details of which are available at: SZ analysed the data and wrote the manuscript, with significant input from all co-authors. GJM and GTJ are Chief Investigator and Deputy Chief Investigator, respectively, on BSRBR-AS and designed the study and oversaw its conduct. In the current project, they discussed results and provided input into drafts of the manuscript. NJG and RJM contributed towards design of the current analysis and drafting of the manuscript. DMH and LED contributed towards statistical analyses and provided input into the manuscript.

Funding: The BSRBR-AS is funded by the British Society for Rheumatology (BSR) who have received funding for this from Pfizer, AbbVie and UCB. These companies receive advance copies of manuscripts for comments. They have no input into determining the topics for analysis or work involved in undertaking it.

Disclosure statement: The authors have declared no conflicts of interest.

Supplementary data
Supplementary data are available at Rheumatology online.


  • axial spondyloarthritis
  • ankylosing spondylitis
  • smoking
  • uveitis
  • extra-axial manifestations
  • registry
  • fatigue
  • sleep
  • psoriasis
  • depression
  • Psoriasis
  • Depression
  • Fatigue
  • Registry
  • Sleep
  • Extra-axial manifestations
  • Uveitis
  • Axial spondyloarthritis
  • Ankylosing spondylitis
  • Smoking


Dive into the research topics of 'Associations between smoking and extra-axial manifestations and disease severity in axial spondyloarthritis: results from the BSR Biologics Register for Ankylosing Spondylitis (BSRBR-AS)'. Together they form a unique fingerprint.

Cite this