I have been complaining about my low productivity levels since I have gotten back to work after my accident. However, last night with a single one hour webinar we have managed to set-up a new international collaboration to study and address the social determinants of health (SDoH) and their impact on MS. Our focus is going to be on which SDoH can we modify and hence improve the outcome for people with MS (pwMS)?
Smoking is one such modifiable factor and needs to be addressed at a (1) population level with policy and legislation, (2) at a local or community level, (3) with the family and (4) at an individual level target the people with MS (pwMS). We know that pwMS who smoke have a worse outcome than people who don’t smoke. The effect of smoking is equivalent to negating the treatment effect of being on an injectable therapy such as interferon beta. Put simply smokers with MS start using a walking stick (EDSS = 6.0) about 6 years earlier than pwMS who don’t smoke. Getting pwMS to stop smoking is easier said than done. What we as MS HCPs can do is simply provide them with the necessary information and sign-post them to the necessary STOP-SMOKING clinics available within the NHS.
What people don’t know is that smoking is an important risk factor for developing MS. How it triggers MS is not known, but some have hypothesised that the inflammation it causes in the lungs alters proteins, by a process called post-translational modification, which then become immunogenic and triggers autoimmunity. Smoking also irritates the lungs and causes inflammation that activates and upregulates the innate immune system, which is required for processing these altered proteins and presenting them to the T-cells and B-cells of the immune system. These autoreactive T and B cells then migrate to the central nervous system and trigger MS. Please note it is not only smoking per se that increases one’s chances of getting MS, but other lung irritants such as solvent exposure and particulate air pollution.
Julia Pakpoor one of the brilliant young trainees who has worked with our group since she was a medical student did the piece of work below that showed that about 15% of new cases of MS could be prevented if we stopped the population from smoking. This is easier said than done. But if you are someone who has MS and has siblings and/or children you may want to stress this point to them. As a first-degree relative your risk of getting MS is about 10x higher than the background population risk; for example, the average woman in the general population has about a 1 in 400 chance of getting MS. In comparison, the daughter of someone with MS has a 1 in 40 chance of getting MS. If they smoked this chance will on average be much higher.
Many of you will say, but I didn’t smoke so how does this apply to me? Smoking is not a necessary or sufficient factor in the complex cascade that causes MS all it does is tip the scales towards you getting MS. But as far as preventive medicine goes simply reducing the number of people getting MS by 15% is a noble goal. This is why I found the study below on the effects of tobacco control policies on global smoking prevalence uplifting. The investigators found that if all countries had adopted smoking bans, health warnings and advertising bans at the strictest level and raised cigarette prices in 2009, there would have been about 100 million fewer smokers in the world in 2017. I wonder how many fewer people there would be with MS, rheumatoid arthritis and several other autoimmune diseases strongly associated with smoking?
Pakpoor et al. Estimated and projected burden of multiple sclerosis attributable to smoking and childhood and adolescent high body-mass index: a comparative risk assessment. Int J Epidemiol. 2021 Jan 23;49(6):2051-2057.
Background: Smoking and childhood and adolescent high body-mass index (BMI) are leading lifestyle-related risk factors of global premature morbidity and mortality, and have been associated with an increased risk of developing multiple sclerosis (MS). This study aims to estimate and project the proportion of MS incidence that could be prevented with the elimination of these risk factors.
Methods: Prevalence estimates of high BMI during childhood/adolescence and smoking in early adulthood, and relative risks of MS, were obtained from published literature. A time-lag of 10 years was assumed between smoking in early adulthood and MS incidence, and a time-lag of 20 years was assumed between childhood/adolescent high BMI and MS incidence. The MS population attributable fractions (PAFs) of smoking and high BMI were estimated as individual and combined risk factors, by age, country and sex in 2015, 2025 and 2035 where feasible.
Results: The combined estimated PAFs for smoking and high BMI in 2015 were 14, 11, 12 and 12% for the UK, USA, Russia and Australia in a conservative estimate, and 21, 20, 19 and 16% in an independent estimate, respectively. Estimates for smoking are declining over time, whereas estimates for high early-life BMI are rising. The PAF for high early-life BMI is highest in the USA and is estimated to increase to 14% by 2035.
Conclusions: Assuming causality, there is the potential to substantially reduce MS incidence with the elimination of lifestyle-related modifiable risk factors, which are the target of global public health prevention strategies.
Flor et al. The effects of tobacco control policies on global smoking prevalence. Nat Med. 2021 Feb;27(2):239-243.
A substantial global effort has been devoted to curtailing the tobacco epidemic over the past two decades, especially after the adoption of the Framework Convention on Tobacco Control1 by the World Health Organization in 2003. In 2015, in recognition of the burden resulting from tobacco use, strengthened tobacco control was included as a global development target in the 2030 Agenda for Sustainable Development2. Here we show that comprehensive tobacco control policies-including smoking bans, health warnings, advertising bans and tobacco taxes are effective in reducing smoking prevalence; amplified positive effects are seen when these policies are implemented simultaneously within a given country. We find that if all 155 countries included in our counterfactual analysis had adopted smoking bans, health warnings and advertising bans at the strictest level and raised cigarette prices to at least 7.73 international dollars in 2009, there would have been about 100 million fewer smokers in the world in 2017. These findings highlight the urgent need for countries to move toward an accelerated implementation of a set of strong tobacco control practices, thus curbing the burden of smoking-attributable diseases and deaths.
CoI: none in relation to this post
CoI: none in relation to this post
I had no idea that the risk of my daughter getting MS is so high. 1 in 40 is very worrying.
ReplyDeleteI am not sure pwMS are aware about how common MS is amongst their family members. 1 in 40 refers to the risk to daughters. For sons it is about 1 in 80.
ReplyDeleteMy maternal grandmother died with MS when she was only 29. My mother died when she was 78, having had MS for many years. My brother died with MS when he was only 26. My sister has MS and she now has real difficulty walking, she is 73. My half sister, my mother's daughter, does not have MS. I do not have MS, I'm 71. So there are three generations in my family who have, or have had, MS. Two with a version that went straight down, and they both died young. Two with a much slower version. I have spoken to a number of medical people about the high incidence of MS in my family, but none of them seemed to think it was significant. My sister and I gave samples for DNA analysis 6 or 7 years ago, but we never received any results from the research project we were part of. Could you comment on the above MS incidence?
DeleteI've never smoked but for years now I've been highly sensitive to indoor air pollutants like air freshener, cleaning products and men's cologne. Even washing powders - if I lend an item of clothing to a friend and they decide to wash it before returning it I usually have to wash it several times once I get it back because I'm so sensitive to whatever chemical it gives off. It's a similar reaction to when I'm around someone who has come back in from having a smoke. Could there be a link to my MS?
ReplyDeleteThe only good thing about spending the past year working from home is being able to control my environment so much better.
Here is my story with regards to smoking- I agree for all the reasons mentioned and more, tobacco should not be sold. Having said that, I am 63 and have been a smoker, essentially, since I was in my mother’s womb. When I lived in the southern US in the 80’s and 90’s, cigs were very cheap, so I smoked them up. I remember moving out of my apartment, taking down pictures and the like, and seeing how the smoke had stuck to the walls such that you could obviously see where items had been hung. “Not good”, I thought at the time.
ReplyDeleteSo I went to half a pack when I got married in 2000, which is quite different than 2 ½ packs. Nevertheless, I always knew I would have to stop, so I decided last year, it would be “When I’m 64” (t’da dum; thanks Paul). I have ceased smoking briefly, a few times, like 7 days in the hospital. There are patches which I have used, which help a lot. And smokeless tobacco works almost as well as the real thing. So I know I’m going to do it and I’m prepared. I watched my brother do it.
That leads to my point. My cousin (my mother’s sister’s daughter), never touched a cigarette in her life. She was diagnosed with MS just a bit after me. No one else on my mother’s side of the family had MS. Would I have MS if I didn’t smoke? Probably. Is my MS worse than my cousin’s? No. (I chose DMT,, she did not). There are lots of factors beyond what I have stated. In his instance only, I am glad my cousin has MS.
So yes, if you are diagnosed with MS, you ought look at your life style and see if there are some changes you can make to help you beat the odds (in the game left to come). Thinking, however, that smoking lead to my MS is a non-starter. As far as stopping, every dedicated smoker knows what it is like to run out of cigarettes. So “cold turkey” probably won’t work for most people. They need to learn, (as in my case), that there are alternatives and they can try these well in advance of setting a quit date.
In terms of lowering overall risk prior to being diagnosed, sure, I guess smoking is a risk factor. But if you want me to go “full steam” in the opposite direction, philosophically, the biggest risk factor of death, is being alive. It is certain to happen. As long as you are here, you should to try to make a difference, and don’t forget to enjoy yourself.
Thank you. I think you highlight the issue very well of smoking being an addiction and needs to be managed as such. However, when teenagers start smoking they are not addicted and this is where we need to act to prevent the next generation of smokers and the next generation of people with MS.
DeleteI thru in the bit about smoking since I was in my mother's womb. She smoked while pregnant, in the 50's. I just remember that my first feeling (of the nicotine) when I smoked was familiar, it seemed to "fill in a space." I thought "wow, this feels right". Something for researchers maybe.
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