Background Smoking is a risk factor for systemic lupus erythematosus (SLE). It has been associated with increased disease activity and decreased effectiveness of hydroxychloroquine in cutaneous lupus. The objective of the study was to determine the association between smoking status and total and individual damage items in SLE.

Methods We analyzed data from the Hopkins Lupus Cohort. Damage was recorded using the Systemic Lupus Erythematosus International Collaborating Clinics/American College of Rheumatology (SLICC/ACR) Damage Index. Fishers exact test and Wilcoxon test were used in exploratory analysis. Logistic regression was used to estimate the association between damage and smoking status (ever/never). Odds ratios and 95% confidence intervals were reported. Stratification by ethnicity was done for individual damage items that were found to be significantly associated with smoking.

Results The prevalence of ever smokers in our cohort was 36%. SLE patients who ever smoked had higher odds of total damage with higher mean total damage index scores (p<0.0001). Data for individual damage items significantly associated with smoking are presented in table 1.

The association between cataract and smoking was still present after adjusting for ethnicity, diabetes, and prednisone use in a multivariate regression model (OR=1.4, p=0.0083).

Stratification by ethnicity showed that African- American SLE patients who ever smoked were more likely to have cataract, scarring chronic alopecia, extensive scarring, skin ulceration, pulmonary hypertension, cerebrovascular events, cardiomyopathy, and diabetes compared to non-smokers. Caucasian SLE patients who ever smoked were more likely to have extensive scarring, gastrointestinal infarction and resection, and muscle atrophy (table 1).

Conclusions Smoking is a modifiable factor for organ damage in SLE. It is already known that it interferes with the efficacy of hydroxychloroquine. Now we are able to prove that smokers have more cutaneous damage (scarring) even after stratification for ethnicity. As expected, smokers had more cardiovascular damage. New findings include associations with gastrointestinal damage, cataracts, pulmonary hypertension, pancreatitis and diabetes. In the general population, these associations have been confirmed in all except gastrointestinal infarction.

Funding Source(s): The Hopkins Lupus Cohort was funded by NIH Grant R01-AR069572.