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The Effect of Cigarette Smoking on Nonalcoholic Fatty Liver Disease

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Authors: Jung H-S et al.

Am J Gastroenterol 2018 Oct 23

Cigarette smoking appears to be a modifiable risk factor for development and progression of NAFLD.

Although there is no specific treatment for nonalcoholic fatty liver disease (NAFLD), weight loss, avoiding alcohol, and control of underlying comorbid conditions such as diabetes are recommended. Should clinicians also be recommending smoking cessation?

To determine if cigarette smoking is associated with NAFLD incidence and progression, researchers in Korea longitudinally assessed self-reported tobacco use, measured urinary cotinine levels, and performed abdominal ultrasound in nearly 200,000 adults without NAFLD at baseline. Patients received comprehensive health exams annually or biennially for a median of 4.1 years, providing about 1 million person-years of follow-up. The severity of NAFLD was assessed using the NAFLD fibrosis score (NFS).

Among men, the proportions of never, former, and current smokers were 37.1%, 25.5%, 37.4%, respectively; and among women, 94.5%, 3.2%, and 2.2%. There was a positive dose-response relationship observed between pack-years of smoking and NAFLD incidence. In multivariate analyses, compared with men who never smoked, men with 10 to 19 pack-years were 25% more likely to develop NAFLD, and those with ≥20 pack-years had a 36% risk increase. For women, compared with never-smokers, NAFLD incidence was 25% higher in those with 5 to 10 pack-years and 46% higher in those with ≥10 pack-years. In addition, the number of smoking pack-years was positively associated with higher fibrosis based on intermediate or high NFS. Urinary cotinine level was also positively associated with risk for NAFLD.

COMMENT

Although the authors note that smoking information was self-reported and measurement error might have led to residual confounding, the positive association with NAFLD was also supported by objective cotinine measures. Moreover, the large cohort size and observed dose-response relationship make these findings compelling. As we advise our NAFLD patients regarding weight loss, we should also emphasize the importance of smoking cessation as a part of medical management.

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