Smoking Remains a Major Driver of Rheumatoid Arthritis Burden Worldwide

The global burden of rheumatoid arthritis (RA) linked to smoking has declined in relative terms but continues to rise in absolute numbers, according to findings from the Global Burden of Disease (GBD) 2021 study published in PLoS One, which highlighted persistent disparities between regions, age groups, and sexes.

Researchers analyzed RA burden attributable to smoking across 204 countries between 1990 and 2021. Indicators included deaths, disability-adjusted life-years (DALYs), years lived with disability (YLDs), and years of life lost (YLLs).

Declines in smoking-attributable RA burden varied widely across regions. | Image credit: methaphum – stock.adobe.com

While age-standardized rates of smoking-attributable RA burden declined over 3 decades, the absolute global number of deaths rose from 1792 to 2264, and DALYs increased from 145,727 to 215,780. Additionally, nearly 6% of age-standardized deaths and 7% of DALYs were attributable to smoking in 2021, underscoring its impact on RA.

“These findings further underscore the need for more targeted tobacco control policies and RA health management strategies that are sensitive to both regional context and sex-specific smoking patterns and healthcare access,” the authors said.

Burden Varies by Region

Age-standardized declines in smoking-attributable RA burden varied widely across regions. The Americas experienced the largest reduction in DALYs (–62.1%) with an estimated annual percentage change (EAPC) of –1.78; Europe saw a similar reduction in DALYs but a slower EAPC of –0.54. The Americas also saw the most significant improvement in YLD rates with a decline of –66.45% and an EAPC of –1.81, while the Western Pacific saw the least improvement at –29.62% and an EAPC of –0.58.

Over 30 years, YLLs decreased most notably in the African region with a percentage change of –16.55% and EAPC of –2.43. The smallest YLL reduction was measured in the Western Pacific region; despite a percentage change of –57.52%, the region’s EAPC was only –0.02. Africa also saw the most substantial drop in mortality rates (–50.9%; EAPC, –2.54), followed by the Americas. Southeast Asia was the only one of the 6 regions to see a percentage increase in deaths, climbing by nearly 10%, but the area still had a negative EAPC.

In contrast, Southeast Asia and the Eastern Mediterranean recorded increases in several burden metrics, with DALYs rising more than 40% and 50%, respectively. Southeast Asia also saw a 44% increase in YLDs, while YLLs increased by 16.55% in Africa and 44.34% in the Eastern Mediterranean.

In 2021, the highest smoking-attributable death and DALY rates were concentrated in Eastern Europe, East Asia, and parts of South America, where smoking prevalence remains high, according to researchers. In some Eastern European countries, smoking rates approached 40%, compared with below 10% in sub-Saharan Africa.

Sociodemographic Impact

From 2000 to 2021, global smoking prevalence declined, but progress varied widely across income levels. In high-income regions, smoking rates fell sharply from about 35% in 2000 to 15% in 2021. Tobacco use rates followed a similar pattern, dropping from roughly 45% to 20% during the same period. In contrast, low- and middle-income regions saw more modest reductions, with smoking rates declining only slightly, from around 25% to 20%. In low-income regions, progress was less pronounced, as tobacco use hovered around 35%.

“These patterns can be attributed to strict public health policies in high-income regions, such as smoking bans and health education campaigns, while weaker tobacco control measures and cultural influences likely contributed to the slower or stagnant decline in low- and middle-income regions,” the authors wrote.

In the US, while cigarette smoking has declined overall from 2011 to 2020, significant racial and ethnic disparities remain.² Previous research showed steady decreases among non-Hispanic White, Black, and Hispanic adults, but the prevalence in non-Hispanic American Indian and Alaska Native adults remained near 37% with rising population estimates. Researchers emphasized that structural and sociocultural factors, along with inequitable implementation of tobacco control policies, contribute to these disparities.

Older Men Carry Greatest Burden

Age and sex also played roles in shaping risk. Men consistently showed higher smoking-attributable RA mortality and YLLs than women, reflecting historically higher smoking prevalence.¹ Deaths were particularly high in individuals 85 years and older, again impacting men more than women across all age groups, underscoring the cumulative effect of long-term tobacco exposure.

DALYs peaked between ages 50 and 80, with men in their early 70s recording 4.5 DALYs per 100,000 compared with 3 per 100,000 for women. Disability burden was greatest in those aged 50 to 74 years, with YLDs at 3.5 per 100,000 for men and 2.5 for women in those aged 65 to 69. YLLs also underscored a stronger effect of premature mortality in men, with rates of 1.2 per 100,000 among those 75 and older compared with 0.6 for women.

“Tobacco control efforts should therefore particularly target middle-aged males to prevent future burden, while health systems need to strengthen RA treatment and comprehensive health management, including comorbidity care, in older populations,” the authors said.

References

1. Lin K, Yi Y, Xu X, et al. Global trends in smoking-attributable rheumatoid arthritis burden: Insights from GBD 2021. PLoS One. 2025;20(8):e0329434. doi:10.1371/journal.pone.0329434
2. Petrullo J. Racial, ethnic disparities still persist in cigarette smoking rates. AJMC^®. June 1, 2023. Accessed August 29, 2025. https://www.ajmc.com/view/racial-ethnic-disparities-still-persist-in-cigarette-smoking-rates