Dr Claudia MarckClaudia Marck, PhD, MSc
Although smoking tobacco is a modifiable risk factor for individuals with multiple sclerosis (MS), it has been estimated that about 15% of those with MS in the United States smoke, and many are long-term heavy smokers.1

With a recent review suggesting that smoking could increase the risk of MS onset by 50% and the literature suggesting that it also has an adverse influence on MS progression, the need to improve smoking cessation success in the disease is of increased importance.2-4 Unfortunately, little to no research has looked into the understanding of how health care professionals can best address this issue, or even evaluate the understanding of smoking behavior in those with MS.

As such, Claudia Marck, PhD, MSc, NHMRC Early Career Fellow, Centre for Health Equity, Melbourne School of Population and Global Health, University of Melbourne, and colleagues conducted a topical review to suggest areas of critical need for research. To learn more about this issue, NeurologyLive spoke with Marck.

NeurologyLive: What is the status of research on smoking cessation in MS? 

Claudia Marck, PhD, MSc: Given the evidence that tobacco smoking is associated with MS progression, we need to focus on helping as many people with MS quit smoking as possible. We are currently undertaking qualitative work to better understand the needs of people with MS who smoke and want to quit. We are also interviewing MS clinicians to understand how they can best support people with MS who want to quit smoking through their clinical practice. We need to understand what is currently being done by MS specialists to assist people with MS to quit smoking, which type of interventions work best, who should deliver the intervention, and what the best timing is. The information gained will enable the development and testing of targeted strategies to ensure that people with MS who smoke are routinely offered the best possible help to increase cessation success.

Are rates of MS smokers higher than the general population? 

Unfortunately, we don’t have rigorous evidence to answer this question, but there are some case-control studies that suggest smoking rates are higher among people with MS.

What might motivate those with MS to start or continue smoking?

There is some evidence to suggest that people with MS use tobacco smoking as a short-term coping strategy for stress, boredom, pain, or depressive symptoms. These symptoms, as well as other MS-related factors such as cognitive impairment, will also make it more difficult for someone to quit smoking compared to someone without these symptoms.

What role has the increased interest and use of cannabis played in smoking rates among those with MS? 

The increasing use of cannabis may also increase the use of tobacco smoking, although there is no clear evidence of this. It’s unclear how many people with MS use cannabis regularly, and what proportion of those smoke it with tobacco. This will differ per country as the availability of different types of cannabis products vary. I envision that if cannabis becomes a more widely approved drug for MS symptom management, safer (smoke-free) cannabis products will become more available.

Are physicians regularly addressing smoking with individuals with MS? What interventions are available to them?

We don’t know whether smoking is regularly addressed, and we are keen to find out. We know that recommendations from a health professional to quit smoking can be a key motivator for people. Anecdotally, it is often not addressed by MS clinicians who have limited time and may prioritize symptom management and medications. Depending on what country you live in, different resources are available for health professionals to assist patients in quitting. Here in Australia, healthcare professionals can complete a quick online referral (or via phone/fax) with the Quitline, a free service for Australians which has been shown to increase cessation success.

When is the ideal time to intervene with patients?

The earlier someone quits smoking, the better in terms of risk for disease progression. However, more research is urgently needed to understand the role of timing, frequency, and mode of delivery of an intervention to increase cessation success.

For information on smoking cessation services through the Centers for Disease Control and Prevention, click here.

Transcript edited for clarity. 
REFERENCES
1. Friend KB, Mernoff ST, Block P, Reeve G. Smoking rates and smoking cessation among individuals with multiple sclerosis. Disabil Rehabil. 2006 Sep 30;28(18):1135-41. doi: 10.1080/09638280500533707.
2. Hedstrom, AK. Smoking and its interaction with genetics in MS etiology. Mult Scler 2019; 25(2): 180–186. doi: 10.1177/1352458518801727.
3. Healy BC, Ali EN, Guttmann CR, et al. Smoking and disease progression in multiple sclerosis. Arch Neurol. 2009 Jul;66(7):858-64. doi: 10.1001/archneurol.2009.122.
4. Waubant E, Lucas R, Mowry E, et al. Environmental and genetic risk factors for MS: an integrated review. Ann Clin Transl Neurol. Published online August 7, 2019. doi: 10.1002/acn3.50862.