Quit smoking improves gastroesophageal reflux symptoms and quality of life

doi:10.4236/health.2011.311114

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Vol.3, No.11, 677-683 (2011)

doi:10.4236/health.2011.311114

Health

Quit smoking improves gastroesophageal reflux

symptoms and quality of life

Kou Nakajima1, Akihito Nagahara1*, Akihiko Kurosawa1, Kuniaki Seyama2, Daisuke Asaoka1,

Taro Osada1, Mariko Hojo1, Sumio Watanabe1

1Department of Gast r o e n t e r ology, Juntendo University School of Medicine, Tokyo, Japan;

*Corresponding Aut hor: nagahara@juntendo.ac.jp

2Department of Res p i r a tory Medicine, Juntendo University School of Medicine, Tokyo, Japan.

Received 11 September 2011; revised 6 October 2011; accepted 21 October 2011.

ABSTRACT

Background: Smoking is considered to be risk

factors of gastroesophageal reflux disease

(GERD). The present study aimed to reveal

whether quit smoking improves GERD symp-

toms and QOL of patients. Methods: In this pro-

spective study, 33 patients who participated in a

12-week quit smoking program filled out the

Frequency Scale for the Symptoms of GERD

(FSSG) questionnaire, and SF8 QOL question-

naire. Patients filled out the questionnaires at

baseline and during the program at 2 weeks, 4

weeks, 8 weeks and 12 weeks. In the FSSG, the

responses were scored and the reflux score

(RS), dysmotility score (DS) and total score (TS)

were calculated. Results: There were 22 males

and 11 females. Their mean age was 54.8 ± 13.0

(mean ± SD) yr, BMI was 22.9 ± 4.0, and duration

of smoking was 33.5 ± 12.5 years. Ten patients

belonged to GERD subgroup (baselineFSSGscore

≥ 8). All patients were successful at quit smok-

ing. Scores of TS/RS/DS are 8.6 ± 1.8 (mean ±

SE)/4.2 ± 0.9/4.5 ± 0.9 at baseline, 4.7 ± 1.6**/2.5 ±

0.9**/2.3 ± 0.7** at 2 w, 5.7 ± 1.3**/2.6 ± 0.6*/3.0 ±

0.7* at 4 w, 4.5 ± 1.4*/2.2 ± 0.8*/2.3 ± 0.8* at 8 w

and 3.7 ± 1.2**/1.7 ± 0.6**/2.0 ± 0.7** at 12 w, re-

spectively (**p < 0.01, *p < 0.05 vs. baseline).

Among GERD subgroup, Scores of TS/RS/DS

are 18.0 ± 2.9/8.9 ± 1.6/9.1 ± 1.5 at baseline, 8.8 ±

3.0/5.1 ± 1.7/3.7 ± 1.6 at 2 w, 10.8 ± 2.9/5.4 ±

1.6/5.4 ± 1.5 at 4 w, 7.6 ± 2.9*/4.1 ± 1.6/3.5 ± 1.5*

at 8 w and 7.1 ± 2.9*/3.2 ± 1.6*/3.9 ± 1.5* at 12w,

respectively. Regarding QOL, physical compo-

nent score has significantly improved at 2, 4, 8

and 12 w and mental component score at 4w,

respectively. Conclusions: Quit smoking sig-

nificantly improved not only GERD symptoms

but also QOL, indicating that quit smoking might

be an option in the treatment strategy of GERD

symptoms.

Keywords: Quit Smoking; FSSG; GERD; SF8

1. INTRODUCTION

Gastrointestinal (GI) symptoms are known to be re-

lated to the habit of smoking, which is reportedly an

aggravating factor of especially GERD symptoms in-

cluding heartburn [1-3]. Quit smoking is well known to

have positive effect on personal health, on the contrary,

some reports described that quit smoking brought about

insomnia, obesity, restlessness, stress, or psychological

instability [4] and was followed by constipation [5].

However, there has been no report describing the rela-

tionship between quit smoking and GERD symptoms.

To reveal whether quit smoking could improve GERD

symptoms and QOL, patients who participated in the

quit smoking program at the outpatient clinic of the De-

partment of Respiratory Medicine in Juntendo Univer-

sity Hospital were asked to fill out the Frequency Scale

for the Symptoms of GERD (FSSG) questionnaire and

SF8 QOL questionnaire.

2. METHODS

In this prospective study, patients who joined a 12-

week quit smoking program at the outpatient clinic of

the Department of Respiratory Medicine in Juntendo

University Hospital between June 2008 and April 2009,

were asked to fill out the FSSG questionnaire as well as

the SF8 QOL questionnaire. All patients were not ad-

ministered proton pump inhibitors.

The FSSG was designed to evalu ate GERD symptoms

in the Japanese population. The FSSG consists of 12

items; 7 items concern gastric acid reflux and 5 items

K. Nakajima et al. / Health 3 (2011) 677-6 83

678

concern dysmotility sy mptoms (Figure 1). Patients were

asked to rate each item on a scale of 0 to 4. Comparisons

of the scores were made for each item between before

and after starting (at 2, 4, 8, and 12 weeks) the quit

smoking program. The RS was calculated as the sum of

the scores of the 7 items concerning gastric acid reflux,

and DS was calculated as the sum of the scores of the 5

items concerning dysmotility symptoms. TS was calcu-

lated as the sum of the scores of all 12 items. The SF8

QOL questionnaire was composed of the physical com-

ponent score (PCS) and mental component score (MCS)

and included 8 items. Similar to the FSSG, the scores

were compared for each item between before and after

starting (at 2, 4, 8, and 12 weeks) the quit smoking pro-

gram.

Patients in the quit smoking program were initially

prescribed varenicline tartrate. In patients who could not

tolerate varenicline tartrate, it was changed to Nicotine

Patch. Varenicline tartrate was taken at a daily dose of 1

tablet containing 0.5 mg from day 1 to 3, 1 tablet twice a

day from day 4 to 7, and 2 tablets containing 1 mg in

each twice a day thereafter.

Data are expressed as the mean ± standard deviation

in patients’ characteristics and QOL scores, and mean ±

standard error in FSSG scores. Data were analyzed with

the Wilcoxon test. Physicians explained in detail the

purpose of this study to each patient and obtained in-

formed consent from them.

3. RESULTS

Thirty-three patients in the 12-week quit smoking pro-

gram were enrolled in the present study. There were 22

males and 11 females. Their age was 54.8 ± 13.0 yr,

BMI was 22.9 ± 4.0. Duration of smoking was 33.5 ±

12.5 years and number of daily smoked cigarettes was

26.0 ± 11.9/day. The Brinkman index was 902.6 ± 561.4.

The Brinkman index was calculated by multiplying the

number of years of smoking and the number of daily

smoked cigarettes. Seventeen patients received vareni-

cline tartrate, while the other 16 patients were switched

to a nicotine patch. Regarding underlying disease, 2 pa-

tients suffered from chronic obstructive pulmonary dis-

ease, 3 patients suffered from asthma and 2 patients suf-

fered from hypert ensi o n.

Figure 1. Frequency Scale for the Symptom of GERD (FSSG) questionnaire is diagnostic tool of GERD consisting of 12 items that

are most commonly being complained by GERD patients and it has 7 questions related to reflux symptoms and 5 questions related to

ysmotility symptoms. d

K. Nakajima et al. / Health 3 (2011) 677-6 83 679679

Four of the 33 patients were excluded from the analy-

sis d

2 weeks (2.3 ± 0.7, p < 0.01), 4weeks (3.0 ± 0.7, p <

ue to missing data in the baseline FSSG question-

naire. Of the remaining all 29 patients succeeded in quit

smoking. Patients who did not fill out the FSSG ques-

tionnaires completely were excluded from the analysis

of TS, DS, and RS. Data analyses on TS, DS, and RS

were performed on 22 patients at 2 weeks, 25 patients at

4weeks, 23 patients at 8 weeks, and 23 patients at 12

weeks. Evaluation of the responses to each questions of

the FSSG was performed on individual patients who

answered each question at 2, 4, 8, and 12 weeks.

In the FSSG before quit smoking, bloat, feeling heavy

in the stomach after meals, unpleasant sensation in the

throat, and burps were commonly complained as 50% or

more of the patients as shown in Figure 2.

Regardless severity of smoking habit (duration of

smoking, the number of daily smoked cigarettes and

Brinkman index), GERD symptoms after quit smoking

were improved.

TS at baseline was 8.6 ± 1.8, and significant im-

provement was seen at 2 weeks (4.7 ± 1.6, p < 0.01), 4

weeks (5.7 ± 1.3, p < 0.01), 8 weeks (4.5 ± 1.4, p < 0.05)

and 12 weeks (3.7 ± 1.2, p < 0.01) compared with that at

baseline (Figure 3(a)). RS at baseline was 4.2 ± 0.9, and

significant improvement was seen at 2 weeks (2.5 ± 0.9,

p < 0.01), 4 weeks (2.6 ± 0.6, p < 0.05), 8 weeks (2.2 ±

0.8, p < 0.05) and 12 weeks (1.7 ± 0.6, p < 0.01) com-

pared with that at baseline (Figure 3(b)). DS at baseline

was 4.5 ± 0.9, and significant improvement was seen at

0.05), 8 weeks (2 .3 ± 0.8, p < 0.05) and 12 weeks (2.0 ±

0.7, p < 0.01) compared with that at baseline (Figure

3(c)). In this program, 15 received varenicline tartrate

and the other 14 patients received a nicotine patch be-

cause of intolerance to varenicline tartrate. However, as

for FSSG score, there was no significant difference be-

tween varenicline tartrate and nicotine p atch group at the

end of this program.

Regarding the change of scores of each item in FSSG,

all items in the FSSG except for Q8 (“feel full while

eating meals”) and Q9 (“stuck”) significantly improved

during the program. Particularly, significant improve-

ments were observed in Q3 (“feel heavy after meals”),

Q7 (“unusual sensation in the throat”), Q10 (“acid into

the throat”), and Q11 (“burp”) at only 2 weeks after

starting the program and thereafter (Figure 4).

Since cutoff score of FSSG is 8 points [6], we ana-

lyzed GERD subgroup (n = 10) whose score >8. TS at

baseline was 18.0 ± 2.9, and significant improvement

was seen at 8weeks (7.6 ± 2.9, p < 0.05), 12 weeks (7.1

± 2.9, p < 0.05) compared with that at baseline (Figure

5(a)). RS at baseline was 8.9 ± 1.6, and significant im-

provement was seen at 12 weeks (3.2 ± 1.6, p < 0.05)

compared with that at baseline (Figure 5(b)). DS at

baseline was 9.1 ± 1.5, and significant improvement was

seen at 8weeks (3.5 ± 1.5, p < 0.05) and 12 w eeks (3.9 ±

1.5, p < 0.05) compared with that at baseline (Figure

5(c)).

Figure 2. Distributions of FSSG score at baseline. In the FSSG before quit smoking, bloat, feeling

heavy in the stomach after meals, unusual sensation in the throat, and burps were commonly com-

plained as 50% or more of the patients.

K. Nakajima et al. / Health 3 (2011) 677-6 83

680

Figure 3. Change of FSSG-Total score (TS) by quit smoking

program (a) upper panel. TS showed significant improvemen

8 QOL score

was 47.3 ± 5.4/48.9 ± 6.6 at baseline, 50.6 ± 4.9*/51.1 ±

n rapidly absorbed into the body of nic-

otine-naïve people, acts on parasympathetic ganglions as

ings, resulting in stimula-

tio

at 2 weeks (p < 0.01), 4 weeks (p < 0.01) 8 weeks (p < 0.05)

and 12 weeks (p < 0.01) compared with that at baseline, re-

spectively. Change of FSSG-Reflux score (RS) by quit smok-

ing program (b) middle panel. RS showed significant im-

provement at 2 weeks (p < 0.01), 4weeks (p < 0.05) 8 weeks (p

< 0.05) and 12 weeks (p < 0.01) compared with that at baseline,

respectively. Change of FSSG-Dysmotility score (DS) by quit

smoking program (c) lower panel. DS showed significant im-

provement at 2 weeks (p < 0.01), 4 weeks (p < 0.05) 8 weeks

(p < 0.05) and 12 weeks (p < 0.01) compared with that at base-

line, respectively.

6.7 at 2 weeks, 51.2 ± 4.7**/51.1 ± 4.6* at 4 weeks, 51.3

± 5.8**/50.7 ± 5

As shown in Figure 6, PCS/MCS in SF

.2 at 8 weeks and 50.6 ± 5.6*/50.2 ± 7.0

at 12 weeks, respectively (**p < 0.01, *p < 0.05 vs.

baseline). PCS showed significant improvements at 2 to

12 weeks after quitting smoking compared with those at

baseline, while MCS improved at 4 weeks. There was no

significant difference in PCS/MCS score between vare-

nicline tartrate and nicotine patch group at the end of this

program.

4. DISCUSSION

Nicotine, whe

well as cholinergic nerve end

n of peristaltic movement of the GI tract and thus

bringing on nausea and diarrhea [7]. In contrast, chronic

long-term ingestion of nicotine alters the peristaltic

movement of the GI tract, influences the function of

multiple endocrine organs, and injures defense mecha-

nisms of the GI tract [8]. It also induces the release of

mediators as well as hormones that affect the structural

integrity of the epithelium and mucosa [9,10]. Further-

more, reducing LES pressure may result in symptom

generation of GERD [11]. Kahrilas PJ et al. described

that the mechanisms of acid reflux during cigarette

smoking were mainly dependent on the coexistence of

diminished LES pressur e and the majority of acid reflux

occurred with cough ing o r d eep in spiration d uring wh ich

abrupt increases in intra-abdominal pressure overpow-

ered a feeble sphincter rather than transient LES relaxa-

tion [12]. Accordingly, cigarette smoking may correlate

GE RD s ymptom through various mechanisms.

Kusano et al. [6] reported the FSSG to evaluate

GERD symptoms. They reported that it showed a sensi-

tivity of 62%, specificity of 59%, and accuracy of 60%

when the cscore was set at 8 points and Futoff SSG is

widely used to evaluate GERD symptoms thereafter

[13-15]. In this study, mean score of FSSG before start-

ing the program was 8.6 and 30% of patients was equal

or more than 8 points. According to the recent review

form Japan, ratio of GERD was reported as 1.3 to 13.7%

in general population [16]. Although the patient number

of this study is a few, ratio of GERD might be more fre-

quent than expected among smokers. Intervention stud-

ies with patients with GERD symptoms, RS and DS are

ameliorating associated with PPI administration [17,18].

Consequently, the FSSG is useful for evaluation of

GERD symptoms and therapeutic effect.

GERD consists of three concept, which are reflux

esophagitis (RE) with symptoms, reflux symptoms with-

out RE and RE without symptoms [16]. Upper GI endo-

K. Nakajima et al. / Health 3 (2011) 677-6 83

681681

Figure 4. Change of scores of each item in FSSG, all items in the FSSG except for “feel full while

eating meals” and “stuck when you swallow” significantly improved during the program. Particularly

scopy is nece

hysicians who don’t have endoscopic equipment should

significant improvements were observed in “feel heavy after meals”, “unusual sensation in the

throat”, “acid into the throat” and “burp” at only 2 weeks after starting the program and thereafter.

ssary to diagnose RE, however, general

deal with GERD patients. Therefore, some study was

focused on uninvestigated GERD, which is diagnosed by

symptoms [17,19]. Indeed, GERD management guide-

line which was published by The Japanese Society of

Gastroenterology described that initial therapy could be

performed without endoscopy for patient with GERD

symptoms [20]. Accordingly, control of GERD symp-

toms should be clinical significance regardless endo-

scopic findings. TS, RS, and DS were improved in all

patient in this study (Figure 3). Surprisingly, GERD

subgroup whose FSSG scor e >8 reveled that FSSG score

significantly improved at 12 week (Figure 5). Among

these patients group, 12.5%, 11.0% ,33.3% and 40.0% of

these recognized complete symptom relief at 2, 4, 8 and

12 week respectively. These result suggested that quit

smoking may be an option of treatment of GERD symp-

toms, or at least lead of quit smoking for patients with

GERD symptom could have additive therapeutic effect.

Quit smoking, as evaluated with the FSSG, improved

the following GERD symptoms promptly only 2 weeks;

“f

g also allevi-

ated the “unusual sensation in your throat” in a short

uld benefit from quit smoking in terms

lt as these

eeling heavy after meals”, “acid in the throat” and

“burp”. This was because quit smoking might improve

the nicotine-induced decline in esophageal lower

sphincter pressure, which had led to frequent occurrence

period of time in this study. Chang-Chun Lin et al. [21]

and Belafsky P.C. et al. [22] pointed out in their studies

using RSI (reflux symptom indexes) scores that smoking

provoked symptoms related to the vocal cord or the

laryngopharynx. Therefore, quit smoking seemed to ease

such symptoms.

Our result indicated that improvement of GERD

symptoms brought about by quit smoking was not re-

lated to Brinkman index. Hence, it seems that even a

heavy smoker wo

of reflux symptoms [3,11,12]. Quit smokin

improvement of GERD symptoms.

There are reports that indicated that quit smoking im-

proved self-control and health transition and that quit

smoking improved the QOL of asthmatic ex-smokers

[23,24]. In this study showed the similar resu

evious studies. Especially, PCS kept improving sig-

nificantly during the program. Moreover, both PCS and

MCS exceeded 50 points which is mean Japanese na-

tional level after starting the program at only 2 weeks

and maintained until the end of program. In this study,

quit smoking led prompt improvement in some symp-

toms, might direct impact on QOL particularly PCS

which is concerning physical health.

In this study, it is unclear whether patients had reflux

K. Nakajima et al. / Health 3 (2011) 677-6 83

682

Figure 5. Change of FSSG-Total score (TS) by quit smoking

program among GERD subgroup (a) upper panel. TS showed

significant improvement at 8weeks (p < 0.05) and 12 weeks

< 0.05) compared with that at baseline, respectively. Change of

FSSG-Reflux score (RS) by quit smoking program among

GERD subgroup (b) middle panel. RS showed significant im-

provement at 12 weeks (p < 0.05) compared with that at base-

line, respectively. Change of FSSG-Dysmotility score (DS) by

quit smoking program among GERD subgroup (c) lower panel.

DS showed significant improvement at 8 weeks (p < 0.05) and

12 weeks (p < 0.05) compared with that at baseline, respec-

tively.

Figure 6. Change of SF8 QOL by quit smoking program.

Physical component summary (PCS) significant improved at 2,

4, 8, and 12 weeks versus baseline. Mental component sum-

mary (MCS) significant improved at 4 weeks versus baseline

Both PCS and MCS exceeded 50 points promptly after starting

t. Moreover, it remains to be studied whether

y: Lower oeso-

implications. Lancet,

7853, 347-349. doi:10.1016/S0140-6736(74)93088-8

the program at only 2 weeks and maintained until the end of

program.

esophagitis or peptic ulcer since we did not perform an

endoscopy. We focused on change of “symptoms” of

GERD by quit smoking program and revealed its im-

rovemenp

quit smoking induced improvement of symptoms is

maintained for a long period of time since our follow-up

period was short. These points are limitation of this

study. We hope that a large-scale long-term study will be

conducted in the future.

In Conclusions, Quit smoking improved not only

GERD symptoms but also QOL. We showed that quit

smoking has the poten tial of being one of the therap eutic

strategic options for GERD symptom treatment.

5. CONFLICT OF INTEREST

There is no conflict of interest.

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