To determine the effect of different methods of modeling smoking on vascular outcomes in rheumatic diseases.


Data from the Canadian Scleroderma Research Group Registry were used. Patients self-reported their smoking history. Vascular outcomes were severity of Raynaud's phenomenon, presence of finger ulcers, and severity of finger ulcers. Several models were developed to capture the experience of smoking: 1) ever compared to never smoking; 2) current and past smoking compared to never smoking; 3) never, past, and current smoking compared using polynomial contrasts; 4) smoking intensity, duration, and time since cessation assessed separately; and 5) smoking modeled using the Comprehensive Smoking Index (CSI), which integrates intensity, duration, and time since cessation into a single covariate.


This study included 606 patients, of which 16% were current, 42% were past, and 42% were never smokers. Current and past smokers smoked a mean ± SD of 25 ± 17 and 17 ± 18 pack-years, respectively. Smoking duration was shorter in past compared to current smokers (18.3 versus 31.7 years). Past smokers reported having stopped smoking approximately mean ± SD 16 ± 12 years prior, although this ranged from 1 to 50 years. Smoking had no effect on vascular outcomes in the simplest model comparing ever to never smokers. Models that isolated past smokers revealed the presence of a healthy smoker bias in that group. The model using the CSI demonstrated a strong negative effect of smoking on vascular outcomes.


Proper modeling of the effect of smoking is essential in studies of vascular outcomes of rheumatic diseases.