On the heels of findings that more people die following liver transplantation for alcoholic liver disease (ALD) compared to other patients, doctors at the University of Pittsburgh have uncovered what they call a continuing and "disturbing" trend of tobacco use after this surgery.¹ As a result, the physicians are calling for better monitoring and relevant medical interventions for these patients aimed at ending their smoking habit.

In an earlier study by the research group,² not only were increased numbers of deaths found in these patients, but it was learned they were also more likely to be diagnosed with lung and throat cancer compared to those in the general population, wrote study chief Andrea DiMartini, MD, and her associates.

DiMartini is an associate professor of Psychiatry and Surgery at the university's Thomas Starzl Transplantation Institute.

"It is a tragedy to bring a patient through transplantation only to have them succumb to another illness that could have been prevented," she told Priority Healthcare. In addition to the higher risk of cancer, smoking can increase the likelihood that the transplanted liver will become diseased, as well, DiMartini pointed out.

Why Do Smokers Resume After Transplant?
Nevertheless, smoking habits after liver transplantation had not been explored much among medical researchers, the study group noted. So they launched their own research on post-transplant smoking habits, whose results are published in the June issue of the journal Liver Transplantation. "Our goal was to examine the prevalence of tobacco use, the quantity and frequency of tobacco use, and redevelopment of nicotine addiction in our ALD liver transplant cohort," they explained.

DiMartini and her associates followed 172 patients who had undergone liver transplants for alcoholic liver disease between 1998 and 2003. Each patient was then followed for three years. During the study, the patients completed questionnaires about their health habits every 3 months in the first year after their transplant procedures, then every 6 months for the next 2 years. The questionnaires were distributed regularly so that the researchers could ascertain each patient's tobacco habit, and whether or not he or she had become addicted to nicotine during that time.

DiMartini and her colleagues analyzed all the data at the conclusion of the study, and found that nearly 40 percent of the patients were smoking after their liver transplant operation.
 
While most reported smoking cigarettes, about 12 percent said they smoked pipes or cigars. A small minority reported using smokeless tobacco. The large majority of smokers said they smoked daily, similar to responses from most smokeless tobacco users. Further, based on the scores calculated in the questionnaires, DiMartini's group also found that nearly half of the smokers were nicotine-dependent by the end of the study.

"It is clear that smokers resume smoking quickly after liver transplantation, most having restarted smoking by 3 months after liver transplantation," they wrote. Additionally, nearly two-thirds of the patients became addicted to nicotine within 9 months after the transplant procedures.

Who Is More Likely to Smoke?
The researchers also looked at associations between post-transplant smoking and patients' medical and demographic characteristics. Only those who had been diagnosed with hepatitis B or C were more likely to smoke after the surgery, as well as patients with a pre-transplant diagnosis of alcohol dependence. Those with a prior history of non-alcohol substance abuse also tended to practice the habit, the study found. The study authors found no link between smoking and depression.

"These results show a disturbing trend in our ALD population; that a significant percentage use tobacco after liver transplantation," DiMartini and her colleagues concluded.

It's apparent that smoking habits persist after liver transplants because physicians are not addressing the issue properly prior to surgery, DiMartini explained. "Medical professionals should screen patients for tobacco, and counsel them on cessation," she said.

Next: Measuring Risk of Death from Smoking
The research group next plans to continue following these patients to determine if their tobacco habits directly contribute to post-transplant morbidity and death. "Considering all associations between tobacco use and poor health outcomes, tobacco use may well outweigh alcohol use for impact on post-liver transplant morbidity and mortality," they wrote.

In an editorial accompanying the study,³ Santiago Munoz, MD, chairman of the Hepatology division at Albert Einstein Medical Center in Philadelphia writes, "The data suggest that post-liver transplantation smoking is not casual, but extensive, and within the detrimental range." As such, post-transplant smoking should now be added to the list of risk factors for post-transplant atherosclerosis, diabetes, hypertension, obesity, hyperlipidemia, and aging, Munoz warns.

"Since continued smoking is unlikely to become a reason to exclude patients from undergoing liver transplantation, nicotine addiction and tobacco use both prior to and after liver transplantation have to be addressed in a proactive and organized manner," he stressed. Some potentially effective interventions might include professional counseling, behavioral therapy, nicotine replacement therapy, or medications, he added.

1. DiMartini A, Javed L, Russell S et al. Tobacco use following liver transplantation for alcoholic liver disease: An underestimated problem. Liver Transpl 2005 Jun;11(6):679-83.
2. Jain A, DiMartini A, Kashyap R, Youk A, Ronal S, Fung J. Long-term follow-up after liver transplantation for alcoholic liver disease under tacrolimus. Transplantation 2000 Nov 15;70(9):1335-42.
3. Munoz SJ. Tobacco use by liver transplant recipients: grappling with a smoking gun. Liver Transpl 2005 Jun;11(6):606-9.

John Martin is a long-time health journalist and an editor for Priority Healthcare. His credits include overseeing health news coverage for the website of Fox Television's The Health Network, and articles for the New York Post and other consumer and trade publications.