The Impact of E-Cigarettes and Heat-Not-Burn Tobacco on Postoperative Recurrence of Crohn's Disease: A Multicenter International Study

Introduction: – Tobacco smoke is an established risk factor for Crohn’s disease (CD) postoperative recurrence; however, the effect of e-cigarettes and heat-not-burn tobacco (HNBT) remains unknown. We aimed to evaluate the impact of e-cigarettes and HNBT on postoperative recurrence in CD patients.Methods: – We retrospectively included consecutive CD patients who underwent ileocolic resection and endoscopic evaluation within one year across nine centers in Italy, Spain, and France. Based on smoking habits between surgery and endoscopy, patients were categorized as non-smokers, cigarette smokers, HNBT users, or e-cigarette users. Those using multiple products were excluded. The primary outcome was endoscopic recurrence (Rutgeerts score ≥2) one year after surgery. Secondary analyses included modified Rutgeerts score (≥i2b), mean Rutgeerts score, transmural disease activity, fecal calprotectin, time from diagnosis to surgery, uni- and multi-variable regression analysis.Results: – 937 patients were included, of which 691 (74%) were non-smokers, 176 (19%) conventional cigarette smokers, 37 (4%) HNBT users, and 33 (4%) e-cigarette users. Recurrence rates were significantly higher in all smoking groups compared to non-smokers (69.4%, 63.9%, and 60.6% for traditional cigarette, HNBT, and e-cigarette users, respectively, vs. 40.8% for non-smokers; all P<0.05). The association was also observed in patients receiving pharmacological prophylaxis, using the modified Rutgeerts score cutoff of i2b, mean Rutgeerts score and fecal calprotectin levels. In multivariable regression analysis, HNBT use remained significantly associated with recurrence (OR 2.76), while the association for e-cigarette missed statistical significance (OR 2.02, P=0.067).Discussion: – HNBT, and possibly e-cigarettes, are associated with increased endoscopic recurrence of CD compared to non-smoking.