title: Effects of smoking on survival for patients with end-stage liver disease.
abstract: BACKGROUND
  Smokers with chronic liver disease can become eligible for transplantation, but some insurers refuse reimbursement pending smoking cessation.
  
  
  METHODS
  Our hypothesis is that liver transplantation candidates and recipients who smoke have inferior survival compared with nonsmokers. Using a retrospective cohort study design, three Cox proportional hazards models were constructed to determine covariate-adjusted mortality from transplantation evaluation and transplantation based on smoking status at evaluation, transplantation, and posttransplantation followup.
  
  
  RESULTS
  From 1999 to 2007, 2,260 patients were evaluated. Seven hundred sixty were active smokers, and 1,500 were nonsmokers. Smokers at evaluation were younger (49.3 versus 51.7 years), were more likely to be men (65.9% versus 58.7%), have hepatitis C (54.2% versus 30.1%), have a lower Model for End-Stage Liver Disease score (10.5 versus 12.3), and less likely to receive transplant (12.2% versus 18.6%) (all p < 0.05). The postevaluation multivariate model indicated that substance use, higher Model for End-Stage Liver Disease score, hepatitis C, and older age increased mortality risk (all p < 0.05), and liver transplantation (hazards ratio = 0.986; 95% CI, 0.977 to 0.994) was associated with lower mortality. Smoking was not associated with increased mortality risk at any time point in those evaluated or receiving transplants.
  
  
  CONCLUSIONS
  Providers should continue encouraging potential liver transplantation candidates to stop smoking, but insurer-driven mandated smoking cessation might not improve survival.
authors.affiliation: Summer Student Research Program, Department of Surgery, University of Michigan, Ann Arbor, MI 48109-0331, USA.
authors.forename: Dennis S
authors.initials: DS
authors.lastname: Lee
authors.forename: Amit K
authors.initials: AK
authors.lastname: Mathur
authors.forename: William B
authors.initials: WB
authors.lastname: Acker
authors.forename: Shaza N
authors.initials: SN
authors.lastname: Al-Holou
authors.forename: Lauren K
authors.initials: LK
authors.lastname: Ehrlichman
authors.forename: Sarah A
authors.initials: SA
authors.lastname: Lewin
authors.forename: Christopher K B
authors.initials: CK
authors.lastname: Nguyen
authors.forename: Sarah F
authors.initials: SF
authors.lastname: Peterson
authors.forename: David N
authors.initials: DN
authors.lastname: Ranney
authors.forename: Kristen
authors.initials: K
authors.lastname: Sell
authors.forename: James
authors.initials: J
authors.lastname: Kubus
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Englesbe
mesh_terms: D015897:Comorbidity; D005260:Female; D006801:Humans; D017093:Liver Failure / Q000453:epidemiology / Q000601:surgery*; D016031:Liver Transplantation / Q000401:mortality*; D008297:Male; D008875:Middle Aged; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D012907:Smoking / Q000009:adverse effects* / Q000453:epidemiology; D016019:Survival Analysis