Heat-Not-Burn Tobacco Linked to Crohn’s Disease Recurrence After Surgery

Key Clinical Summary

• In a 937-patient European study, postoperative endoscopic Crohn’s disease recurrence occurred in 63.9% of heat-not-burn tobacco users and 60.6% of e-cigarette users, compared with 40.8% of nonsmokers.
• Heat-not-burn tobacco remained independently associated with recurrence after adjustment (OR, 2.76; 95% CI, 1.36–5.82).
• The e-cigarette association did not reach statistical significance in multivariable analysis (OR, 2.02; P=.067).

Patients with Crohn’s disease who use heat-not-burn tobacco (HNBT) after ileocolic resection may face a substantially increased risk of postoperative endoscopic recurrence, according to a multicenter European study published in The American Journal of Gastroenterology.

Study Findings

Investigators retrospectively evaluated 937 consecutive patients with Crohn’s disease who underwent ileocolic resection and subsequent endoscopic assessment within 6 to 12 months at 9 centers in Italy, Spain, and France. Patients were classified according to postoperative use of conventional cigarettes, HNBT, e-cigarettes, or no smoking; individuals using multiple products were excluded.

The cohort included 691 nonsmokers, 176 conventional cigarette smokers, 37 HNBT users, and 33 e-cigarette users. The primary outcome was postoperative endoscopic recurrence, defined as a Rutgeerts score of at least i2.

At 1 year, recurrence occurred in 69.4% of conventional cigarette smokers, 63.9% of HNBT users, and 60.6% of e-cigarette users, versus 40.8% of nonsmokers (all P<.05). Among patients receiving postoperative prophylaxis with azathioprine or biologic therapy, recurrence rates remained 70.0%, 66.7%, 63.0%, and 41.6%, respectively.

Biochemical findings followed a similar pattern. Fecal calprotectin levels of at least 150 μg/g were observed in 64.6% of conventional smokers, 53.9% of HNBT users, 46.2% of e-cigarette users, and 26.3% of nonsmokers.

After adjustment for potential confounders, conventional cigarette smoking (OR, 3.49; 95% CI, 2.34–5.28; P<.001) and HNBT use (OR, 2.76; 95% CI, 1.36–5.82; P=.006) remained significantly associated with endoscopic recurrence. The association for e-cigarettes was elevated but did not reach statistical significance (OR, 2.02; 95% CI, 0.96–4.39; P=.067).

Clinical Implications

The investigators noted that HNBT users—and potentially e-cigarette users—may warrant similar postoperative caution to conventional smokers.

Smoking cessation timing may also be clinically relevant. Endoscopic recurrence occurred in 36.6% of never-smokers and 44.4% of patients who stopped smoking more than 1 year before surgery, compared with 60.0% among those who quit at surgery or during the preceding year. Recurrence among recent quitters was not significantly different from active conventional smokers.

The retrospective design and small numbers of HNBT and e-cigarette users limit causal interpretation. The authors also cited potential underreporting of product use, heterogeneity among e-cigarette products, and difficulty quantifying exposure.

Expert Commentary

The investigators concluded that their findings challenge perceptions of newer smoking products as safe alternatives. They recommended that patients with Crohn’s disease using HNBT or e-cigarettes be managed similarly to conventional smokers after surgery and stated that switching products “should not be viewed as a risk-free alternative.” Complete smoking cessation, they wrote, should remain the recommended strategy.

Overall, the findings identify HNBT as an independent correlate of postoperative Crohn’s disease recurrence and raise concern about e-cigarette use. Prospective studies with larger exposure groups are needed to better define the risks associated with newer tobacco and nicotine products.

Reference: Parigi TL, Nardone OM, Lisa M, et al. The impact of e-cigarettes and heat-not-burn tobacco on postoperative recurrence of Crohn’s disease: a multicenter international study. Am J Gastroenterol. 2026; 121(8):1954-1962. doi:10.14309/ajg.0000000000003810.