About Graves' disease and thyroid eye disease

Hyperthyroidism is a condition where the thyroid produces more thyroxine than is needed by the body. It is also referred to as thyrotoxicosis, or an over-active thyroid. Graves' disease is an autoimmune condition and the most common cause of hyperthyroidism. It is caused by antibodies that attack the thyroid gland: the body's immune system turns against the thyroid gland, which in response becomes over-active.

About a quarter of people with Graves' disease develop thyroid eye disease (TED). TED is an autoimmune disease. It occurs when the body's immune system attacks the back of the eye and causes inflammation. This can cause the eyes to be pushed forward ('staring' or 'bulging' eyes) and the eyes and eyelids to become swollen and red. In some cases there is swelling and stiffness of the muscles that move the eyes so that the eyes are no longer in line with each other; this can cause double vision. Rarely, TED can cause blindness from pressure on the nerve at the back of the eye or ulcers forming on the front of the eyes.

TED can happen at any time. It can develop before, during, or after the over-active thyroid disorder is diagnosed, though the two usually come on roughly at the same time. In most cases the eye disease is mild, but it can be a distressing and disfiguring complication that can be difficult to treat.

Cigarette smoking is known to have a major influence on Graves' disease and on TED.

How smoking affects the thyroid and the eyes

Smoke contains thousands of chemicals and some of these can stimulate the immune system to react against the thyroid. Non-smokers or ex-smokers are more likely to be cured of their thyroid over-activity after a course of carbimazole (CMZ) or propylthiouracil (PTU) treatment, than smokers.

Smoking reduces the amount of oxygen in tissues and it has been shown that a low oxygen content makes tissues in the back of the eye prone to inflammation. The association between smoking and TED is strong and is also related to the number of cigarettes smoked per day (1). Overall, if you smoke your chance of developing TED is doubled. If have radioactive iodine treatment and you smoke you are four times more likely to develop TED.

If you are a heavy smoker, the chances of developing TED is increased eight times compared to non-smokers. The risk seems to decline very rapidly after quitting.

Patients with TED who continue to smoke respond less well to treatments, but this disadvantage seems to disappear soon after giving up smoking.

It is not known whether nicotine itself has an effect on TED. Nicotine replacement as a means of helping people with TED quit is thought by TED experts to be as appropriate in smokers with TED as for other smokers.

Passive smoking may also have a detrimental effect, especially for children – who can also develop Graves' disease and TED. Avoidance of passive smoking is likely to be beneficial.

Vaping and TED

Vaping may be a stepping stone to stopping smoking. There is no research yet on vaping and TED. However, the safest thing for your TED and you general health is to stop doing either. 

Key points

• Smokers with Graves' disease are about two times more likely to develop TED (2) and heavy smokers are eight times more likely to develop TED.
• If you develop TED and you continue to smoke you are more likely to suffer the more severe forms of the disease than if you quit (3). These are 'proptosis' or 'exophthalmos' (protrusion of the eyeball) (figure 1), double vision due to squints developing (figure 2) and the most severe form which can cause blindness ('dysthyroid optic neuropathy') (figure 3).

Figure 1	Figure 2	Figure 3

• If you need any specific treatment for your eyes (such as steroids, radiotherapy or surgery), the treatment will not work as well if you continue to smoke (4, 5) because it seems that smoking makes you resistant to treatment and healing of tissues is slower and less complete.
• Apart from the effects of smoking on the eyes of people with Graves' disease, smoking reduces the chance of a cure of the thyroid over-activity after a course of tablets (5) because it is thought that smoking fuels the autoimmune attack on the thyroid and counteracts the effects of the medication.

Your general health can benefit if you quit smoking. Your thyroid health and TED can improve significantly.

Finding help to stop smoking

You can get support to help you arrive at a decision to quit and choose the treatment option that is right for you.

Help is available from the NHS – all help, support and advice is free. You are four times more likely to be successful in stopping smoking, and not go back to smoking, by using NHS support services and treatment than trying to stop on your own.

Help is available from:

• Your GP surgery
• Your thyroid clinic or eye clinic - a doctor or nurse will be able to advise you
• Pharmacists and health visitors can also give advice and will be able to refer you to NHS stop smoking services in your area.
• You can find your local NHS Stop Smoking Service

Other websites and helplines

• NHS Smokefree
• canstopsmoking.com
• Smokeline: 0800 84 84 84
• quitwithhelp.co.uk
• No Smoking Day
• NHS Choices - Motivate Yourself (available in other languages by clicking on the 'Translate' link at the top of that page)
• Information about e-cigarettes from the NHS

Comments from TED patients

We conducted an on-line survey on the first draft of our information. We are grateful for the many helpful comments, which helped us to redraft our information about the effects of smoking on (Graves' disease?) and thyroid eye disease.

Below are comments from TED patients about the benefits of quitting

I was a smoker when I was diagnosed with TED. I also gave up quickly with Champix. I wish I had realised how easy stopping smoking could be. Also just how much tobacco affects the eyes. TED is a cruel illness but it was in my own hands to stop smoking and shorten the damage to my health and well being. I wish I had known before the damage I was causing myself and it has taken years to get so far and almost better. I have had lots of eye surgery too!

I stopped smoking 8 months ago due to wanting to be at the best level of health and fitness I could be to combat Graves Disease. Until reading [your information] I was not aware of the relationship with smoking and this will give that extra reason on those bad days when temptation calls.

I have now stopped smoking for over a year - the truth is my eyesight has significantly improved as has the protruberance of my eyes - this is what you need to let people know.

I only stopped smoking a week ago. Having read the information has made me even more determined to remain a non smoker even though I am finding this difficult at times.

On my first consultation, my endo advised about the dangers of smoking and TED and stopped smoking since.

I was never informed of the link between smoking and TED when I had it - this is useful information

I stopped as soon as I was told. Most people with TED will do pretty much anything to improve appearances.
I am classing myself as an ex-smoker even though I have not given up for too long. I am determined not to make my eyes worse by continuing to smoke and therefore I am now (hopefully) an ex smoker.

If you would like to let us know whether having TED made you decide to quit smoking please email [email protected] We will publish anonymised encouraging comments on our TED patients' comments page to help others.

References

1. Wiersinga WM. Smoking and thyroid. Clin Endocrinol (Oxf). 2013;79:145-51
2. Vestergaard, P. (2002) Smoking and thyroid disorders – a meta-analysis. European Journal of Endocrinology, 146, 153–161.
3. Pfeilschifter, J. & Ziegler, R. (1996) Smoking and endocrine ophthalmopathy: impact of smoking severity and current versus lifetime cigarette consumption. Clinical Endocrinology, 45, 477– 481.
4. Thornton, J., Kelly, S.P., Harrison, R.A. et al. (2007) Cigarette smoking and thyroid eye disease: a systematic review. Eye, 21,1135–1145.
5. Eckstein, A., Quadbeck, B., Mueller, G. et al. (2003) Impact of smoking on the response to treatment of thyroid associated ophthalmopathy. British Journal of Ophthalmology, 87, 773–776.

Resources for medical/health professionals

Smoking cessation: supporting people to stop smoking (NICE)

National Centre for Smoking Cessation and Training (NCSCT) - Service and delivery guidance:

Contact us

If you would like to leave a comment about the information we have provided about smoking and thyroid eye disease please email [email protected] 

TEAMeD (Thyroid Eye Disease Amsterdam Declaration) Implementation Group UK is working to improve the patient experience for people with thyroid eye disease. Its activities are supported by the British Thyroid Foundation, TEDct, the Royal College of Physicians, the Royal College of Ophthalmologists, the Scottish Ophthalmologists Club, the Society for Endocrinology, the British OculoPlastic Surgery Society, British & Irish Orthoptic Society and the British Thyroid Association. 

© TEAMeD 2014 All rights reserved
First draft published December 2013. Our literature is reviewed every three years

This information may be downloaded and copied freely.

© TEAMeD 2014 All rights reserved
First draft published December 2013. Our literature is reviewed every three years

This information may be downloaded and copied freely.