The Impact of Smoking Cessation on Thyroid Eye Disease (TED) Outcomes

Thyroid Eye Disease (TED) is sometimes called Graves’ orbitopathy pror Graves’ ophthalmopathy and its development and severity are associated with several risk-factors such as uncontrolled thyroid levels, radioiodine treatment, high autoantibody titres, and one of the most important modifiable ones, smoking (2).

Quitting smoking has been proven to improve outcomes in TED, reduce severity, enhance treatment responsiveness, lower the need for surgery, and improve long-term quality of life. This article explores the evidence, practical implications, and steps to support smoking cessation in patients with TED.

The Correlation Between Smoking and Thyroid Eye Disease

Multiple studies have demonstrated a strong association between smoking and both the incidence and severity of TED (3). For example, smokers with Graves’ disease are significantly more likely to develop TED compared to non-smokers (odds ratios in early studies ranged from ~2 to 10). Smoking is also associated with more severe TED resulting in greater proptosis (bulging of the eyes), increased diplopia (double vision), higher clinical activity and poorer response to treatment. Smoking is known to reduce orbital tissue oxygenation, increase oxidative stress in orbital fibroblasts, and sensitize immune pathways causing inflammation relevant to TED. In short: smoking does not just raise the risk of developing TED, it also makes the disease worse and harder to treat once it occurs.

Evidence that Smoking Cessation Improves Outcomes

As elaborated above, smoking cessation is among the few modifiable factors in TED that patients have direct control over. Quitting smoking without delay has been shown to reduce the severity of TED such as:

• Reduced risk of onset: Former smokers have lower TED rates than current smokers, indicating the benefit of abstinence.
• Improved treatment response, especially to biologic interventions and corticosteroids: Studies show that smokers treated with biologic therapies (e.g., teprotumumab) or steroids for TED have more dismal outcomes than non-smokers. By contrast, non-smokers and those who quit smoking have been shown to have better outcomes.
• Lower likelihood of surgery: One registry-based study found that patients who quit smoking were at a lower risk of having to undergo orbital decompression or eyelid surgery vis a vis persistent smokers (4).
• Counseling helps TED smokers to quit: A recent 2025 study showed in a TED clinic cohort that ~49% of active smokers were able to successfully give up smoking after verbal counselling (5).

How Smoking Impacts TED Severity and Development

It is important to understand the mechanistic basis by which smoking exacerbates TED risk and severity to be able to persuade patients to quit. Smoking increases oxidative stress and the excess reactive oxygen species (ROS) in cigarette smoke can activate orbital fibroblasts and promote fat expansion and fibrosis, all of which are key features of TED (6). This reduced oxygenation leads to vascular changes as smoking impairs blood flow and oxygen delivery behind the eye, further compounding inflammatory and fibrotic changes in the orbit.

Smoking also stimulates autoimmune pathways and modifies antibody responses to thyroid autoantigens which worsens inflammatory burden in Graves’ disease and TED. Collectively these deleterious changes result in impaired treatment response and render orbital tissues less responsive to steroids, biologics, and other therapies, which means worse outcomes in incumbent smokers. Hence by ceasing to smoke, you stop feeding many of these damaging processes which in turn shift the balance back in your favor for recovery and management.

Practical Advice and Roadmap to Help Quitting Smoking in TED

Given the clear benefits, quitting smoking must be a central part of any TED care plan for those who smoke and below are some practical strategies to assist them in their journey:

1. Set a clear quit date and plan:

• Choose a target quit date.
• Remove all triggers from your environment (ashtrays, lighters, spare cigarettes etc.).
• Develop a strong support system by informing friends, family, and your care team.

2. Seek support:

• Consider counseling, support groups, and helplines.
• Ask about nicotine replacement therapy or medications (e.g., varenicline) if appropriate. Some TED-specialty clinics now incorporate cessation programs.

3. Monitor progress as small steps and reward milestones:

• Track cigarette count and nicotine cravings.
• Celebrate small milestones, for example, when you reach 1 week, 1 month, 3 months smoke-free.

4. Integrate TED-specific counselling:

• As mentioned above, having a rudimentary understanding of how smoking affects your eye disease, worsens bulging, deepens diplopia and lessens treatment success can provide further impetus to quit.

5. Address relapse proactively:

• Quitting may take multiple attempts and do not be discouraged if you slip.
• Recognize that each day you smoke adds risk, and each smoke-free day adds benefit.

6. Coordinate with thyroid function and TED care:

• Keep your thyroid levels stable by adhering to your medication routine.
• Utilize lubrication to minimize eye dryness, ocular care, selenium supplements and monitor for other signs of disease activity such as pain and inflammation around the eyes.
• Make smoking cessation a “non-negotiable” part of your TED plan. Your thyroid/eye care team can refer you to specific cessation or groups to assist you in your attempts to quit, thereby making quitting a strategic part of your treatment.

In short, quitting smoking can make a big difference in your TED journey through:

• Reduced need for surgery: Less severe disease means fewer patients will require orbital decompression or eyelid surgery.
• Better treatment response: Steroids, biologics, and radiation work better when the damaging effect of smoking is removed.
• Improved quality of life: Less proptosis, reduction in diplopia, markedly reduced inflammation and pain with better cosmetic and functional outcomes.
• Lower long-term risk: In addition to worsening TED, smoking increases the risk of cardiovascular disease, eye problems, cancer, infertility, and other systemic health issues. Quitting supports your overall health well beyond TED.

Start Making Choices That Help Your TED

Smoking cessation is not just another “nice to have” for patients with TED and it is one of the most powerful interventions and modifying factors that you can personally control. While the effects may not be felt immediately, quitting sets the stage for better outcomes. If you or someone you know has TED and would like to explore treatment options and smoking cessation, do not hesitate to schedule an appointment with Dr. Raymond Douglas.

References

1. Shah SS, Patel BC. Thyroid Eye Disease. StatPearls. Treasure Island (FL)2025.
2. Thornton J, Kelly SP, Harrison RA, Edwards R. Cigarette smoking and thyroid eye disease: a systematic review. Eye (Lond). 2007;21(9):1135-45. Epub 20060915. doi: 10.1038/sj.eye.6702603. PubMed PMID: 16980921.
3. O’Dell JM, Mussatto CC, Chu RL, Al-Sabbagh MQ, Timoney PJ, Sokol JA. Effects of Smoking on Outcomes of Thyroid Eye Disease Treated with Teprotumumab: A Retrospective Cohort Study. Kans J Med. 2023;16(1):62-4. Epub 20230315. doi: 10.17161/kjm.vol16.18940. PubMed PMID: 36970041; PMCID: PMC10035644.
4. Oke I, Reshef ER, Elze T, Miller JW, Lorch AC, Hunter DG, Freitag SK, Consortium IRAC. Smoking Is Associated With a Higher Risk of Surgical Intervention for Thyroid Eye Disease in the IRIS Registry. Am J Ophthalmol. 2023;249:174-82. Epub 20230120. doi: 10.1016/j.ajo.2023.01.020. PubMed PMID: 36690290; PMCID: PMC10767645.
5. Karimi N, Kashkouli MB, Keyhani A, Aghili S, Ghahvehchian H, Askari S, Akbarian S. Mitigating the risks: addressing smoking cessation in thyroid eye disease. BMJ Open Ophthalmol. 2025;10(1). Epub 20250831. doi: 10.1136/bmjophth-2025-002226. PubMed PMID: 40889896; PMCID: PMC12406940.
6. Regensburg NI, Wiersinga WM, Berendschot TT, Saeed P, Mourits MP. Effect of smoking on orbital fat and muscle volume in Graves’ orbitopathy. Thyroid. 2011;21(2):177-81. Epub 20101212. doi: 10.1089/thy.2010.0218. PubMed PMID: 21142817.