Patients with chronic liver disease commonly have abnormal lung function, however the impact of smoking on outcomes in these patients is unknown. We hypothesized current or past smoking would be associated with worse survival in patients with advanced liver disease. The Pulmonary Vascular Complications in Liver Disease Study 2 (PVCLD2) was a prospective cohort of patients with advanced liver disease undergoing evaluation for liver transplantation (LT). Patients were classified by self-report as a "non-smoker", "past smoker", or "current smoker". We used Cox proportional hazards models and Fine-Gray models with LT as a competing risk. Models were adjusted for age, sex, body mass index, race, family income, liver disease etiology, and Model for End-Stage Liver Disease-Sodium (MELD-Na) score. Of the 410 patients included, most (65%) were male with mean age at enrollment was 56.5 years. 160 (39%) patients were non-smokers, 183 (45%) were past smokers, and 67 (16%) were current smokers. In total, 151 (37%) patients received a LT, and 88 (20%) patients died. When compared to non-smokers, current smokers had a 2.17-fold increase in risk of death overall (95% CI 1.12-4.18, p=0.02). There was a 7% increase in overall risk of death for every 5 pack-years increase (95% CI 1.01-1.13, p=0.02). With LT as a competing risk, the sub-distributional hazard ratio (sHR) of current smokers versus non-smokers for death was 2.45 (95% CI 1.31-4.60, p=0.005). In this model, past smokers displayed a non-significant increase in risk of death compared to non-smokers (sHR1.58, 95% CI 0.91-2.72, p=0.10). Patients with advanced liver disease undergoing evaluation for LT who smoke have an increased risk of death. Smoking cessation could lead to improved overall survival with or without LT.
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