Introduction It is widely accepted that smoking predisposes to Crohn's disease (CD) but is protective against ulcerative colitis (UC). The precise impact of stress, the influence of diet and the efficacy of complementary medicines on the course of inflammatory bowel disease (IBD) are unclear (ECCO guidelines). The study aim was to assess our IBD patients' knowledge about the association between IBD and smoking and to evaluate which factors they consider important in controlling bowel disease.

Methods During a 6 weeks interval the authors prospectively recruited all patients attending the IBD clinic in our Institution. Patients were asked to complete an anonymous questionnaire which assessed basic demographics, smoking history and patient knowledge about their disease. Patients were asked to rank (in a scale from 0 to 10) the importance, in their opinion, of the following factors in controlling IBD activity: drugs, surgery, diet, stress control, stopping smoking and alternative therapy.

Results The authors surveyed 199 patients (median age 44 years; M/F: 92/107) with IBD: 101 (51%) had CD, 86 (44%) had UC and 12 (5%) had IBD-unclassified. Median IBD duration was 12 years (range 1–60). 89% of CD patients were non-smoker compared to 95% of UC (p=0.015). 69% of CD patients reported to be aware of the negative association between smoking and CD; while only 36% of UC patients were aware of the positive association with UC. CD patients rated medications (mean value 7.8), followed by stress control (7.6) and even diet (7.4) as the most important factors able to influence their disease activity. Smoking cessation (7.0) and surgery (6.5) were considered less effective. Alternative treatment (3.6) was considered only marginally effective in IBD. There was a strong correlation between stress and diet (p<0.001). Smoking correlated with stress (p<0.002) and alternative therapy with diet (p<0.001). UC patients gave rating similar to CD, except for smoking cessation (3.9). CD smokers considered stress (8.2) and diet (7.7) more important compared to CD non-smokers; while they rated smoking cessation (6.7) and surgery (4.2) less effective.

Conclusion Only two thirds of CD patients recognise the importance of smoking cessation on disease activity, and one third of UC patients are aware of the positive association with smoking. IBD patients consider stress and diet as effective as drugs in controlling bowel disease; moreover, CD patients value stress and diet as more important than smoking in affecting disease activity. Clinicians should always consider the perceptions and beliefs of the patient when discussing treatment strategy in IBD.