Management of Gastroesophageal Reflux Disease in Tobacco Users

Lifestyle Modifications

The American College of Gastroenterology recommends complete smoking cessation rather than reduction for maximal benefit in patients with GERD 1
Weight loss is recommended for overweight or obese patients with GERD, as it has the strongest evidence for efficacy 3
Elevating the head of the bed 6-8 inches is recommended for nighttime symptoms, and avoiding lying down for 2-3 hours after meals is also advised 1
Limiting dietary fat to ≤45g per 24 hours and avoiding trigger foods such as coffee, tea, chocolate, mints, citrus products, tomatoes, and alcohol is recommended 2, 4
Sleeping in the left lateral decubitus position is also recommended 4

The American Gastroenterological Association recommends starting proton pump inhibitor (PPI) once daily, 30-60 minutes before breakfast, for initial treatment of GERD 1
Standard doses of omeprazole 20mg or lansoprazole 30mg are recommended, and allowing 4 weeks to assess response is advised 3
For persistent symptoms, escalating to twice-daily PPI dosing (before breakfast and dinner) is recommended, as it is superior to once-daily dosing for acid suppression 1, 3

Maintaining twice-daily PPI and adding prokinetic therapy is recommended for patients with persistent symptoms despite initial treatment 2, 1
Implementing a strict antireflux diet (≤45g fat/day, eliminating all trigger foods) and addressing comorbid conditions (sleep apnea, medications that worsen reflux) is also recommended 1, 3

The American College of Surgeons recommends surgical referral for patients with objective documentation of persistent GERD on testing, failed minimum 3 months intensive medical therapy, and significant quality of life impairment 2, 3
A success rate of 85-86% improvement or cure in properly selected patients is expected 1, 3

The American Thoracic Society recommends requiring more aggressive initial therapy, such as twice-daily PPI for 8-12 weeks minimum, for chronic cough, laryngitis, or asthma attributed to GERD 2, 4, 1
Response rates are lower than for typical GERD symptoms, and meta-analyses show limited benefit of PPIs over placebo for chronic laryngitis and cough 4