In spondyloarthritis, smoking was found in several studies from the literature to be associated with earlier onset, more severe disease in activity, function, quality of life and imaging (inflammatory and structural lesions), sometimes in a dose-dependent manner. Smoking is also associated with elevated inflammatory biologic parameters (e.g., C-reactive protein). Periodontitis, associated with smoking, is more frequent in patients with ankylosing spondylitis as compared with controls. This periodontal disease may favor citrullination, as in rheumatoid arthritis. Citrullinated vimentin has been demonstrated to be associated with radiographic damage. In this line, smoking was found to be associated with matrix metalloproteinase levels, which is also a predictive factor for spinal radiographic progression. Finally, smoking has a negative influence on bronchopulmonary and cardiovascular outcomes, already impaired by the disease itself. Smoking represents a target for therapeutic impact and disease modification in spondyloarthritis.