Smoking is a real danger to your bone health

man lighting up cigarette
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Smoking is associated with lower bone density and increased risk of experiencing a fracture. This World No Tobacco Day, follow these steps to eliminate this key risk factor.

World No Tobacco Day, coming up on May 31, draws attention to the health problems that tobacco use can cause. But while most people are aware that smoking harms cardiovascular health and increases cancer risk, fewer are aware that smoking endangers bone health too.

Many studies have shown a direct relationship between smoking and decreased bone density, as well as increased risk of experiencing a fracture. In fact, because the evidence linking smoking with increased fracture risk is so strong, smoking is one of the scientifically validated risk factors which is included in FRAX® (WHO Fracture Risk Assessment Tool), the online tool which calculates an individual’s 10-year risk of osteoporotic fracture.

According to the National Institute of Health (NIH) in the USA1, evidence shows that:

  • The longer you smoke and the more cigarettes you consume, the greater your risk of fracture in old age.
  • Older women and men who smoke experience significant bone loss.
  • Smokers who fracture tend to take longer to heal than nonsmokers and they may experience more complications during the healing process.
  • Exposure to secondhand smoke during youth and early adulthood may increase the risk of developing low bone mass.
  • Compared with nonsmokers, women who smoke may produce less estrogen (a sex hormone) and tend to experience menopause earlier, which may lead to increased bone loss.

Fracture risk is higher in smokers, especially with increasing age

The strongest evidence of the effects of smoking in decreasing bone mineral density comes from a landmark study which concluded that roughly one in eight hip fractures may result from cigarette smoking2. The study showed that current smokers lose bone at faster rates than non-smokers, and by age 80 this can translate into 6% lower bone mineral density, and greater fracture risk. Hip fracture risk among smokers, as compared to non-smokers, was shown to be greater at all ages but rises from 17% greater at age 60 to 71% at age 80.

Male smokers may be at even higher risk than women, with a recent study finding that male smokers had a small, but significantly greater risk of low bone density, and more vertebral fractures, than female smokers3.

Many factors increase osteoporosis and fracture risk in smokers

Nicotine and other toxic substances in cigarettes trigger bone-damaging changes in many ways, including by4:

  • Reducing the blood supply to bones (as it does to many other body tissues).
  • Slowing the production of bone-forming cells (osteoblasts) so that they make less bone.
  • Decreasing the absorption of calcium from the diet.
  • Breaking down estrogen in the body more quickly. Estrogen is important to build and maintain a strong skeleton.

In addition there are other factors which may place smokers at an increased risk for osteoporosis apart from their tobacco use. People who smoke tend to be thinner than nonsmokers, may be less physically active, and have poor diets. Women who smoke also tend to have an earlier menopause than nonsmokers.

Start by quitting - and follow a bone-healthy lifestyle

The best thing smokers can do to protect their bones is to quit smoking. At any age, this will help limit smoking-related bone loss and reduce fracture risk. You can find smoking cessation resources here: 

BeTobaccoFree.gov https://betobaccofree.hhs.gov  
Tobacco Free Life.org https://tobaccofreelife.org/

If you’re a former smoker, attention to a bone-healthy lifestyle is essential. This includes eating a well-balanced diet rich in calcium and vitamin D; regular weight-bearing exercise; and avoiding excessive alcohol use. You should also talk to your doctor about bone health and request a bone density test. A bone density test together with a FRAX risk assessment will help detect osteoporosis before a fracture occurs and can predict one’s chances of fracturing in the future. The results of the bone density test and clinical assessment will help your doctor determine whether osteoporosis medication should be prescribed.

Quit smoking today and start on the path to healthier bones.

References and further reading

  1. Smoking and Bone Health (NIAMS)
  2. Law MR, Hackshaw AK. A meta-analysis of cigarette smoking, bone mineral density and risk of hip fracture: recognition of a major effect. BMJ 1997; 315:841-6.
  3. www.atsjournals.org/doi/abs/10.1513/AnnalsATS.201412-591OC#.VVN985OAsuN
  4. Smoking and Musculoskeletal Health (AAOS)