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Impact of Smoking on Bone Health

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Chris Dounis

Chris is an accredited exercise physiologist with over 15 years professional experience working with a wide range of clients.
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The evidence is strong. Tobacco smoking can have severe negative consequences for our health.  It can contribute to a range of cancers and chronic disease such as coronary heart disease and chronic obstructive pulmonary disease. It can cause early death.

However many of us may not be aware of the extent to which smoking can also impact on bone health. Research suggests that there is a link between cigarette smoking and osteoporosis. Smoking can contribute to reduced bone mass and increased bone fragility. Over time this can lead to the development of musculoskeletal diseases including osteoporosis (Pivot, 2024; Shahab, L & McLewen, A., 2012).  Read on to find out more about the impact of smoking on bone health.

The discussion begins with a brief overview of the process of bone growth, noting factors that influence the development of strong or weak bones.  It then focuses specifically on how smoking impacts on this development.

The discussion draws on current professional and research literature. It is intended to provide information not advice. If you or someone you know is seeking advice or support regarding matters raised, you should seek expert professional help.

Why are bones important?

Bones play an important role in maintaining our overall general health and well-being. They provide a framework that gives structure and shape to our body. They protect our organs from injury. Bones store important minerals such as such as calcium and phosphorous which are released into the bloodstream when needed by other parts of the body. They provide marrow needed for the development of blood cells.

It is important to ensure we have healthy bones that can fulfil these functions.

Healthy bones

Healthy bones are strong, dense and flexible. Calcium makes them strong and dense while collagen provides the flexibility that makes them resistant to fractures and breaks. Bones also incorporate a network of blood vessels. These provide the oxygen, nutrients and hormones needed for healthy bone formation. Most bones also contain bone marrow where blood cells are made. Bones containing higher amounts of these proteins, minerals and other nutrients are denser, stronger, more flexible and less likely to break.

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Bone Development

Bone is living tissue that continuously grows and develops throughout our life. In a process known as bone remodelling, bone cells called osteoclasts break down old or damaged bone tissue (resorption) while other bone cellsosteoblasts, build new, strong tissue to replace the old bone.

The amount of bone that is broken down and rebuilt varies as we age. From childhood through adolescence to early adulthood, osteoblasts make new bone faster than osteoclasts break down old bone. This enables the bones to grow, increasing in mass and strength. By about age 35, most people reach their peak bone mass (also referred to as bone mineral density or BMD). After achieving this peak the bones begin to store calcium that the body may need as we age. The higher the BMD, the more calcium the body is able to store. This can reduce the possibility of developing osteoporosis.

While bone remodeling continues throughout life we tend, as we age, to lose slightly more bone than we gain. This means that in older adults bone mass may begin to decrease. While males tend to lose bone mass more slowly than females, by age 65–70 years, males and females lose it at the same rate (Australian Institute of Health, 2014).

If bone density decreases too much, bones become brittle and susceptible to the fracture risks and breaks. Low bone mineral density is not, in itself, a disease. However continuing decrease in BMD is a risk factor for developing osteoporosis.

Osteoporosis

Osteoporosis is a skeletal condition characterised by low BMD. It occurs when new bone development doesn’t keep pace with the loss of old bone. Bones become weak and brittle. This can cause fractures, the most common being wrist, spine and hip fractures.

Osteoporosis can develop slowly over many years without any symptoms. People may not know they have the condition until they break a bone. It is diagnosed by a bone mineral density (BMD) test which measures the level of calcium and other minerals in the bone.

Osteoporosis is quite prevalent in older people. It is the major cause of fractures in postmenopausal women and older men. It has been estimated that the prevalence of condition among those aged 50 and over is 23% of women and 6% of men (Australian Institute of Health, 2014).

Osteoporosis Risk Factors

There are number of risk factors that influence the development of osteoporosis. Some cannot be changed but others may be managed through changes in lifestyle. Factors which cannot be changed include sex, age, body structure, menopause and family history. Women, particularly post-menopausal women, older individuals, those with small body structure or a family history of the disease are more vulnerable to developing osteoporosis. While research points to these factors playing a role in determining healthy bones, controllable lifestyle factors such nutrition, calcium and vitamin D intake, sedentary lifestyle, low body mass index and the use of substances such as alcohol and tobacco also have a significant impact on bone health.

A number of research studies have focused on the link between smoking and osteoporosis.

How does smoking affect bones?

Cigarette smoking weakens bones in several ways including reduction of blood supply to bones and soft tissues, reduced production of bone-forming osteoblasts, reduction in calcium formation and absorption, and an imbalance of hormones in bone structure.

Impact of Smoking on Bone Health

Disruption of Blood Supply to Bones and tissues

Studies show that people who smoke are more likely to suffer from musculoskeletal conditions than those who don’t. This is largely due to the toxic chemicals in tobacco smoke that reduce blood flow. Blood supplies oxygen, nutrients and regulatory hormones to the musculoskeletal system. It also removes waste products such as carbon dioxide and acids. Without an adequate blood supply to perform these functions, the skeletal system can become weak and fragile. Cigarette smoking damages blood vessels and restricts the flow of nutrient-rich blood to musculoskeletal tissues. (Ahmad et al., 2018; Pivot, 2023).

Reduction in Calcium Production and Absorption

Calcium production and absorption is essential for the development of healthy bones. Calcium makes bones strong and dense. The body also needs vitamin D to absorb calcium. Inadequate absorption of calcium and vitamin D can lower bone density (BMD) resulting in bones being vulnerable to breaks and fractures. Smoking can affect the body’s ability to produce and absorb calcium.  Studies have shown that smokers have significantly lower bone density than non-smokers. They are also more vulnerable to developing fragile bones than non-smokers. In study of pre and postmenopausal healthy female smokers and non-smokers, BMD was found to be significantly lower in postmenopausal smokers (Pivot, 2024). Another study from OrthoInfo (2024) found that elderly smokers are 30% to 40% more at risk of hip fracture than their non-smoking counterparts.

Calcium in the blood is also essential to enable the body to carry out physiological functions such as muscle contractions, nerve impulse conduction, constriction and relaxation of blood vessels. If there is inadequate calcium in the blood, the body will use calcium stored in bone. This can further lower bone density and weaken bones.

Slowing of Osteoblast Production

As noted previously, healthy bone development (remodeling) involves osteoclasts breaking down old or damaged tissue while osteoblasts replace this old bone with new, strong tissue. Studies point to smoking interfering with this process by slowing down bone metabolism. This results in osteoblasts producing less bone.  Over time, this can lead to an imbalance of bone turnover, a reduction in bone mass and increased risk of fractures (Pivot, 2024; Weng, 2022).

Smoking Can Affect Hormone Balance

Hormones, including oestrogen, are necessary for bone health in both men and women. Oestrogen has a protective effect on bone and helps build and maintain a strong skeleton. Smoking appears to have a negative impact on oestrogen, causing the hormone to breaking down more quickly. This impacts bone health (Ahmad et al., 2018 Pivot, 2023).

Can Quitting Smoking Improve Bone Health?

While there appear to be few, if any current interventions to counteract smoking related osteoporosis (Weng, 2022), a number of studies indicate that quitting smoking, even when damage is severe, may slow or even partially reverse the impact of smoking on bones. These studies indicate that smoking cessation may be associated with increased BMD, improved hormones levels, stronger bone formation, and increased bone resorption markers. (Winnall et al. 2020; Medical News Today, 2024). A further study found that bone marrow density in non-smokers was higher than in smokers and ex-smokers but that ex-smokers appear to have higher BMD levels than smokers (Ahmad, 2018).These studies suggest that quitting smoking may help limit bone loss and reduce osteoporosis risk.

This risk may be further reduced if other risk factors such as poor nutrition, sedentary lifestyle and the use of substances such as alcohol consumption are also addressed. Smokers may be thinner, drink more alcohol, may be less physically active, and have poorer diets than non-smokers, (OrthoInfo, 2024).

Managing Lifestyle Risk Factors

A balanced diet with Adequate Calcium and Vitamin D

Calcium is essential for bone development. A diet low in calcium contributes to lower bone density, early bone loss and increased risk of fractures. Good sources of calcium include leafy green vegetables, dairy products such as yoghurt and cheese, and calcium-fortified foods and beverages. Vitamin D is needed to enable the body to absorb calcium. The body makes vitamin D from exposure to sunlight. It can also be obtained from foods like egg yolks, saltwater fish and liver

Physical Activity

Bone formation is fostered through weight-bearing and high-impact activity. This can also help to prevent bone loss in older adults. Physical activity contributes to coordination and balance, thereby reducing the risk of falling.

Healthy Body Weight

A healthy body weight is important for bone health. Low weight can mean the body has less bone mass to draw on as it ages. Smokers are often underweight. This increases their risk of fracture and bone loss.

Avoid Substance Abuse

As this discussion clearly indicates, smoking should be avoided. The consumption of other potentially damaging substances should also be monitored and managed. Alcohol, for example, can impact on calcium and Vitamin D absorption.

Key Points

Our bones play an important role in maintaining our overall general health and well-being. They give shape and structure to our bodies. They protect our organs and store important minerals such as calcium and phosphorous.

Growing and maintaining healthy bones is a lifelong process. In children and adolescents bones rapidly increase in mass and strength as our skeleton grows and develops.  In healthy young adults, similar amounts of bone are removed and replaced. The bones reach their peak mass (bone mineral density). This is the point at which the bones reach their maximum strength and density. Achieving this peak enables bones to store the extra calcium the body may need throughout life. In older adults bone mass, begins to decrease. Bones may become brittle and susceptible to osteoporosis and bone fractures.

Research points to smoking as being a risk factor in bone health. Smoking has been found to have serious negative effects on the growth and development of our skeletal system. Evidence points to smoking as causing an imbalance in the mechanisms of bone remodeling, resulting in lower bone mass and bone mineral density.

The specific effects of smoking include reduction of blood supply to bones and soft tissues, reduced production of bone-forming osteoblasts, reduction in calcium formation and absorption, and an imbalance of hormones in bone structure. Research has linked these effects of cigarette smoke with reduced bone mass and increased risk of osteoporosis.

While there appear to be few, if any current interventions to counteract smoking related     osteoporosis, several studies indicate that quitting smoking, even when damage is severe, may slow or even partially reverse the effects of smoking.

In addition to quitting smoking, bone health can be fostered by addressing other risk factors related to lifestyle.  These include a balanced diet that includes calcium and vitamin D, physical activity to increase or preserve bone mass and reduce the risk of falling, a healthy body weight, and managing potentially harmful substances such as alcohol.

Stopping smoking has many health benefits, including decreasing a person’s risk factor for developing osteoporosis. It’s never too late to quit.

This information is not intended as a substitute for informed professional advice. Healthcare professionals can offer assessments and guidance, take into consideration health conditions and recommend appropriate treatment and management strategies.

References

Ahmad M. Al-Bashaireh ,  Linda G. Haddad , Michael Weaver, Xing Chengguo,4 Debra Lynch Kelly,5 and Saunjoo Yoon (2018), The Effect of Tobacco Smoking on Bone Mass: An Overview of Pathophysiologic Mechanisms Journal of Osteoporosis, Volume 2018, Article ID 1206235, 17 pages https://doi.org/10.1155/2018/120623

Australian Institute of Health, (2014), Estimating the Presence of Osteoporosis in Australiahttps://www.aihw.gov.au/reports/chronic-musculoskeletal-conditions/estimating-the-prevalence-of-osteoporosis-in-austr/summary

Medical News Today (2023) What to know about smoking and Osteoporisis https://www.medicalnewstoday.com/articles/smoking-and-osteoporosis#managing-osteoporosis

OrthoInfo (2024), Hip Fractures https://orthoinfo.aaos.org/en/diseases–conditions/hip-fractures/

Pivot (2024) Smoking Is Bad for Your Musculoskeletal Health https://pivot.co/blog/smoking-musculoskeletal-health

Shahab, L McLewen, A., (2012) Smoking and bone health, National Centre for Smoking Cessation and Training (NCSCT), https://www.ncsct.co.uk/library/view/pdf/smoking_and_bone_health.pdf Tobin

Weng W, Li H, Zhu S. An Overlooked Bone Metabolic Disorder: Cigarette Smoking-Induced Osteoporosis. Genes (Basel). 2022 Apr 30;13(5):806. doi: 10.3390/genes13050806. PMID: 35627191; PMCID: PMC9141076.

Winnall, WR, Hurley, S & Winstanley, MH. 3.13 Musculoskeletal conditions. In Greenhalgh, EM, Scollo, MM and Winstanley, MH [editors]. Tobacco in Australia: Facts and issues. Melbourne: Cancer Council Victoria; 2021. Available from http://www.tobaccoinaustralia.org.au/chapter-3-health-effects/3-13-musculoskeletal-conditions 

Disclaimer

This series does not serve as specific medical advice, and should be viewed as educational ONLY. Chronic pain is an individual and complex experience, and as such, any treatment needs to be tailored to the individual. Always seek advice from a relevant medical professional before undertaking any treatment or exercise program.

 

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