The relationship between smoking and bone health has taken on new urgency as healthcare systems grapple with aging populations and rising fracture-related costs. This comprehensive evidence synthesis reveals smoking's impact on skeletal integrity varies dramatically by sex, with implications for how clinicians assess fracture risk in their patients.
Analyzing data from 1.69 million adults across 58 international cohorts, researchers quantified smoking's bone-damaging effects independent of bone mineral density measurements. Current smokers faced significantly elevated risks across all fracture types, with hip fractures showing the strongest association. The sex differential proved striking: men who smoke experienced substantially higher fracture hazard ratios than women smokers across all bone sites. Among current smokers, 15.2% were men compared to 10.1% women, yet men's fracture vulnerability exceeded women's proportionally.
Crucially, former smokers demonstrated meaningfully lower fracture risks than current users, suggesting cessation's protective benefits extend beyond cardiovascular and pulmonary health to skeletal preservation. This dose-response relationship supports causation rather than mere correlation between tobacco use and bone fragility.
These findings will directly influence the next iteration of FRAX, the world's most widely used fracture prediction algorithm. Currently, FRAX treats smoking as a binary risk factor without sex stratification. The evidence suggests men's smoking history deserves heavier weighting in fracture risk calculations, potentially reshaping clinical guidelines for osteoporosis screening and prevention strategies. For the estimated 1.3 billion global smokers, this research underscores smoking cessation as a concrete step toward preserving bone health into later life.