Smoking and Bone Health

January 2012

Many of the health problems caused by tobacco use are well known. Cigarette smoking causes heart disease, lung and esophageal cancer, and chronic lung disease. Additionally, several research studies have identified smoking as a risk factor for osteoporosis and bone fracture. The Centers for Disease Control and Prevention estimates that smoking-related illnesses cost Americans more than $193 billion each year in lost productivity and health care expenditures.

Facts About Osteoporosis

Osteoporosis is a condition in which bones weaken and are more likely to fracture. Fractures from osteoporosis can result in pain and disability. In the United States, more than 40 million people either already have osteoporosis or are at high risk due to low bone mass.

In addition to smoking, risk factors for developing osteoporosis include:

  • thinness or small frame
  • family history of the disease
  • being postmenopausal and particularly having had early menopause
  • abnormal absence of menstrual periods (amenorrhea)
  • prolonged use of certain medications, such as those used to treat lupus, asthma, thyroid deficiencies, and seizures
  • low calcium intake
  • lack of physical activity
  • excessive alcohol intake

Osteoporosis can often be prevented. It is known as a “silent” disease because, if undetected, bone loss can progress for many years without symptoms until a fracture occurs. It has been called a childhood disease with old age consequences because building healthy bones in youth helps prevent osteoporosis and fractures later in life. However, it is never too late to adopt new habits for healthy bones.

Smoking and Osteoporosis

Cigarette smoking was first identified as a risk factor for osteoporosis more than 20 years ago. Recent studies have shown a direct relationship between tobacco use and decreased bone density. Analyzing the impact of cigarette smoking on bone health is complicated. It is hard to determine whether a decrease in bone density is due to smoking itself or to other risk factors common among smokers. For example, in many cases smokers are thinner than nonsmokers, tend to drink more alcohol, may be less physically active, and have poor diets. Women who smoke also tend to have an earlier menopause than nonsmokers. These factors place many smokers at an increased risk for osteoporosis apart from their tobacco use.

In addition, most studies on the effects of smoking suggest that smoking increases the risk of having a fracture. Not all studies support these findings, but the evidence is mounting. For example:

  • The longer you smoke and the more cigarettes you consume, the greater your risk of fracture in old age.
  • Smokers who fracture may take longer to heal than nonsmokers and may experience more complications during the healing process.
  • Significant bone loss has been found in older women and men who smoke.
  • At least one study suggests that exposure to secondhand smoke during youth and early adulthood may increase the risk of developing low bone mass.
  • Compared with nonsmokers, women who smoke often produce less estrogen (a sex hormone) and tend to experience menopause earlier, which may lead to increased bone loss.
  • Quitting smoking appears to reduce the risk of low bone mass and fractures. However, it may take several years to lower a former smoker’s risk.

Osteoporosis Management Strategies

Start by quitting: The best thing smokers can do to protect their bones is to quit smoking. Smoking cessation, even later in life, may help limit smoking-related bone loss. Many resources are available to help you stop smoking, some of which are listed at the end of this fact sheet.

Eat a well-balanced diet rich in calcium and vitamin D: Good sources of calcium include low-fat dairy products; dark green, leafy vegetables; and calcium-fortified foods and beverages. Supplements can help ensure that you get adequate amounts of calcium each day, especially in people with a proven milk allergy. The Institute of Medicine recommends a daily calcium intake of 1,000 mg (milligrams) for men and women up to age 50. Women over age 50 and men over age 70 should increase their intake to 1,200 mg daily.

Vitamin D plays an important role in calcium absorption and bone health. Food sources of vitamin D include egg yolks, saltwater fish, and liver. Many people, especially those who are older, may need vitamin D supplements to achieve the recommended intake of 600 to 800 IU (International Units) each day.

Exercise for your bone health: Like muscle, bone is living tissue that responds to exercise by becoming stronger. Weight-bearing exercise that forces you to work against gravity is the best exercise for bone.

Some examples include walking, climbing stairs, weight training, and dancing. Regular exercise, such as walking, may help prevent bone loss and will provide many other health benefits.

Avoid excessive use of alcohol: Chronic alcohol use has been linked to an increase in fractures of the hip, spine, and wrist. Drinking too much alcohol interferes with the balance of calcium in the body. It also affects the production of hormones, which have a protective effect on bone, and of vitamins, which we need to absorb calcium. Excessive alcohol consumption also can lead to more falls and related fractures.

Talk to your doctor about a bone density test: A bone mineral density (BMD) test measures bone density at various sites of the body. This safe and painless test can detect osteoporosis before a fracture occurs and can predict one’s chances of fracturing in the future. If you are a current or former smoker, you may want to ask your health care provider whether you are a candidate for a BMD test, which can help determine whether medication should be considered.

See if medication is an option for you: There is no cure for osteoporosis. However, several medications are available to prevent and treat the disease in postmenopausal women and in men. Your doctor can help you decide whether medication might be right for you.

Smoking Cessation Resources

Smokefree.gov: Created by the National Cancer Institute (NCI), smokefree.gov is a Website designed to help you quit smoking. Different people need different resources as they try to quit. The information and professional assistance available on this Website can help to support both your immediate and long-term needs as you become, and remain, a nonsmoker. Available at www.smokefree.gov.

Pathways to Freedom: Winning the Fight Against Tobacco: Intended for use by African Americans, this guide was produced by the Centers for Disease Control and Prevention in partnership with key segments of the African American community, including churches, service organizations, and educational institutions. The development and revision of this guide was inspired by national concern over the high smoking rates in the African American population and the absence of relevant materials. The guide addresses many issues that are specific to African Americans, such as targeted advertising campaigns and historical, cultural, and socioeconomic influences. This resource offers proven strategies for anyone who wants to quit, information on how friends and family can help, and ideas on how the community and its leaders can promote the value of living a tobacco-free life. Available at www.cdc.gov/tobacco/quit_smoking/ how_to_quit/pathways.

Smokefree Women: Designed to provide information about topics that are often important to women, such as smoking and pregnancy, this website provides resources such as an online step-by-step smoking cessation guide, quizzes about subjects like depression, relationships, and withdrawal, and NCI’s instant messaging service, which allows people to receive information and advice about quitting smoking through real-time text messaging with a smoking cessation counselor. Available at women.smokefree.gov.

Harms of Smoking and Health Benefits of Quitting/Perjuicios por fumar tabaco y beneficios para la salud al dejar el hábito: This NCI fact sheet, available in English and Spanish, discusses why tobacco smoking is harmful, explains possible risks and consequences of tobacco smoking, and relays reasons why quitting is beneficial to overall health. Resources that help people get support for quitting also are provided. Available at www.cancer.gov/cancertopics/factsheet/Tobacco/cessation.

For Your Information

This publication contains information about medications used to treat the health condition discussed here. When this publication was produced, we included the most up-to-date (accurate) information available. Occasionally, new information on medication is released.

For updates and for any questions about any medications you are taking, please contact:

U.S. Food and Drug Administration

Website: http://www.fda.gov
Toll free: 888–INFO–FDA (888–463–6332)


For additional information on specific medications, visit Drugs@FDA at www.accessdata.fda.gov/scripts/cder/drugsatfda. Drugs@FDA is a searchable catalog of FDA-approved drug products.

For updates and questions about statistics, please contact:

Centers for Disease Control and Prevention’s National Center for Health Statistics

Website: http://www.cdc.gov/nchs
Toll free: 800–232–4636

NIH Osteoporosis and Related Bone Diseases ~ National Resource Center

2 AMS Circle
Bethesda, MD 20892-3676
Phone: 202-223-0344
Toll Free: 800-624-BONE (2663)
TTY: 202-466-4315
Fax: 202-293-2356
Email: NIHBoneInfo@mail.nih.gov
Website: http://www.bones.nih.gov

The NIH Osteoporosis and Related Bone Diseases ~ National Resource Center provides patients, health professionals, and the public with an important link to resources and information on metabolic bone diseases. The mission of NIH ORBD~NRC is to expand awareness and enhance knowledge and understanding of the prevention, early detection, and treatment of these diseases as well as strategies for coping with them.

The NIH Osteoporosis and Related Bone Diseases ~ National Resource Center is supported by the National Institute of Arthritis and Musculoskeletal and Skin Diseases with contributions from:

The National Institutes of Health (NIH) is a component of the U.S. Department of Health and Human Services (HHS).

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