Orthopedic Conditions

How Smoking Affects Musculoskeletal Health

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By Apollo 24/7, Published on - 20 July 2021, Updated on - 28 July 2023

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Exposure to tobacco over a long period of time has been linked to cardiovascular and lung diseases. However, it is not well known that smoking is also a risk factor for poor musculoskeletal health. The risk is more pronounced when one begins to smoke cigarettes at a young age or has been indirectly in contact with tobacco smoke for a prolonged time. This article will shed light on the effect of smoking on musculoskeletal health, including bone health.

How smoking affects the bones

Osteoporosis, a condition characterized by weak and brittle bones, is often associated with cigarette smoking. Tobacco smoke affects vitamin D levels, calcium absorption, metabolism of hormones, body weight, and blood circulation. It also disrupts the reabsorption and the formation of new bones (remodelling) leading to increased oxidative stress. All these factors gradually increase the risk of osteoporosis in smokers. When compared to non-smokers, smokers have a 25% increased risk of fractures and a 50% increased risk of hip fractures.  Smokers also experience complications such as delayed bone healing post-fractures and surgeries.

Smoking and bone density

The chemicals in cigarettes, particularly nicotine, interferes with the body’s ability to absorb calcium from the diet, resulting in low bone mineral density. Calcium is essential for bone mineralization and since there is lesser absorption, smokers develop fragile bones. A study further indicates that men and women who smoked for several years had osteopenia or osteoporosis, lower back pain, decreased hormone estrogen levels, and exhibited reduced cortical thickness, especially in young men.

Smoking and the risk of rheumatoid arthritis

Smoking affects the joints, cartilages, blood supply to bones, and other parts of the body, often triggering joint pains and autoimmune diseases. Research done by the American Academy of Orthopedic Surgeons reports that people who smoke are at an increased risk of inflammatory conditions such as rheumatoid arthritis and systematic lupus erythematosus (SLE). Even mild smoking is known to increase the risk of developing rheumatoid arthritis in people with a genetic predisposition to autoimmune diseases. On the other hand, regular smoking is known to increase the chances of autoimmune diseases and several cancers manifold. In addition, smoking reduces the effectiveness of drugs used to treat rheumatoid arthritis, making treatment difficult.

Smoking and the risk of soft tissue injuries and fractures

Smoking impacts the bone-forming cells (osteoblasts) along with other tissues that comprise the musculoskeletal system. The harmful chemicals in cigarettes make smokers prone to frequent soft tissue injuries, sprains, fractures, back pains than non-smokers, with special mention of rotator cuff tears and overuse injuries such as bursitis and tendonitis. Also, due to improper blood circulation, the healing of these soft tissue injuries, sprains, fractures become slow and prone to reinjuries. Research suggests that 30-40 % of older men and women who have been smoking cigarettes are prone to hip fractures due to minor falls.

Effect of smoking on body weight and athletic performance

Maintaining a healthy body mass index (BMI) has many health benefits, including enhanced musculoskeletal health. However, smokers usually have a low BMI and a thin skeletal frame. This is because smoking interferes with the absorption of essential nutrients (e.g. calcium) and other minerals. Moreover, nicotine and other chemicals present in tobacco are known to send signals to the brain to consume less food. All of these contribute to the increased risk of osteoporosis and fractures in smokers. Smoking can also affect the performance of athletes by impairing blood circulation and lung function. Consequently, the muscles do not get enough oxygen leading to fatigue, breathing difficulties, difficulty in running, walking, etc.

How does passive smoking impact bone health?

There is increasing evidence that passive smoking is equally impactful and can increase the risk of many conditions in people who do not smoke but are exposed to tobacco smoke, such as women and children The conditions include sinus, throat cancer, larynx cancer, breast cancer, loss of lung function, and chronic obstructive pulmonary disease (COPD). The Young Finns Cardiovascular Risk Study establishes that children exposed to tobacco smoke during their growing years showed impaired bone health with a high risk of developing osteoporosis in adulthood. Further studies conducted on growing rats revealed that extended exposure to tobacco smoke directly altered bone density (resulting in weaker bones) and interfered with the development of bones. Hence, it can be concluded that exposure to tobacco smoke is equally harmful as direct tobacco smoking.

Few effective ways to stop smoking

Various studies have shown that quitting smoking can reverse the risk of experiencing fractures to some extent. However, it may be easier said than done which is why we have listed some effective ways to quit smoking.

  • Decide on a day: Fix a date from when to quit smoking and stick to it. This is the first step to challenge the mind, body, and respect the commitment to begin a healthy habit. 
  • Control urges and triggers: Learn to control smoking triggers and urges, also known as nicotine rush, by opting for a glass of water, healthy beverages, juices, chewing gums, candies, fruit, or a snack, instead of cigarettes. Also, manage stress and social smoking with friends, by finding better ways to de-stress and engage oneself.   
  • Use nicotine replacement therapy: People who have been smoking for several years may have severe withdrawal symptoms. For such individuals, nicotine replacement therapy is recommended.
  • Practice deep breathing and meditation: Deep breathing and meditation can help to naturally de-stress and control mood swings caused due to smoking withdrawal.
  • Seek behavioural support: Some researchers suggest that along with pharmacotherapy, telephonic support and counselling from an expert can increase the success rate of quitting smoking, especially when the person is going through withdrawal symptoms.
  • Start exercising outdoors during morning hours: Exercising will ensure fitness and release pain and stress relieving hormones such as endorphins, serotonin, etc. Exercising outdoors can provide vitamin D essential for calcium absorption and enhance lung functions while allowing one to breathe in the fresh air.
  • A reminder of the benefits: Reminding oneself daily that quitting has helped and enabled a healthier life can make one feel better. Improved breathing, proper blood circulation, low risk of heart diseases, and maintaining bone density to prevent osteoporosis and fractures are some of the benefits that one can remind oneself of.


Smoking is detrimental to musculoskeletal health and people may experience lower back and joint pains without realizing that smoking could be one of the causes. Smoking cigarettes can lead to soft tissue injuries, rheumatoid arthritis, osteoporosis, surgeries, and make bone healing complicated. The risk of developing osteoporosis and bone deformities in growing children can increase in passive smokers as well. Hence, one should advise their partners, colleagues, friends against smoking, to prevent diseases. Additionally, smokers who have been smoking for a long time and find it challenging to stop smoking are advised to seek expert help and family support to make quitting easier.

For any questions on musculoskeletal health, you can:

Talk to an Orthopedician


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