Smoking, smoking cessation, and risk of hip fracture in women

doi:10.1016/S0002-9343(99)00022-4

The American Journal of Medicine

Volume 106, Issue 3, March 1999, Pages 311-314

https://doi.org/10.1016/S0002-9343(99)00022-4 Get rights and content

Abstract

PURPOSE: To examine the effects of cigarette smoking and smoking cessation on the risk of hip fracture in women.

PATIENTS AND METHODS: We studied 116,229 female nurses, 34 to 59 years of age at baseline in 1980, who were followed for up to 12 years. Smoking habits and the occurrence of incident hip fractures (n = 377) due to low or moderate trauma were self-reported on biennial mailed questionnaires.

RESULTS: Compared with women who had never smoked, the age-adjusted relative risk (RR) of hip fracture among current smokers was 1.3 (95% confidence interval [CI] 1.0 to 1.7). The risk of hip fracture increased linearly (P = 0.09) with greater cigarette consumption (RR = 1.6, 95% CI 1.1 to 2.3 for 25 or more cigarettes per day). These associations were somewhat reduced by adjusting for other risk factors for osteoporosis (menopausal status, use of postmenopausal estrogen, physical activity, and intakes of calcium, alcohol, and caffeine): RR = 1.2, 95% CI 0.8 to 1.3 for all current smokers; RR = 1.4, 95% CI 0.9 to 2.1 for 25 or more cigarettes per day. Relative risks were further reduced when body mass index was added to the model. There was no apparent benefit from quitting smoking until 10 years after cessation. After 10 years, former smokers had a reduced risk of hip fracture (adjusted RR = 0.7, 95% CI 0.5 to 0.9) compared with current smokers.

CONCLUSION: Smokers are at increased risk of hip fracture and their risk rises with greater cigarette consumption. Risk declines among former smokers, but the benefit is not observed until 10 years after cessation. Both the increased risk among current smokers and the decline in risk after smoking cessation are in part accounted for by differences in body weight.

Section snippets

Methods

The Nurses’ Health Study is a prospective cohort of 121,701 female registered nurses (98% Caucasian) who were 30 to 55 years of age when the study began in 1976 (14). On the initial questionnaire, women provided their age, height, weight, and past and current information on smoking habits, postmenopausal estrogen use, and major illnesses. Follow-up questionnaires have been mailed every 2 years to identify incident diseases and to update or obtain new information on lifestyle characteristics.

Results

In 1980, 31% of the cohort were current smokers and 26% were former smokers. By 1992, an additional 11% of women had quit smoking. During 1.32 million person-years of follow-up, we identified 377 incident cases of hip fracture. The median age at fracture was 60 years.

Current smokers experienced higher rates of hip fracture than women who never smoked and risk increased with the number of cigarettes smoked daily (Table 1). The age-adjusted relative risk (RR) of hip fracture was 1.3 (95%

Discussion

In this 12-year prospective study, we confirmed reports that cigarette smoking is a risk factor for hip fracture. Our results are in agreement with those from a recent meta-analysis (17) in which a 17% increased risk of hip fracture was reported for current smokers compared with nonsmokers at age 60, the median age at fracture in our cohort. We also observed a dose-response effect between smoking and hip fracture and found that smoking cessation leads to a decline in risk. The benefits of

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  Al año de la fractura menos del 50% de los pacientes son capaces de realizar las actividades cotidianas que realizaban antes.
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  Los pacientes que han sufrido una fractura de cadera, a pesar de ser de alto riesgo, muy a menudo no son correctamente evaluados, ni reciben tratamiento adecuado.
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  Disponemos de medidas no farmacológicas y tratamientos farmacológicos que reducen el riesgo en estos pacientes de nuevas fracturas tanto vertebrales, como no vertebrales y de la cadera contralateral.
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Smoking cessation reduces the risk of vertebral and hip fractures but usually increases body weight. Since underweight is known as a risk factor for vertebral fractures, smoking cessation is considered to have a protective effect on vertebral fractures. However, the actual effect of weight change after smoking cessation on the risk of vertebral fractures remains uncertain.
This study aimed to assess the risk of vertebral fractures among individuals who reported smoking cessation with a specific focus on changes in body weight.
Retrospective cohort study based on nationwide health insurance database.
Participants were from nationwide biennial health checkups between 2007 and 2009 conducted by the Korean National Health Insurance Service. Participants were followed up from 2010 to 2018 to find incidence of newly developed vertebral fractures.
The incidence rate was defined as the incidence rate (IR) per 1,000 person-years (PY). Cox proportional regression analysis was used to analyze the risk of vertebral fracture to determine the hazard ratio (HR) associated with the incidence of vertebral fractures based on smoking status and weight changes.
Based on their self-reported questionnaires, the participants were classified into three groups: current smokers, quitters, and nonsmokers. The quitter was defined as an individual who were smokers in 2007 and ceased smoking in 2009. Individuals with smoking cessation were categorized according to the weight change between baseline and 2 years prior: weight maintenance (−5∼5 % of weight change), weight loss (<−5 % of weight change), and weight gain (>5 % of weight change). We used Cox proportional hazards analysis to determine the hazard ratio (HR) associated with the incidence of vertebral fractures based on smoking status and temporal weight change over 2 years.
This study evaluated 913,805 eligible participants, of whom 672,858 were classified as nonsmokers, 34,143 as quitters, and 206,804 as current smokers. Among quitters, 2,372 (6.9%) individuals had weight loss, and 7,816 (22.9%) had weight gain over 2 years. About 23,952 (70.2%) individuals maintained their weight over 2 years. The overall risk of vertebral fractures was significantly higher in quitters (adjusted HR [aHR]=1.110, 95% confidence interval [CI] 1.013-1–216) than in nonsmokers, but it was lower than in current smokers (aHR=1.197, 95%CI 1.143–1.253), regardless of weight change after smoking cessation. However, individuals who experienced weight loss after smoking cessation exhibited a notably higher risk of vertebral fractures than current smokers (aHR=1.321, 95%CI 1.004–1.461). In the female population, weight gain after smoking cessation was associated with a higher risk of vertebral fractures (aHR = 1.470, 95%CI 1.002–2.587) than in current female smokers.
Maintaining weight after smoking cessation may mitigate the risk of vertebral fractures. Weight loss after smoking cessation adversely affects the protective effects of smoking cessation on vertebral fractures in the general population.
Smoking Is Associated with Sex-Specific Effects on Bone Microstructure in Older Men and Women
2021, Journal of Clinical Densitometry
Background: Smoking is a risk factor for fracture, but the mechanism by which smoking increases fracture risk is unclear. Methods: Musculoskeletal health was compared with dual energy X-ray absorptiometry (DXA), high resolution peripheral quantitative computed tomography (HR-pQCT), trabecular bone score, and vertebral fracture assessment in current and past smokers and nonsmokers from a multiethnic study of adults ≥ age 65. Skeletal indices were adjusted for age and weight. Results: Participants (n = 311) were mean age (±SD) 76.1 ± 6.5 years, mostly female (66.0%) and non-white (32.7% black/39.4% mixed race/26.3% white). Mean pack-years was 34.6 ± 20.4. In men (n = 106), weight and BMI were lower (both p < 0.05) in current vs past smokers. Male smokers consumed half the calcium of never and past smokers. BMD by DXA did not differ by smoking status at any skeletal site in either sex. Current male smokers had 13.5%–15.3% lower trabecular bone score vs never and past smokers (both p < 0.05). By HR-pQCT, trabecular volumetric BMD was 26.6%–30.3% lower and trabeculae were fewer, thinner and more widely spaced in male current vs past and never smokers at the radius (all p < 0.05). Cortical indices did not differ. Tibial results were similar, but stiffness was also 17.5%–22.2% lower in male current vs past and never smokers (both p< 0.05). In women, HR-pQCT trabecular indices did not differ, but cortical porosity was almost twice as high in current vs never smokers at the radius and 50% higher at the tibia (both p < 0.05). Conclusions: In summary, current smoking is associated with trabecular deterioration at the spine and peripheral skeleton in men, while women have cortical deficits. Smoking may have sex-specific skeletal effects. The consistent association with current, but not past smoking, suggests the effects of tobacco use may be reversible with smoking cessation.
Osteoporosis
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National incidence of traumatic fractures in China: a retrospective survey of 512 187 individuals
2017, The Lancet Global Health
Citation Excerpt :
Cornuz and colleagues7 did a large study of 116 229 female nurses aged 34–59 years at baseline and followed them up for 12 years, elucidating an increased relative risk of 1·3 (95% CI 1·0–1·7) for hip fractures in current smokers when compared with those who had never smoked. Furthermore, they also demonstrated the benefits of quitting with a reduced relative risk of 0·7 (95% CI 0·5–0·9) 10 years after quitting.7 On the basis of these findings, health policies that focus on decreasing alcohol consumption and helping more smokers to quit smoking should clearly be implemented in China to reduce fracture risk.
Traumatic fractures place a substantial burden on health-care systems worldwide. Although detailed information about incidence, distribution, and risk factors for traumatic fractures is vital for planning and prevention, in China, national data are unavailable. We aimed to do an up-to-date national survey on the population-weighted incidence of traumatic fractures in China.
The China National Fracture Study (CNFS) was a retrospective epidemiological study that recruited a nationally representative sample from eight provinces, 24 urban cities, and 24 rural counties in China using stratified random sampling and the probability proportional to size method. All eligible household members who had lived in their current residence for 6 months or longer were personally interviewed by trained research teams about traumatic fractures of the trunk, arms, or legs (not including the skull, sternum, and ribs) that had occurred in 2014. Telephone surveys were used for participants who were non-contactable after repeated visits. Fracture cases were verified by clinical records, medical history, and radiographs by orthopaedic surgeons and radiologists. We estimated incidence rates for traumatic fractures for the overall population and for subgroups by age and sex, as well as by demographic factors such as ethnic origin, occupation, geographical region, and residency category. We also studied potential associations between fractures and various factors of interest, such as age, ethnic origin, education, smoking, alcohol drinking, sleep time per day, and history of previous fracture. Data were weighted during statistical analysis to ascertain the national incidence rate. This study is registered with the Chinese Clinical Trial Registry, number ChiCTR-EPR-15005878.
Between Jan 19, 2015, and May 16, 2015, 535 836 individuals were selected and invited to participate in the study. Questionnaires from 23 649 (4%) individuals were excluded due to missing items, insufficient responses, or logical errors. Following exclusions, 512 187 (96%) individuals participated in the CNFS, consisting of 259 649 (51%) boys and men and 252 538 (49%) girls and women. Of these individuals, 1763 individuals had experienced traumatic fractures during 2014 (n=1833). The population-weighted incidence rate of traumatic fractures of the trunk, arms, or legs was 3·21 (95% CI 2·83–3·59) per 1000 population in 2014 (3·65, 3·12–4·18 in men and 2·75, 2·46–3·04 in women). For all ages, sleeping less than 7 h per day was identified as a risk factor for traumatic fractures. We identified previous fracture history as a risk factor for adults aged 15 years and older. Alcohol consumption incurred a risk effect for men aged 15 years and older and women aged 15–64 years.
Our results provide detailed information about fracture incidence, distribution, and risk factors, which can now be used as an up-to-date clinical evidence base for national health-care planning and preventive efforts in China and elsewhere. Specific public health policies that focus on decreasing alcohol consumption, prohibiting drunk driving, promoting smoking cessation, and encouraging individuals to obtain sufficient sleep and maintain a healthy bodyweight should be urgently implemented to help reduce the risk of traumatic fractures.
The Hebei Province Medical Science Special Major Projects Research Fund.
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Citation Excerpt :
Even exposure to second-hand smoke either during childhood or as an adult predisposes to later bone loss.127 Smoking cessations seems to reduce the risk of low bone mass and fractures, with positive changes noted even within the first year of quitting.128,129 Women face unique challenges whether during pregnancy, reproductive years, or through the menopausal transition.

View all citing articles on Scopus

^☆: Supported by Research Grants CA40356 and HL34594 from the National Institutes of Health.

¹: Dr. Cornuz was the recipient of a research fellowship granted by the Swiss National Science Foundation (No 832B-036980).

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Clinical StudiesSmoking, smoking cessation, and risk of hip fracture in women☆

Abstract

Section snippets

Methods

Results

Discussion

Am J Med

Am J Med

Lancet

Radiol Clin North Am

The prevention and treatment of osteoporosis

NEJM

Strategies for prevention of osteoporosis and hip fracture

BMJ

Exercise and other factors in the prevention of hip fracturethe Leisure World study

Epidemiology

Cigarette smoking and estrogen dependent diseases

Am J Epidemiol

Dietary calcium, physical activity and risk of hip fracturea prospective study

BMJ

Interaction between current smoking, leanness, and physical inactivity in the prediction of hip fracture

J Bone Miner Res

Risk factors for hip fracture in white women

NEJM

Alcohol consumption and hip fracturesthe Framingham Study

Am J Epidemiol

The Health Benefits of Smoking Cessation

Clinical Studies
Smoking, smoking cessation, and risk of hip fracture in women☆