Position Statement

The Effects of Tobacco Exposure on the Musculoskeletal System

This Position Statement was developed as an educational tool based on the opinion of the authors. It is not a product of a systematic review. Readers are encouraged to consider the information presented and reach their own conclusions.

An estimated 21 percent of all adults (45.3 million people) smoke cigarettes in the United States.1 The consequences of smoking results in substantial health care costs and tobacco related deaths each year. The direct medical costs attributable to smoking total about $75.5 billion a year.1 In addition, the Centers for Disease Control and Prevention, estimates that tobacco-related diseases result in more than 400,000 deaths, or 1 out of every 5 deaths, among adults in the United States each year.2,3 Smokers on average, die 14 years earlier then those who do not smoke.4

Cigarette smoking not only affects the quantity and quality of the smoker's life, but also the lives of those who are exposed to secondhand smoke. Approximately 60 percent of nonsmokers in the United States have biologic evidence of exposure to secondhand smoke, and studies suggest that even the smallest amount of exposure to secondhand smoke is associated to negative health affects.5-7 The rates of exposure to secondhand smoke have lead it to be the third leading cause of preventable death in America.

The musculoskeletal system- the bones, muscles, tendons, ligaments and nerves in the body- is significantly affected by tobacco exposure. Tobacco smokers experience a decrease in bone mineral density which increases the risk of osteoporotic fractures.8-12 Bone density loss is also found in people exposed to secondhand smoke.13 Furthermore, smokers have impaired bone healing, which can delay the healing of fractures and wounds, and has shown to negatively influence wound healing, bone surgery results and patient satisfaction when compared to nonsmokers.14-17

There are many musculoskeletal risk factors associated with tobacco use:

  • Smoking is associated with an increase in the incidence of rheumatoid arthritis.18-20
  • Smokers have a greater chance of developing systemic lupus erythematosus. An inflammatory, multisystemic, autoimmune disease of the connective tissue, characterized by fever, skin lesions, joint pain or arthritis, and anemia, and often affecting the kidneys, spleen, and various other organs.21
  • Smoking is associated with rotator cuff disease in the shoulder.22
  • Nicotine, the most powerful substance in tobacco, causes a decrease in blood flow to all tissues in the human body. Proper blood flow is vital for wound healing.14,16,23
  • Smoking has been shown to be related to poor wound healing and delayed fracture healing.14,16,23
  • Each year more women will die from hip fractures than by breast cancer. Smoking has been identified as a major risk factor for the development of osteoporosis and osteoporotic related hip fractures.24,25
  • There is a strong association between decreased bone density and altered reproductive functions in women. 12
  • Studies show that mothers who were exposed to tobacco delivered babies with low birth weight, and decreased bone development.7

Quitting smoking before surgery can help improve post-operative wound healing, and decrease recovery time.15,17,26 Listed below are some resources for smoking cessation:

The American Academy of Orthopaedic Surgeons (AAOS) is concerned that the American public is not fully aware that the use and exposure to tobacco products has harmful effects on the musculoskeletal system. The AAOS strongly recommends avoiding use and exposure to tobacco products due to the severe and negative impact on the musculoskeletal system.


  1. Cigarette smoking among adults--United States, 2006. MMWR Morb Mortal Wkly Rep 2007 Nov 9;56(44):1157-61.
  2. Annual smoking-attributable mortality, years of potential life lost, and productivity losses--United States, 1997-2001. MMWR Morb Mortal Wkly Rep 2005 Jul 1;54(25):625-8.
  3. U.S. Deparment of Health and Human Services, CDC, National Center for Health Statistics. Centers for Disease Control and Prevention. Health United States, 2005 With Chartbook on Trends in the Health of Americans. 2006. Ref Type: Generic
  4. Annual smoking-attributable mortality, years of potential life lost, and economic costs--United States, 1995-1999. MMWR Morb Mortal Wkly Rep 2002 Apr 12;51(14):300-3.
  5. Secondhand Smoke: The Health Risks- Fact Sheet #1. 2008. 12-28-2007. Ref Type: Generic
  6. American Cancer Society. Secondhand Smoke. 1-9-2008. Ref Type: Generic
  7. U.S. Department of Health and Human Services. U.S. Department of Health and Human Services. The Health Consequences of Involuntary Exposure to Tobacco Smoke: A Report of the Surgeon General. Atlanta, GA; 2006.
  8. Akhter MP, Lund AD, Gairola CG. Bone biomechanical property deterioration due to tobacco smoke exposure. Calcif Tissue Int 2005 Nov;77(5):319-26.
  9. Hollenbach KA, Barrett-Connor E, Edelstein SL, Holbrook T. Cigarette smoking and bone mineral density in older men and women. Am J Public Health 1993 Sep;83(9):1265-70.
  10. Olofsson H, Byberg L, Mohsen R, Melhus H, Lithell H, Michaelsson K. Smoking and the risk of fracture in older men. J Bone Miner Res 2005 Jul;20(7):1208-15.
  11. Ortego-Centeno N, Munoz-Torres M, Jodar E, Hernandez-Quero J, Jurado-Duce A, de la Higuera Torres-Puchol. Effect of tobacco consumption on bone mineral density in healthy young males. Calcif Tissue Int 1997 Jun;60(6):496-500.
  12. Slemenda CW. Cigarettes and the skeleton. N Engl J Med 1994 Feb 10;330(6):430-1.
  13. Blum M, Harris SS, Must A, Phillips SM, Rand WM, wson-Hughes B. Household tobacco smoke exposure is negatively associated with premenopausal bone mass. Osteoporos Int 2002 Aug;13(8):663-8.
  14. Andersen T, Christensen FB, Laursen M, Hoy K, Hansen ES, Bunger C. Smoking as a predictor of negative outcome in lumbar spinal fusion. Spine 2001 Dec 1;26(23):2623-8.
  15. Haverstock BD, Mandracchia VJ. Cigarette smoking and bone healing: implications in foot and ankle surgery. J Foot Ankle Surg 1998 Jan;37(1):69-74.
  16. Hollinger JO, Schmitt JM, Hwang K, Soleymani P, Buck D. Impact of nicotine on bone healing. J Biomed Mater Res 1999 Jun 15;45(4):294-301.
  17. Warner DO. Tobacco dependence in surgical patients. Curr Opin Anaesthesiol 2007 Jun;20(3):279-83.
  18. Finckh A, Dehler S, Costenbader KH, Gabay C. Cigarette smoking and radiographic progression in rheumatoid arthritis. Ann Rheum Dis 2007 Aug;66(8):1066-71.
  19. Harel-Meir M, Sherer Y, Shoenfeld Y. Tobacco smoking and autoimmune rheumatic diseases. Nat Clin Pract Rheumatol 2007 Dec;3(12):707-15.
  20. Voigt LF, Koepsell TD, Nelson JL, Dugowson CE, Daling JR. Smoking, obesity, alcohol consumption, and the risk of rheumatoid arthritis. Epidemiology 1994 Sep;5(5):525-32.
  21. D S Majka, VM Holers. Cigarette smoking and the risk of systemic lupus erythematosus and rheumatoid arthritis. Ann Rheum Dis 2006;65:561-3.
  22. Kane SM, Dave A, Haque A, Langston K. The incidence of rotator cuff disease in smoking and non-smoking patients: a cadaveric study. Orthopedics 2006 Apr;29(4):363-6.
  23. Waeber B, Schaller MD, Nussberger J, Bussien JP, Hofbauer KG, Brunner HR. Skin blood flow reduction induced by cigarette smoking: role of vasopressin. Am J Physiol 1984 Dec;247(6 Pt 2):H895-H901.
  24. Sharma S, Fraser M, Lovell F, Reece A, McLellan AR. Characteristics of males over 50 years who present with a fracture: EPIDEMIOLOGY AND UNDERLYING RISK FACTORS. J Bone Joint Surg Br 2008 Jan;90(1):72-7.
  25. Thomas PA. Racial and ethnic differences in osteoporosis. J Am Acad Orthop Surg 2007;15 Suppl 1:S26-S30.
  26. Warner DO, Sarr MG, Offord KP, Dale LC. Anesthesiologists, general surgeons, and tobacco interventions in the perioperative period. Anesth Analg 2004 Dec;99(6):1766-73, table.

December 2000 American Academy of Orthopaedic Surgeons.
Revised June 2008.

This material may not be modified without the express written permission of the American Academy of Orthopaedic Surgeons.

Position Statement 1153

For additional information, contact the Public Relations Department at 847-384-4036.