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A Meta-Analysis of Smoking and Fracture Risk to Update the Frax® Tool Publisher Pubmed



Schini M ; Johansson H ; Harvey NC ; Lorentzon M ; Liu E ; Vandenput L ; Leslie WD ; Akesson KE ; Anderson FA ; Azagraledesma R ; Bager CL ; Beaudart C ; Bischoffferrari HA ; Biver E Show All Authors
Authors
  1. Schini M
  2. Johansson H
  3. Harvey NC
  4. Lorentzon M
  5. Liu E
  6. Vandenput L
  7. Leslie WD
  8. Akesson KE
  9. Anderson FA
  10. Azagraledesma R
  11. Bager CL
  12. Beaudart C
  13. Bischoffferrari HA
  14. Biver E
  15. Bruyere O
  16. Cauley JA
  17. Center JR
  18. Chapurlat R
  19. Christiansen C
  20. Cooper C
  21. Crandall CJ
  22. Cummings SR
  23. Da Silva JAP
  24. Dawsonhughes B
  25. Diezperez A
  26. Dufour AB
  27. Eisman JA
  28. Elders PJM
  29. Ferrari S
  30. Fujita Y
  31. Fujiwara S
  32. Gluer CC
  33. Goldshtein I
  34. Goltzman D
  35. Gudnason V
  36. Hall J
  37. Hans D
  38. Hoff M
  39. Hollick RJ
  40. Huisman M
  41. Iki M
  42. Ishshalom S
  43. Jones G
  44. Karlsson MK
  45. Khosla S
  46. Kiel DP
  47. Koh WP
  48. Koromani F
  49. Kotowicz MA
  50. Kroger H
  51. Kwok T
  52. Lamy O
  53. Langhammer A
  54. Larijani B
  55. Lippuner K
  56. Mcguigan FEA
  57. Mellstrom D
  58. Merlijn T
  59. Nguyen TV
  60. Nordstrom A
  61. Nordstrom P
  62. Obermayerpietsch B
  63. Ohlsson C
  64. Oneill TW
  65. Orwoll ES
  66. Pasco JA
  67. Rivadeneira F
  68. Schei B
  69. Schott AM
  70. Shiroma EJ
  71. Siggeirsdottir K
  72. Simonsick EM
  73. Sornayrendu E
  74. Sund R
  75. Swart KMA
  76. Szulc P
  77. Tamaki J
  78. Torgerson DJ
  79. Van Schoor NM
  80. Van Staa TP
  81. Vila J
  82. Wareham NJ
  83. Wright NC
  84. Yoshimura N
  85. Zillikens M
  86. Zwart M
  87. Kanis JA
  88. Mccloskey EV

Source: Osteoporosis International Published:2026


Abstract

Summary: In this meta-analysis of international cohorts, current smoking is confirmed as a significant BMD-independent predictor of future fracture with a stronger relationship in men than in women. A causative and reversible effect of smoking on fracture risk is suggested by past smoking having a significantly lower risk than current smoking. Purpose: In this meta-analysis of international cohorts, the aim was to examine the relationship of current and past smoking with fracture risk to provide an update for future iterations of the FRAX tool. Methods: The risk of fracture associated with current and past smoking was estimated using an extended Poisson model applied separately to each of 58 prospective international cohort studies. Covariates included current time since start of follow up, current age, and in an additional model, BMD at the femoral neck. The results of the different studies were merged by using inverse-variance weighted β-coefficients. Results: This analysis included a total of 1,691,024 participants (61.2% women, overall mean age 58.8 years). Current smoking, documented in 12.1% of all participants (15.2% and 10.1% respectively in men and women), was associated with a significantly increased risk of any clinical fracture, osteoporotic fracture, major osteoporotic fracture, and particularly hip fracture in both sexes. The hazard ratio (HR) for fracture was greater in men than in women for all fracture categories [e.g. hip fracture HR (95% confidence interval): 1.78 (1.58–2.00) vs. 1.64 (1.50–1.78)]. Low BMD explained about 19–54% of the increase in risk. When compared with never smoking, past smoking was associated with a significantly lower risk than current smoking [e.g. hip fractures for men, HR in past smokers: 1.08 (1.05–1.12) vs. 1.73, 95%CI (1.46–2.05) in current smokers]. Conclusions: Our results confirm the association between current smoking and increased fracture risk that is partly independent of BMD; these data will be used to inform future iterations of FRAX. © The Author(s), under exclusive licence to the International Osteoporosis Foundation and the Bone Health and Osteoporosis Foundation 2026.
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