Musculoskeletal System & Smoking

A lot of excellent work and money has gone into discouraging smoking and for many of its potentially fatal side effects, things are improving! According to the NHS in 2020, there were 74,600 deaths attributable to smoking which was a decrease of 3% from 2019 and 9% from 2009.

This type of information is clearly fantastic, but it does tend to be these types of reports that reach mainstream media. Hopefully, we are now all acutely aware that smoking is harmful to our general health and exercise capacity. What is less well known amongst the public is the relationship between the musculoskeletal system & smoking.  

Working in primary care is a great job, but as with all roles within healthcare it comes with its challenges. With time limitations it can be difficult to explore and discuss all the factors that might be impacting someone’s condition 

As physiotherapists working in primary care, we want to do a good job and identifying potential musculoskeletal drivers for someone’s pain whilst remaining vigilant for potential systemic masquerades. Sometimes this might cause a tendency to overlook some of the low-hanging fruits of sleep, diet, weight management, exercise, and the focus of this blogsmoking.  

We are fortunate to have great social prescribing services which can address these areas but if we really want to make every contact count we should, at a minimum, be exploring these areas during our consultations.  

The following information is far from an exhaustive list, it gives a tiny insight into some of the potential negative effects of smoking in relation to the musculoskeletal system.  

Smoking & Inflammation 

Smoking is associated with local inflammationWhilst most smoking-induced changes are reversible after quitting, some inflammatory mediators are still significantly raised in ex-smokers (10 to 20 years after quitting), suggesting ongoing low-grade inflammatory response persisting in former smokers (1) 

Smoking & Low Back Pain 

An excessive amount of research exists linking smoking and low back pain (2,3). Smoking accelerates osteoarthritis by impairing spinal tissue blood supply which causes a deficiency in the amount of oxygen reaching the tissues. This leads to a cascade of other changes which lead to a compromise of the spinal discs, cartilage, synovium, bone, and blood vessels (4). The good news is that an association between quitting smoking and mitigation of low back pain has been reported (5).  

Smoking & Bone Health 

A  positive relationship exists between years smoked and bone thinning and fractures, which is also observed in second-hand smokers. Smoking delays healing and increases complications from fractures and trauma. Furthermore, bone loss is worsened with high caffeine and alcohol consumption, which often accompany smoking (6). 

It is estimated that smoking increases the lifetime risk of developing a vertebral fracture by 32% in men and 13% in women, and a hip fracture by 40% and 31%, respectively (7).  

Smoking & Tendon Health 

In a Finnish study of almost 6,000 participants, smoking was identified as an independent risk factor for medial epicondylitis (golfers elbow) (8)The incidence of certain tendon ruptures has also been found to be more prevalent in smokers (9) 

Smoking & Pain 

Smokers have been reported to have a lower pain threshold and experience more pain than non-smokers and former smokers (10,11). Both smoking early in life and over many years increases the risk of experiencing frequent pain over one’s life (12). 

Smoking & Surgery  

Smoking can lead to delayed wound healing, increased surgical site infection, failed fusion, and chronic spinal pain (13)Outcomes after orthopaedic surgery are improved in smokers who have quit and have been associated with faster wound healing, reduced complications and hospital stays which all lead to a faster recovery of function.  

For clinicians, we hope this blog gives you some useful information to aid discussions with patients who smokeFor any patients who might have stumbled across this blog who are smokers, we hope it gives you some food for thought especially if you had not considered smoking’s impact on the musculoskeletal system.  

Learn more about smoking.


  1. Yanbaeva, D.G., Dentener, M.A., Creutzberg, E.C., Wesseling, G. & Wouters, E.F. (2007). Systemic effects of smoking. Chest, 131(5), 1557-1566. 
  2. Leboeuf-Yde, C. (1995). Does smoking cause low back pain? A review of the epidemiologic literature for causality. Journal of Manipulative and Physiological Therapeutics, 18(4), 237-243. 
  3. Shiri, R., Karppinen, J., Leino-Arjas, P., Solovieva, S. & Viikari-Juntura, E. (2010). The association between obesity and low back pain: a meta-analysis. American journal of epidemiology, 171(2), 135-154. 
  4. Khurana, V.G. (2021). Adverse impact of smoking on the spine and spinal surgery. Surgical Neurology International, 12. 
  5. Behrend, C., Prasarn, M., Coyne, E., Horodyski, M., Wright, J. & Rechtine, G.R. (2012). Smoking cessation related to improved patient-reported pain scores following spinal care. JBJS, 94(23), 2161-2166. 
  6. Ragucci, K.R. & Shrader, S.P. (2011). Osteoporosis treatment: an evidence-based approach. Journal of gerontological nursing, 37(7), 17-22. 
  7. Behrend, C., Prasarn, M., Coyne, E., Horodyski, M., Wright, J. & Rechtine, G.R. (2012). Smoking cessation related to improved patient-reported pain scores following spinal care. JBJS, 94(23), 2161-2166. 
  8. Shiri, R., Viikari-Juntura, E., Varonen, H. & Heliövaara, M. (2006). Prevalence and determinants of lateral and medial epicondylitis: a population study. American journal of epidemiology, 164(11), 1065-1074. 
  9. Safran, M.R. & Graham, S.M. (2002). Distal biceps tendon ruptures: incidence, demographics, and the effect of smoking. Clinical Orthopaedics and Related Research (1976-2007), 404, 275-283. 
  10. Pisinger, C., Aadahl, M., Toft, U., Birke, H., Zytphen-Adeler, J. & Jørgensen, T. (2011). The association between active and passive smoking and frequent pain in a general population. European journal of pain, 15(1), 77-83. 
  11. Pulvers, K., Hood, A., Limas, E.F. & Thomas, M.D. (2012). Female smokers show lower pain tolerance in a physical distress task. Addictive behaviors, 37(10), 1167-1170. 
  12. Abate, M., Vanni, D., Pantalone, A. & Salini, V. (2013). Cigarette smoking and musculoskeletal disorders. Muscles, ligaments and tendons journal, 3(2), 63.  
  13. Khurana, V.G. (2021). Adverse impact of smoking on the spine and spinal surgery. Surgical Neurology International, 12.