Archives of Osteoporosis

, 13:16 | Cite as

Smoking and bone mineral density: comprehensive analyses of the third National Health and Nutrition Examination Survey (NHANES III)

  • Dominik Strozyk
  • Thomas M. Gress
  • Lutz P. BreitlingEmail author
Short Communication



Some questions remain on the relationship between smoking and bone health. Detailed analyses of the relationship between smoking and BMD are presented, essentially ruling out non-linear associations as an explanation for inconsistent results in the literature.


To provide comprehensive multiple regression and dose-response analyses of the association between smoking behavior variables and bone health as assessed by radiologically determined bone mineral density in NHANES III.


Analyzes of a representative cross-sectional survey of the noninstitutionalized population of the USA. Self-reported smoking behavior and bone mineral density of 14,510 participants were analyzed using survey design-based multiple linear regression modeling. Dose-response patterns were analyzed using restricted cubic spline regression.


Femoral neck bone mineral density in current smokers was numerically lower than in never smokers, but this was not statistically significant after controlling for confounders. In former smokers, bone mineral density T scores were 0.064 units higher for every 10 years of abstinence, with little impact of confounder adjustment. Spline regression revealed no relevant non-linearity in the associations studied.


Non-linearity is an unlikely explanation for inconsistent results in the literature on smoking and bone mineral density. Further and especially longitudinal studies of the complex relationship smoking with bone health would be particularly important given the still substantial prevalence of smoking in an aging global population.


Tobacco Osteoporosis Non-linearity Dose-response Epidemiology 


Author contributions

Conceived research question, drafted the manuscript and supervised all aspects of the work: LB. Data analysis: DS, LB. Interpretation of results, critical manuscript revision for intellectual content, approval of final version of manuscript: all authors.

Funding information

No specific funding was received for this work. The NCHS is responsible only for the initial data, which this work is based upon. However, solely the authors are responsible for any analyses, interpretations, and conclusions described in the present work.

Compliance with ethical standards

Conflict of interest

DS and LB declare that they have no conflict of interest. TMG has received research grants from Novartis and speaker honoraria from Novartis, Ipsen, and Pfizer.

Supplementary material

11657_2018_426_MOESM1_ESM.pdf (166 kb)
ESM 1 (PDF 166 kb).


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Copyright information

© International Osteoporosis Foundation and National Osteoporosis Foundation 2018

Authors and Affiliations

  • Dominik Strozyk
    • 1
  • Thomas M. Gress
    • 2
  • Lutz P. Breitling
    • 2
    • 3
    Email author
  1. 1.Department of Internal MedicineGRN Hospital SinsheimSinsheimGermany
  2. 2.Department of Gastroenterology, Endocrinology, Metabolism and InfectiologyPhilipps University of MarburgMarburgGermany
  3. 3.Division of Clinical Epidemiology and Aging ResearchGerman Cancer Research CenterHeidelbergGermany

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