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The association of tobacco smoking and bone health in the elderly population of Iran: results from Bushehr elderly health (BEH) program



Smoking has been linked with osteoporosis, but further evidence is required, especially concerning the effects of different types of tobacco smoking. We sought to examine the association between smoking and bone health in a large cohort of elderly Iranians.


The data from 2377 participants aged >60 years of Bushehr Elderly Health (BEH) program were used. Regardless of the type of smoking, participants were initially classified as non-smokers, ex-smokers and current smokers. Current smokers were also categorized based on the smoking type (pure cigarette, pure hookah and both). Dual-energy X-ray absorptiometry was used to evaluate bone density as well as Trabecular Bone Score (TBS). T-score ≤ −2.5 in either of the femoral neck, total hip or spinal sites was applied to determine the osteoporosis. The association of smoking and osteoporosis was assessed using multivariable modified Poisson regression model and reported as adjusted prevalence ratios (APR). The linear regression model was used to assess the association between smoking and TBS, adjusting for potential factors.


A total of 2377 (1225 women) were enrolled [mean age: 69.3 (±6.4) years], among which 1054 (44.3%) participants were nonsmokers. In all, 496 (20.9%) participants were current smokers. Multivariable regression analysis revealed no significant association between smoking (either current or past) and osteoporosis in women. In men, current smoking was negatively associated with osteoporosis (APR: 1.51, 95%CI: 1.16–1.96). Among current users, cigarette smoking was associated with osteoporosis (APR: 1.57, 95%CI: 1.20–2.03); however, we could not detect a significant association between current smoking of hookah and osteoporosis. In men, a significant association was also detected between current cigarette smoking and TBS (coefficient: -0.03, 95%CI: −0.01, −0.04).


Current cigarette smoking is associated with both the quantity and quality of bone mass in elderly men. Although we could not detect a significant association between hookah and osteoporosis in men, considering the prevalence of hookah smoking in the middle eastern countries, further studies are needed to determine the effect of hookah smoking on bone health.

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  1. Ayo-Yusuf O, Olutola B. Epidemiological association between osteoporosis and combined smoking and use of snuff among south African women. Niger J Clin Pract. 2014;17(2):174–7.

    CAS  Article  Google Scholar 

  2. Hemmati F, Sarokhani D, Sayehmiri K, Motadayen M. Prevalence of osteoporosis in postmenopausal women in Iran: a systematic review and meta-analysis. Iran J Obstet Gynecol Infertility. 2018;21(3):90–102.

    Google Scholar 

  3. Organization TIWH. fact-sheets-tobacco. World Health Organization. 2019. [cited 2019Nov9].

  4. Moosazadeh M, Ziaaddini H, Mirzazadeh A, Ashrafi-Asgarabad A, Haghdoost AA. Meta-analysis of smoking prevalence in Iran. Addiction Health. 2013;5(3–4):140–53.

    PubMed  PubMed Central  Google Scholar 

  5. Al-Bashaireh AM, Haddad LG, Weaver M, Chengguo X, Kelly DL, Yoon S. The effect of tobacco smoking on bone mass: an overview of pathophysiologic mechanisms. J Osteoporos. 2018;2018:1–17.

    Article  Google Scholar 

  6. Yoon V, Maalouf N, Sakhaee K. The effects of smoking on bone metabolism. Osteoporos Int. 2012;23(8):2081–92.

    CAS  Article  Google Scholar 

  7. Brook JS, Balka EB, Zhang C. The smoking patterns of women in their forties: their relationship to later osteoporosis. Psychol Rep. 2012;110(2):351–62.

    Article  Google Scholar 

  8. Lentle BC, Prior JC. Osteoporosis: what a clinician expects to learn from a patient’s bone density examination. Radiology. 2003;228(3):620–8.

    Article  Google Scholar 

  9. Sighaldeh SS, Baheiraei A, Dehghan S, Charkazi A. Persistent use of hookah smoking among Iranian women: a qualitative study. Tob Prev Cessat. 2018;4.

  10. Shafiee G, Ostovar A, Heshmat R, Darabi H, Sharifi F, Raeisi A, et al. Bushehr elderly health (BEH) programme: study protocol and design of musculoskeletal system and cognitive function (stage II). BMJ Open. 2017;7(8):e013606.

    Article  Google Scholar 

  11. Mahan LK, Raymond JL. Krause's food & the nutrition care process-e-book: Elsevier Health Sciences; 2016.

  12. Camacho PM, Petak SM, Binkley N, Clarke BL, Harris ST, Hurley DL, et al. American Association of Clinical Endocrinologists and American College of endocrinology clinical practice guidelines for the diagnosis and treatment of postmenopausal osteoporosis—2016. Endocr Pract. 2016;22(s4):1–42.

    Article  Google Scholar 

  13. Zou G. A modified poisson regression approach to prospective studies with binary data. Am J Epidemiol. 2004;159(7):702–6.

    Article  Google Scholar 

  14. Hannan MT, Felson DT, Dawson-Hughes B, Tucker KL, Cupples LA, Wilson PW, et al. Risk factors for longitudinal bone loss in elderly men and women: the Framingham osteoporosis study. J Bone Miner Res. 2000;15(4):710–20.

    CAS  Article  Google Scholar 

  15. Kim KH, Lee CM, Park S, Cho B, Chang Y, Park S, et al. Secondhand smoke exposure and osteoporosis in never-smoking postmenopausal women: the fourth Korea National Health and nutrition examination survey. Osteoporos Int. 2013;24(2):523–32.

    CAS  Article  Google Scholar 

  16. Kanis JA, Johnell O, Odén A, Johansson H, De Laet C, Eisman J, et al. Smoking and fracture risk: a meta-analysis. Osteoporos Int. 2005;16(2):155–62.

    CAS  Article  Google Scholar 

  17. Halmenschlager G, Rossetto S, Lara GM, Rhoden EL. Evaluation of the effects of cigarette smoking on testosterone levels in adult men. J Sex Med. 2009;6(6):1763–72.

    CAS  Article  Google Scholar 

  18. Wang W, Yang X, Liang J, Liao M, Zhang H, Qin X, et al. Cigarette smoking has a positive and independent effect on testosterone levels. Hormones. 2013;12(4):567–77.

    Article  Google Scholar 

  19. Yoo JE, Park HS. Prevalence and associated risk factors for osteoporosis in Korean men. Arch Osteoporos. 2018;13(1):88.

    Article  Google Scholar 

  20. González J, Rodriguez-Fraile M, Rivera P, Restituto P, Colina I, de los Desamparados Calleja M, et al. Trabecular bone score in active or former smokers with and without COPD. PloS one. 2019;14(2):e0209777.

    Article  Google Scholar 

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This study with project was financially supported by Tehran University of Medical Sciences.

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Correspondence to Bagher Larijani.

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Valeh, T., Gharibzadeh, S., Tajrishi, F.Z. et al. The association of tobacco smoking and bone health in the elderly population of Iran: results from Bushehr elderly health (BEH) program. J Diabetes Metab Disord 19, 461–468 (2020).

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  • Smoking
  • Tobacco products
  • Hookah
  • Osteoporosis
  • Iran