{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,11,7]],"date-time":"2026-11-07T04:22:48Z","timestamp":1794025368228,"version":"4.8.0"},"reference-count":46,"publisher":"Oxford University Press (OUP)","issue":"10","license":[{"start":{"date-parts":[[2026,2,10]],"date-time":"2026-02-10T00:00:00Z","timestamp":1770681600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/501100004359","name":"Swedish Research Council","doi-asserted-by":"publisher","id":[{"id":"10.13039\/501100004359","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/501100005754","name":"Sahlgrenska University Hospital","doi-asserted-by":"publisher","id":[{"id":"10.13039\/501100005754","id-type":"DOI","asserted-by":"publisher"}]},{"name":"IngaBritt and Arne Lundberg Foundation"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2026,9,24]]},"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:p>While smoking is a known risk factor for fractures, its precise mechanisms among older women, particularly involving physical function, bone density, and bone microarchitecture, remain incompletely understood. This prospective cohort study included 3024 community-dwelling Swedish women aged 75-80\u00a0yr, followed for a median of 7.3\u00a0yr. Participants were categorized as current smokers (n\u2009=\u2009157), former smokers (n\u2009=\u20091343), and never smokers (n\u2009=\u20091524). Radiographically verified fractures and all-cause mortality were assessed. Cox proportional hazards models, mediation analyses, and competing risk models evaluated associations between smoking status, fracture risk, and potential mediators, including walking speed and total volumetric BMD (vBMD). Current smokers had significantly increased risks of any fracture (HR 1.35; 95% CI 1.04-1.75) and hip fracture (HR 2.23, 95% CI 1.43-3.49) compared to never smokers. Former smokers exhibited intermediate risks. Women who had ceased smoking for 5-10\u00a0yr had substantially lower fracture risk than current smokers. Each year since cessation conferred an ~1% relative reduction in fracture and mortality risk. Mediation analyses revealed significant indirect effects via slower walking speed (18%-28%) and lower total vBMD, suggesting these factors are key contributors to fracture risk. Importantly, competing risk models confirmed elevated fracture risk in smokers even after accounting for increased mortality. These findings demonstrate that smoking is associated with increased fracture risk in older women, partly through impairments in physical function and vBMD. Smoking cessation appears to confer meaningful skeletal benefits, indicating a need for integrated strategies targeting both behavior change and physical function to reduce fracture burden in aging populations.<\/jats:p>","DOI":"10.1093\/jbmr\/zjag028","type":"journal-article","created":{"date-parts":[[2026,2,6]],"date-time":"2026-02-06T12:53:33Z","timestamp":1770382413000},"page":"1096-1108","source":"Crossref","is-referenced-by-count":2,"title":["Impact of current and previous smoking on fracture risk in older women: the role of physical function, bone density, and bone microarchitecture"],"prefix":"10.1093","volume":"41","author":[{"given":"Michail","family":"Zoulakis","sequence":"first","affiliation":[{"name":"Sahlgrenska Osteoporosis Centre, Department of Internal Medicine and Clinical Nutrition, University of Gothenburg , 405 30 Gothenburg ,","place":["Sweden"]},{"name":"Department of Internal Medicine, Emergency Medicine and Geriatric Medicine, Sahlgrenska University Hospital , 431 80 M\u00f6lndal ,","place":["Sweden"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Margarita","family":"Ambj\u00f6rn","sequence":"additional","affiliation":[{"name":"Sahlgrenska Osteoporosis Centre, Department of Internal Medicine and Clinical Nutrition, University of Gothenburg , 405 30 Gothenburg ,","place":["Sweden"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Raju","family":"Jaiswal","sequence":"additional","affiliation":[{"name":"Sahlgrenska Osteoporosis Centre, Department of Internal Medicine and Clinical Nutrition, University of Gothenburg , 405 30 Gothenburg ,","place":["Sweden"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4118-6038","authenticated-orcid":false,"given":"Kristian F","family":"Axelsson","sequence":"additional","affiliation":[{"name":"Sahlgrenska Osteoporosis Centre, Department of Internal Medicine and Clinical Nutrition, University of Gothenburg , 405 30 Gothenburg ,","place":["Sweden"]},{"name":"Region V\u00e4stra G\u00f6taland, N\u00e4rh\u00e4lsan Norrmalm, Health Centre , 549 40 Sk\u00f6vde ,","place":["Sweden"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Henrik","family":"Litsne","sequence":"additional","affiliation":[{"name":"Sahlgrenska Osteoporosis Centre, Department of Internal Medicine and Clinical Nutrition, University of Gothenburg , 405 30 Gothenburg ,","place":["Sweden"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lisa","family":"Johansson","sequence":"additional","affiliation":[{"name":"Sahlgrenska Osteoporosis Centre, Department of Internal Medicine and Clinical Nutrition, University of Gothenburg , 405 30 Gothenburg ,","place":["Sweden"]},{"name":"Department of Orthopedics, Sahlgrenska University Hospital , 431 80 M\u00f6lndal ,","place":["Sweden"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0749-1431","authenticated-orcid":false,"given":"Mattias","family":"Lorentzon","sequence":"additional","affiliation":[{"name":"Sahlgrenska Osteoporosis Centre, Department of Internal Medicine and Clinical Nutrition, University of Gothenburg , 405 30 Gothenburg ,","place":["Sweden"]},{"name":"Department of Internal Medicine, Emergency Medicine and Geriatric Medicine, Sahlgrenska University Hospital , 431 80 M\u00f6lndal ,","place":["Sweden"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"286","published-online":{"date-parts":[[2026,2,10]]},"reference":[{"issue":"12","key":"2026092707515650100_ref1","doi-asserted-by":"publisher","first-page":"1726","DOI":"10.1007\/s00198-006-0172-4","article-title":"An estimate of the worldwide prevalence and disability associated with osteoporotic fractures","volume":"17","author":"Johnell","year":"2006","journal-title":"Osteoporos Int"},{"issue":"1","key":"2026092707515650100_ref2","doi-asserted-by":"publisher","first-page":"4","DOI":"10.1080\/13697137.2021.1951206","article-title":"Osteoporosis and fractures in women: the burden of disease","volume":"25","author":"Lorentzon","year":"2022","journal-title":"Climacteric."},{"issue":"1","key":"2026092707515650100_ref3","doi-asserted-by":"publisher","first-page":"82","DOI":"10.1007\/s11657-020-00871-9","article-title":"SCOPE 2021: a new scorecard for osteoporosis in Europe","volume":"16","author":"Kanis","year":"2021","journal-title":"Arch Osteoporos"},{"issue":"1","key":"2026092707515650100_ref4","doi-asserted-by":"publisher","first-page":"249","DOI":"10.1007\/s00198-015-3290-z","article-title":"Smoking, smoking cessation, and fracture risk in elderly women followed for 10 years","volume":"27","author":"Thorin","year":"2016","journal-title":"Osteoporos Int"},{"key":"2026092707515650100_ref5","doi-asserted-by":"publisher","DOI":"10.1155\/2018\/1206235","article-title":"The effect of tobacco smoking on bone mass: an overview of pathophysiologic mechanisms","volume":"2018","author":"Al-Bashaireh","journal-title":"J Osteoporos"},{"issue":"2","key":"2026092707515650100_ref6","doi-asserted-by":"publisher","first-page":"428","DOI":"10.1210\/jc.2006-2651","article-title":"Smoking and the skeleton","volume":"92","author":"Compston","year":"2007","journal-title":"J Clin Endocrinol Metab"},{"key":"2026092707515650100_ref7","doi-asserted-by":"publisher","first-page":"33","DOI":"10.1016\/j.jot.2024.04.003","article-title":"Smoking and osteoimmunology: understanding the interplay between bone metabolism and immune homeostasis","volume":"46","author":"Xie","year":"2024","journal-title":"J Orthop Transl"},{"issue":"8","key":"2026092707515650100_ref8","doi-asserted-by":"publisher","first-page":"1424","DOI":"10.1002\/jbmr.4014","article-title":"Smoking-induced risk of osteoporosis is partly mediated by cadmium from tobacco smoke: the MrOS Sweden study","volume":"35","author":"Li","year":"2020","journal-title":"J Bone Miner Res"},{"issue":"10","key":"2026092707515650100_ref9","doi-asserted-by":"publisher","first-page":"2189","DOI":"10.1002\/jbmr.1674","article-title":"Smoking is associated with impaired bone mass development in young adult men: a 5-year longitudinal study","volume":"27","author":"Rud\u00e4ng","year":"2012","journal-title":"J Bone Miner Res"},{"issue":"7","key":"2026092707515650100_ref10","doi-asserted-by":"publisher","first-page":"983","DOI":"10.1001\/archinte.161.7.983","article-title":"Cigarette smoking, alcohol consumption, and risk of hip fracture in women","volume":"161","author":"Baron","year":"2001","journal-title":"Arch Intern Med"},{"issue":"2","key":"2026092707515650100_ref11","doi-asserted-by":"publisher","DOI":"10.3390\/healthcare9020185","article-title":"Association between cigarette smoking and physical fitness level of Korean adults and the elderly","volume":"9","author":"Jeon","year":"2021","journal-title":"Healthcare."},{"issue":"1","key":"2026092707515650100_ref12","doi-asserted-by":"publisher","first-page":"67","DOI":"10.1111\/ggi.15040","article-title":"Smoking, alcohol consumption, and risk of recurrent falls in community-dwelling Japanese people aged 40\u201374\u2009years: the Murakami cohort study","volume":"25","author":"Kimura","year":"2025","journal-title":"Geriatr Gerontol Int"},{"issue":"01","key":"2026092707515650100_ref13","doi-asserted-by":"publisher","first-page":"60","DOI":"10.47419\/bjbabs.v3i01.108","article-title":"Cigarette smoking increases plasma levels of IL-6 and TNF-\u03b1","volume":"3","year":"2022","journal-title":"Baghdad J Biochem Appl Biol Sci"},{"issue":"5","key":"2026092707515650100_ref14","doi-asserted-by":"publisher","first-page":"806","DOI":"10.3390\/genes13050806","article-title":"An overlooked bone metabolic disorder: cigarette smoking-induced osteoporosis","volume":"13","author":"Weng","year":"2022","journal-title":"Genes."},{"issue":"3","key":"2026092707515650100_ref15","doi-asserted-by":"publisher","first-page":"341","DOI":"10.1016\/j.jocd.2020.07.002","article-title":"Smoking is associated with sex-specific effects on bone microstructure in older men and women","volume":"24","author":"Agarwal","year":"2021","journal-title":"J Clin Densitom"},{"issue":"4","key":"2026092707515650100_ref16","doi-asserted-by":"publisher","first-page":"451","DOI":"10.1080\/1462220021000018399","article-title":"Effects of smoking cessation or reduction on hormone profiles and bone turnover in postmenopausal women","volume":"4","author":"Oncken","year":"2002","journal-title":"Nicotine Tob Res"},{"issue":"10","key":"2026092707515650100_ref17","doi-asserted-by":"publisher","first-page":"1141","DOI":"10.1089\/jwh.2006.15.1141","article-title":"Impact of smoking cessation on bone mineral density in postmenopausal women","volume":"15","author":"Oncken","year":"2006","journal-title":"J Women's Health"},{"issue":"1","key":"2026092707515650100_ref18","doi-asserted-by":"publisher","first-page":"16845","DOI":"10.1038\/s41598-020-73789-4","article-title":"Smoking cessation increases levels of osteocalcin and uncarboxylated osteocalcin in human sera","volume":"10","author":"Kiyota","year":"2020","journal-title":"Sci Rep"},{"key":"2026092707515650100_ref19","doi-asserted-by":"publisher","first-page":"e2013001","DOI":"10.4178\/epih\/e2013001","article-title":"The relationship between smoking, socioeconomic status and grip strength among community-dwelling elderly men in Korea: Hallym aging study","volume":"35","author":"Quan","year":"2013","journal-title":"Epidemiol Health"},{"issue":"5","key":"2026092707515650100_ref20","doi-asserted-by":"publisher","first-page":"259","DOI":"10.1007\/BF02390832","article-title":"A meta-analysis of the effects of cigarette smoking on bone mineral density","volume":"68","author":"Ward","year":"2001","journal-title":"Calcif Tissue Int"},{"issue":"4","key":"2026092707515650100_ref21","doi-asserted-by":"publisher","first-page":"101523","DOI":"10.1016\/j.jocd.2024.101523","article-title":"The effect of smoking cessation versus current smoking on fracture risk: the Manitoba BMD Registry","volume":"27","author":"Zarzour","year":"2024","journal-title":"J Clin Densitom"},{"issue":"6","key":"2026092707515650100_ref22","doi-asserted-by":"publisher","first-page":"572","DOI":"10.1111\/j.1365-2796.2003.01232.x","article-title":"Fracture risk associated with smoking: a meta-analysis","volume":"254","author":"Vestergaard","year":"2003","journal-title":"J Intern Med"},{"issue":"6","key":"2026092707515650100_ref23","doi-asserted-by":"publisher","first-page":"1297","DOI":"10.1007\/s00198-019-04872-4","article-title":"Extensive undertreatment of osteoporosis in older Swedish women","volume":"30","author":"Lorentzon","year":"2019","journal-title":"Osteoporos Int"},{"issue":"9","key":"2026092707515650100_ref24","doi-asserted-by":"publisher","first-page":"1137","DOI":"10.1002\/jbmr.5650080915","article-title":"Vertebral fracture assessment using a semiquantitative technique","volume":"8","author":"Genant","year":"1993","journal-title":"J Bone Miner Res"},{"issue":"2","key":"2026092707515650100_ref25","doi-asserted-by":"publisher","first-page":"250","DOI":"10.1002\/jbmr.3297","article-title":"The prevalence of vertebral fractures is associated with reduced hip bone density and inferior peripheral appendicular volumetric bone density and structure in older women","volume":"33","author":"Johansson","year":"2018","journal-title":"J Bone Min Res"},{"issue":"4","key":"2026092707515650100_ref26","doi-asserted-by":"publisher","first-page":"1585","DOI":"10.1007\/s00198-015-3419-0","article-title":"Bone material strength is associated with areal BMD but not with prevalent fractures in older women","volume":"27","author":"Rudang","year":"2016","journal-title":"Osteoporos Int"},{"issue":"3","key":"2026092707515650100_ref27","doi-asserted-by":"crossref","first-page":"220","DOI":"10.1097\/00005650-199603000-00003","article-title":"A 12-item short-form health survey: construction of scales and preliminary tests of reliability and validity","volume":"34","author":"Ware","year":"1996","journal-title":"Med Care"},{"issue":"5","key":"2026092707515650100_ref28","doi-asserted-by":"publisher","first-page":"373","DOI":"10.1016\/0021-9681(87)90171-8","article-title":"A new method of classifying prognostic comorbidity in longitudinal studies: development and validation","volume":"40","author":"Charlson","year":"1987","journal-title":"J Chronic Dis"},{"issue":"1","key":"2026092707515650100_ref29","doi-asserted-by":"publisher","first-page":"15","DOI":"10.1093\/ageing\/26.1.15","article-title":"Comfortable and maximum walking speed of adults aged 20\u201379 years: reference values and determinants","volume":"26","author":"Bohannon","year":"1997","journal-title":"Age Ageing"},{"issue":"2","key":"2026092707515650100_ref30","doi-asserted-by":"publisher","first-page":"142","DOI":"10.1111\/j.1532-5415.1991.tb01616.x","article-title":"The timed \u201cup & go\u201d: a test of basic functional mobility for frail elderly persons","volume":"39","author":"Podsiadlo","year":"1991","journal-title":"J Am Geriatr Soc"},{"issue":"1","key":"2026092707515650100_ref31","doi-asserted-by":"publisher","first-page":"75","DOI":"10.1007\/s00198-020-05681-w","article-title":"The timed up and go test predicts fracture risk in older women independently of clinical risk factors and bone mineral density","volume":"32","author":"Larsson","year":"2021","journal-title":"Osteoporos Int"},{"issue":"6","key":"2026092707515650100_ref32","doi-asserted-by":"crossref","first-page":"735","DOI":"10.1111\/j.1532-5415.1997.tb01479.x","article-title":"One-leg balance is an important predictor of injurious falls in older persons","volume":"45","author":"Vellas","year":"1997","journal-title":"J Am Geriatr Soc"},{"issue":"1","key":"2026092707515650100_ref33","doi-asserted-by":"publisher","first-page":"185","DOI":"10.1007\/s00198-021-06039-6","article-title":"One leg standing time predicts fracture risk in older women independent of clinical risk factors and BMD","volume":"33","author":"Larsson","year":"2022","journal-title":"Osteoporos Int"},{"issue":"2","key":"2026092707515650100_ref34","doi-asserted-by":"publisher","first-page":"113","DOI":"10.1080\/02701367.1999.10608028","article-title":"A 30-s chair-stand test as a measure of lower body strength in community-residing older adults","volume":"70","author":"Jones","year":"1999","journal-title":"Res Q Exerc Sport"},{"issue":"5","key":"2026092707515650100_ref35","doi-asserted-by":"publisher","first-page":"1062","DOI":"10.1002\/jbmr.3057","article-title":"Type 2 diabetes mellitus is associated with better bone microarchitecture but lower bone material strength and poorer physical function in elderly women: a population-based study","volume":"32","author":"Nilsson","year":"2017","journal-title":"J Bone Min Res."},{"issue":"7","key":"2026092707515650100_ref36","doi-asserted-by":"publisher","first-page":"643","DOI":"10.1016\/s0895-4356(99)00049-9","article-title":"The physical activity scale for the elderly (PASE): evidence for validity","volume":"52","author":"Washburn","year":"1999","journal-title":"J Clin Epidemiol"},{"key":"2026092707515650100_ref37","doi-asserted-by":"publisher","first-page":"117204","DOI":"10.1016\/j.bone.2024.117204","article-title":"Real-world effectiveness of osteoporosis screening in older Swedish women (SUPERB)","volume":"187","author":"Zoulakis","year":"2024","journal-title":"Bone."},{"issue":"8","key":"2026092707515650100_ref38","doi-asserted-by":"publisher","first-page":"e2425106","DOI":"10.1001\/jamanetworkopen.2024.25106","article-title":"Type 2 diabetes and fracture risk in older women","volume":"7","author":"Zoulakis","year":"2024","journal-title":"JAMA Netw Open"},{"issue":"2","key":"2026092707515650100_ref39","doi-asserted-by":"publisher","first-page":"155","DOI":"10.1007\/s00198-004-1640-3","article-title":"Smoking and fracture risk: a meta-analysis","volume":"16","author":"Kanis","year":"2005","journal-title":"Osteoporos Int"},{"issue":"1","key":"2026092707515650100_ref40","doi-asserted-by":"publisher","first-page":"9892","DOI":"10.1038\/s41598-024-60301-5","article-title":"The positive impact of smoking cessation on fracture risk in a nationwide cohort study","volume":"14","author":"Park","year":"2024","journal-title":"Sci Rep"},{"issue":"4","key":"2026092707515650100_ref41","doi-asserted-by":"publisher","first-page":"1511","DOI":"10.1002\/jcsm.13508","article-title":"The role of different physical function tests for the prediction of fracture risk in older women","volume":"15","author":"Gregori","year":"2024","journal-title":"J Cachexia Sarcopenia Muscle"},{"issue":"4","key":"2026092707515650100_ref42","doi-asserted-by":"publisher","first-page":"453","DOI":"10.1093\/jbmr\/zjae026","article-title":"Sarcopenia definitions and their association with fracture risk in older Swedish women","volume":"39","author":"Gandham","year":"2024","journal-title":"J Bone Miner Res"},{"key":"2026092707515650100_ref43","doi-asserted-by":"publisher","DOI":"10.1007\/s00198-024-07196-0","article-title":"Sarcopenia definitions and their association with injurious falls in older Swedish women from the Sahlgrenska University Hospital Prospective Evaluation of Risk of Bone fractures (SUPERB) study","volume":"35","author":"Gandham","year":"2024","journal-title":"Osteoporos Int"},{"issue":"4","key":"2026092707515650100_ref44","doi-asserted-by":"publisher","first-page":"732","DOI":"10.1002\/jbmr.2743","article-title":"Low-level cadmium exposure is associated with decreased bone mineral density and increased risk of incident fractures in elderly men: the MrOS Sweden study","volume":"31","author":"Wallin","year":"2016","journal-title":"J Bone Min Res."},{"issue":"2","key":"2026092707515650100_ref45","doi-asserted-by":"publisher","first-page":"420","DOI":"10.1002\/jbmr.3050","article-title":"Response to low-level cadmium exposure and bone health","volume":"32","author":"Wallin","year":"2017","journal-title":"J Bone Min Res"},{"issue":"1","key":"2026092707515650100_ref46","doi-asserted-by":"publisher","first-page":"59","DOI":"10.1080\/13697130802587689","article-title":"The influence of smoking on bone loss and response to nasal estradiol","volume":"12","author":"Bjarnason","year":"2009","journal-title":"Climacteric"}],"container-title":["Journal of Bone and Mineral Research"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/academic.oup.com\/jbmr\/advance-article-pdf\/doi\/10.1093\/jbmr\/zjag028\/66840381\/zjag028.pdf","content-type":"application\/pdf","content-version":"am","intended-application":"syndication"},{"URL":"https:\/\/academic.oup.com\/jbmr\/article-pdf\/41\/10\/1096\/66840381\/zjag028.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"syndication"},{"URL":"https:\/\/academic.oup.com\/jbmr\/article-pdf\/41\/10\/1096\/66840381\/zjag028.pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,9,27]],"date-time":"2026-09-27T11:52:03Z","timestamp":1790509923000},"score":1,"resource":{"primary":{"URL":"https:\/\/academic.oup.com\/jbmr\/article\/41\/10\/1096\/8471192"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,2,10]]},"references-count":46,"journal-issue":{"issue":"10","published-online":{"date-parts":[[2026,2,10]]},"published-print":{"date-parts":[[2026,9,24]]}},"URL":"https:\/\/doi.org\/10.1093\/jbmr\/zjag028","relation":{},"ISSN":["0884-0431","1523-4681"],"issn-type":[{"value":"0884-0431","type":"print"},{"value":"1523-4681","type":"electronic"}],"subject":[],"published-other":{"date-parts":[[2026,10]]},"published":{"date-parts":[[2026,2,10]]}}}