Review Article The Effect of Tobacco Smoking on Musculoskeletal Health: A Systematic Review

107 Pages·2017·2.54 MB·English

Hindawi
Journal of Environmental and Public Health
Volume 2018, Article ID 4184190, 106 pages
https://doi.org/10.1155/2018/4184190
Review Article
The Effect of Tobacco Smoking on Musculoskeletal Health:
A Systematic Review
AhmadM.AL-Bashaireh ,1LindaG.Haddad ,2MichaelWeaver ,1DebraLynchKelly,1
XingChengguo,3andSaunjooYoon 1
1CollegeofNursing,UniversityofFlorida,Gainesville,FL,USA
2CollegeofHealthandHumanServices,UniversityofNorthCarolinaWilmington,Wilmington,NC,USA
3CollegeofPharmacy,UniversityofFlorida,Gainesville,FL,USA
CorrespondenceshouldbeaddressedtoAhmadM.AL-Bashaireh;[email protected]
Received 7 December 2017; Accepted 30 May 2018; Published 11 July 2018
AcademicEditor:EvelynO.Talbott
Copyright©2018AhmadM.AL-Bashairehetal.ThisisanopenaccessarticledistributedundertheCreativeCommonsAttribution
License,whichpermitsunrestricteduse,distribution,andreproductioninanymedium,providedtheoriginalworkisproperlycited.
This systematic review explored associations between smoking and health outcomes involving the musculoskeletal system.
AMSTARcriteriawerefollowed.AcomprehensivesearchofPubMed,WebofScience,andScienceDirectreturned243articles
meetinginclusioncriteria.Amajorityofstudiesfoundsmokinghasnegativeeffectsonthemusculoskeletalsystem.Inresearch
onbones,smokingwasassociatedwithlowerBMD,increasedfracturerisk,periodontitis,alveolarboneloss,anddentalimplant
failure.Inresearchonjoints,smokingwasassociatedwithincreasedjointdiseaseactivity,poorfunctionaloutcomes,andpoor
therapeuticresponse.Therewasalsoevidenceofadverseeffectsonmuscles,tendons,cartilage,andligaments.Therewerefew
studiesonthemusculoskeletalhealthoutcomesofsecondhandsmoke,smokingcessation,orothermodesofsmoking,suchas
waterpipesorelectroniccigarettes.Thisreviewfoundevidencethatsuggeststobaccosmokinghasnegativeeffectsonthehealth
outcomesofthemusculoskeletalsystem.Thereisaneedforfurtherresearchtounderstandmechanismsofactionfortheeffectsof
smokingonthemusculoskeletalsystemandtoincreaseawarenessofhealthcareprovidersandcommunitymembersoftheadverse
effectsofsmokingonthemusculoskeletalsystem.
1.Introduction mortalitydiseases,suchascanceranddiseasesofthecardio-
vascularandrespiratorysystems,withlessresearchattention
Tobacco smoke has more than 7,000 harmful chemical on other body systems, such as the musculoskeletal system
compoundsthatenterahumanbodyeitherdirectlythrough [3].Themusculoskeletalsystemisoneofthelargesthuman
smoking,indirectlythroughsecondhandexposuretosmoke bodysystems,comprisedofbones,joints,muscles,cartilage,
exhaledbyasmoker,orthroughdownstreamsmokereleased tendons, ligaments, and other connective tissues [4]. An
fromacigaretteorpipe[1].Bothsmokersandnonsmokersare intact and functioning musculoskeletal (locomotor) system
atriskofexposuretothecompoundsofsmokedtobaccothat isnecessarytoperformactivitiesofdailylivingandmaintain
accumulate on the surfaces in a poorly ventilated environ- quality of life [5, 6]. Several studies have investigated the
ment;thismethodofexposureisknownasthirdhandsmoke association between smoking and musculoskeletal disor-
exposure [2]. In the United States, there are approximately ders. According to the recent Surgeon General report, the
500,000 annual deaths causally related to smoking and causal relationship between tobacco smoking and rheuma-
secondhandexposuretosmoke[3]. toidarthritis,periodontitis,andhipfractureshasbeencon-
Tobacco smoking has known adverse consequences on firmed[3];however,thereisinconclusiveevidencetosupport
most human body systems. Researchers have focused more causalitybetweensmokingandmanyothermusculoskeletal
attention on the deleterious effects of smoking for high disorders.
2 JournalofEnvironmentalandPublicHealth
Searching online databases revealed significant growth failed to recognize duplicates discovered by the authors
inthebodyofliteratureinvestigatingrelationshipsbetween during title/abstract reviews. After that, abstracts of the
tobacco smoking and the musculoskeletal system. During retainedrecordswerescreenedforinclusioncriteria:English
ourcomprehensiveonlinesearch,wedidnotencounterany language,humansubjects,publishedJanuary1,2007–March
systematic reviews examining those relationships; however, 18,2017,andinvestigatingeffectsofsmokingonthemuscu-
we did find 10 systematic reviews of the effects of tobacco loskeletalsystem.Retainedrecordsthenunderwentfull-text
smokingoncomponentsofthemusculoskeletalsystem.Five screeningandrecordsthatdidnotmeettheinclusioncriteria
systematic reviews focused on smoking and the effects on orwereeditorials,commentaries,dissertations,casestudies,
dental implants and found smoking increases the risk of or reviews (e.g., overview, systematic review, and meta-
peri-implant bone loss and implant failure [7–11]. Another analysis)wereexcluded.Atotalof243finalfull-textarticles
systematicreviewrevealedanassociationbetweensmoking wereincludedinthereviewandusedfordataabstraction.
andlumbardischerniation[12].Threeotherreviewsfound Based on an a priori protocol, data abstraction from
smokingwasrelatedtonegativepostoperativeoutcomeson selected full-text articles included citation (authors, year),
kneeligaments[13],highercomplicationratesafteranterior studydesign,samplecharacteristics(size,age,sex,race/ethni-
cruciate ligament (ACL) reconstruction [14], and slowed city, and type of sampling), study purpose, findings, com-
healing of rotator cuff repair [15]. Also, one review found ments, and/or limitations on data quality and validity. Two
smoking was associated with rotator cuff tears and other independentauthors(firstandsecond)extracteddatausing
shouldersymptoms[16].Ourreviewwillbethefirsttocollect astandardform.Thedataabstractionprocesswaspilotedfor
andassessalltherecentliteratureontheeffectsofsmokingon the first 10 articles; it was successful and was used for the
themusculoskeletalsystem.Thissystematicreviewwillorient remainingarticles.Anydisagreementsbetweenauthorswere
scientistsinterestedinthehealtheffectsofsmokingaboutthe resolvedthroughdiscussion.
stateofthescienceoverthelastdecadeastheyconductmore Thefindingsinthisreviewweresynthesizedqualitatively
advancedresearch.Also,theamalgamationofthesedatain astherewasheterogeneityinstudydesignsandpopulations.
onedocumentwillbehelpfultotheresearchcommunityas Ournarrativeanalysesconsideredstudydesignandquality.
thereisahighdegreeofsimilarityandsharedcharacteristics
betweenmusculoskeletalsystemcomponents. 3.Results
This systematic review evaluated literature published in
thelastdecadetosummarizetheevidenceregardingtheeffect The comprehensive search of the literature identified 8,709
of smoking on the musculoskeletal system. This systematic potentially relevant records; however, only 243 records met
reviewwillanswertwomainquestions:Isthereanassociation the inclusion criteria and underwent data abstraction and
betweentobaccosmokingandmusculoskeletalhealth?What synthesis(Figure1).The243articleswerereviewedandthe
are the effects of tobacco smoking on the musculoskeletal effects of tobacco smoking on musculoskeletal system were
health? classified into 7 categories: (1) tobacco smoking and bones
(n =132), which were subdivided into (a) bone mass: bone
2.Methodology mineral density (BMD), bone mineral content (BMC), and
bone turnover (n = 40); (b) fractures ( n = 16); (c) alveolar
This systematic review followed the criteria of A Measure- bone(n=4);(d)periodontitis(n=34);(e)implants(n=33);
ment Tool to Assess Systematic Review (AMSTAR). Before and(f)grafts(n=5);(2)tobaccosmokingandjoints(n=54),
the onset of the systematic review, a specific protocol was whichweredividedintofoursubcategories:(a)rheumatoid
developed to minimize bias. This protocol included a pri- arthritis(RA) (n=29),(b)osteoarthritis(OA)(n=14),(c)
ori research questions, a comprehensive literature search, spondyloarthritis(SA)(n=7),and(d)temporomandibular
inclusioncriteriaforstudies,screeningmethodsandreasons joint disorders (n = 4); (3) tobacco smoking and skeletal
for exclusion, data abstraction, scientific study quality, data muscles(n=20);(4)tobaccosmokingandcartilage(n=19),
analysis,andsynthesis. whichweredividedintotwosubcategories:(a)cartilage(n=
A comprehensive literature search using PubMed, Web 7)and(b)spinalcartilage(n=12);(5)tobaccosmokingand
of Science, and Science Direct was conducted. This search tendons(n=6);(6)tobaccosmokingandligaments(n=4);
covered 10 years from January 1, 2007, to March 18, 2017, and(7)intrauterineandsecondhandsmokingeffectsonthe
and included only articles written in English. The search musculoskeletalsystem(n=8).
strategiesincludedacombinationofthefollowingkeywords: This review included studies using various designs:
smoking,musculoskeletalsystem,bone,bones,joints,muscles, cohort studies (n = 106; 67 were prospective and 39 were
tendons, ligaments, and cartilage. Medical Subject Headings retrospective),cross-sectionalstudies(n=90),case-control
(MeSH) were used during the search of PubMed. This step studies (n = 16), randomized controltrials (RCTs) (n = 14),
washelpfultoexpandthesearch;forexample,theentryterms andquasi-experimentalstudies(n=10).Otherstudydesigns
forMeSHofsmokingwereasfollows:smoking,cigarsmoking, includedsecondarydataanalysis(n=5)andcross-sequential
cigar, tobacco smoking, tobacco, hookah smoking, smoking, design (n = 2). Table 1 presents the classification of study
hookah, waterpipe smoking, waterpipe, pipe smoking, pipe, designsandrelatedinformationbasedonthecategoriesand
cigarette smoking, and cigarette. All retrieved records were subcategories.Table2summarizestheeffectofsmokingon
pulledfromdatabasesusingEndNoteX7.Duplicatedrecords majoroutcomesofmusculoskeletalhealth.Table3provides
were removed via EndNote or manually when EndNote comprehensiveinformationoneachstudyinthereview.
JournalofEnvironmentalandPublicHealth 3
Total 10690161410524942351719193
(7)Sec-ond-handSmok-ing(n=8) 43000100400810
6)ments=4) 40000000000400
(an
g(
Li
(5)ndonsn=6) 23100002000600
Te(
(4)Cartilage(n=19)A.B.KneeSpinalJointCarti-Carti-lagelage(12)(7)411102000000100000000007120000
(3)keletalMusclen=20) 45101000132811100
S (
D
D.TM(4) 21100000001300
ofstudycharacteristics. (2)Joints(n=54) C.B.Spondy-Osteoarthri-A.Rheumatoidlarthro-tisArthritis(29)sis(14)(7) 17111735301100000100000500122003000029117100000
y
r
mma F.BoneGraft(5) 30020002000500
u
ble1:S E.BoneImplant(33) 19734000110003300
Ta nes(n=132) D.Periodontitis(34) 4241500072702730
o
(1)B C.Alve-olarBone(4) 02110001001300
B.Frac-ture(16) 1321000063221210
A.BoneMass(40) 7271102221715121333
CohortCross-sectionalCase-controlRCTQuasi-experimentalSecondarydataanalysisCross-sequentialportedbyauthor)argestudyMaleFemaleBothsexesCotinineEXCO
plesize(remplefroml urements
StudyDesign UsedsmallsamUseddataorsa Sex ObjectiveMeas
4 JournalofEnvironmentalandPublicHealth
Table2:Summaryfortheeffectofsmokingonmajoroutcomesofmusculoskeletalhealth.
Sizeofthe
Contextof Qualityof Consistency Strengthofa
bodyof
Outcomes thebodyof thebodyof ofthebody bodyof
evidence
evidence evidence ofevidence evidence
(number)
Effectofsmokingonbones
Relevantand Highly
DecreasedBMD Large(24) High Verystrong
global consistent
Relevantbut Lowlevelof
DecreasedBMC Small(3) High Limited
specific consistency
Relevantand Highly
Increasedriskforfracture Large(6) High Verystrong
global consistent
Relevantand Highly
Delayedfracturehealing Large(5) High Verystrong
global consistent
Relevantand Moderately
Increasedalveolarboneloss Medium(9) High Strong
global consistent
Relevantand Highly
Poorperiodontalparameters Large(17) High Verystrong
global consistent
Relevantand Highly
Increasedboneimplantfailure Large(13) High Verystrong
global consistent
Relevantbut Highly
Poorhistometricparametersfortissuessurroundimplants Small(4) High Strong
specific consistent
Effectofsmokingonjoints
Relevantand Moderately
IncreasedRAdiseaseactivity Medium(5) High Medium
global consistent
Relevantbut
IncreasedremissionofRA Small(2) High Inconsistent Limited
specific
Relevantbut
IncreasedRAprogression Small(2) High Inconsistent Limited
specific
Relevantand Highly
PoorresponsetoRAtherapies Large(10) High Verystrong
global consistent
Relevantbut Lowlevelof
Decreasedincidence/prevalenceofOA Small(4) High Limited
specific consistency
Relevantbut
IncreasedpainscoreassociatedwithOA Small(2) High Consistent Medium
specific
Relevantbut
IncreasedriskfortotaljointreplacementinOApatients Small(2) High Inconsistent Limited
specific
Relevantand Highly
IncreasedriskforcomplicationsafterjointreplacementinOA Small(4) High Strong
global consistent
Relevantand Highly
IncreasedSAdiseasedactivity Small(3) Moderate Medium
global consistent
Relevantand Moderately
IncreasedpainintensityinpatientswithTMD Small(4) High Strong
global consistent
Effectofsmokingonmuscle
Relevantand Highly
Decreasedmusclestrength Medium(6) High Verystrong
global consistent
Relevantbut Lowlevelof
Decreasedmaximalmusclevoluntarycontraction Small(3) High Limited
specific consistency
Effectofsmokingoncartilage
Relevantbut
Increasedvolumeofkneejointcartilage Small(2) High Consistent Medium
specific
Relevantbut
Increaseddefectofkneejointcartilage Small(2) High Mixed Limited
specific
Relevantbut Highly
Poorpostoperativeoutcomesafterkneejointsurgery Small(3) High Strong
specific consistent
Relevantbut Highly
Increasedriskforspinalreoperation Small(3) High Strong
specific consistent
JournalofEnvironmentalandPublicHealth 5
Table2:Continued.
Sizeofthe
Contextof Qualityof Consistency Strengthofa
bodyof
Outcomes thebodyof thebodyof ofthebody bodyof
evidence
evidence evidence ofevidence evidence
(number)
Relevantand Moderately
Decreasedspinalfusionrate Small(4) Moderate Medium
global consistent
Effectofsmokingontendons
Relevantbut
Increasedseverityofrotatorcufftears Small(2) High Consistent Medium
specific
Relevantbut
Pooroutcomesafterrotatorcuffreconstruction Small(2) High Consistent Medium
specific
Effectofsmokingonligaments
Relevantand Moderately
PoorfunctionalandstabilityscoresafterACLreconstruction Small(4) High Medium
global consistent
Records identified through database searching
(PubMed = 1,346, Web of Science = 6,091,
Science Direct = 1,272)
(N = 8,709)
1,749 duplicated records identified by EndNote
349 duplicates identified by authors
Records after duplicates removal
(n = 6,611)
Reason for exclusion: 6,067 contain non pertinent
information, 13 not in English, 185 in
vitro/animal studies (n = 6,265)
Records retained after title & abstracts
screening (n = 346)
Reasons for exclusion: 35 were reviews
(overview, systematic review, meta-analysis), 48
were commentaries, case study/report, or thesis,
or symposia, and 20 full texts did not meet
inclusion criteria (n = 103)
Articles retained after full-text review and
were legible for final inclusion of qualitative
synthesis (n = 243)
Figure1:Processofliteraturesearch.
3.1.TobaccoSmokingandBones(n=132) Table3providescomprehensivedetailsonthefindingsfrom
thosestudiesforeffectsofsmokingonselectedbone-related
3.1.1. Bone Mass: BMD, BMC, and Bone Turnover (n = 40). outcomes.
Overall characteristics of these studies were as follows: 15 Accordingtoamajorityofstudies,smokinghadadverse
studieswereconductedinmales,12studieswereconducted effects on BMD across age categories and sex. In males,
infemales,and13includedbothsexes;22studiesuseddata regardless of age, method, and site of measurement for
or samples from large-scale longitudinal studies; all studies bonedensity,thecross-sectionalstudiesfoundsmokershad
usedself-reporttoassesssmokinghabits,withtheexception significantlylowerBMDthannonsmokers[27,42–44,46,52,
of6studiesthatusedobjectivemeasuresinadditiontoself- 54, 55]. The cohort studies found male smokers exhibited a
report:3assessedlevelofcotinine[24,48,49]and3assessed significantdeclineinBMD[32,33,50,54].Therewasonlyone
level of exhaled carbon monoxide (EXCO) [22, 36, 41]. cross-sectional study that reported no significant difference
6 JournalofEnvironmentalandPublicHealth
Findings (i)Comparedtononsmokers,smokershadlower±averageconcentrationofBMPCs(3.52x105/mL2.45±x105/mLversus1.31x105/mL1.61x105/mLforsmokers,t=3.2,P=0.004) (i)Duringtreatmentwithnasalestradiol,theBMDofthelumbarspineforsmokershadincreasedat2yearsbutwithlessthanthatinnonsmokers(2.6%versus3.9%,P=0.03).Similartrendexhibitedamongcontrols(-3.6%versus-2.4%,P=0.08)(ii)Whensmokerscomparedtononsmokers,therewasnodifferenceintheresponsetoestradiolinhipBMD(P=0.89),whereasthechangeinthehipontheplacebowassimilartothatseeninthespine(P=0.08).SupportivechangeswereseenwithinurinaryCTXandserumOC(i)Therewasanoverallpositivetrendbetweencalciumintakeandbonemineraldensityamongthreesmokingbehaviorcategories(ii)TheinteractionofsmokingwithcalciumintakeonBMDdidnotreachstatisticalsignificanceandthedose-responsecurvesbecamemoresimilaracrosssmokingbehaviorstrataafteradjustmentforseveralfactors(BMIandphysicalactivity)
)
s
e
andmusculoskeletalsystem. StudyPurpose ndBoneTurnover(BT)(40Articl (i)Toinvestigatewhethersmokingisassociatedwithlowerlevelsofbonemarrowprogenitorcells(BMPCs)expressCD15whichisnecessaryformusculoskeletalhealing/regeneration (i)Toinvestigatetheinfluenceofsmokingonboneduringtherapy(nasallyadministratedestradiolwithoralprogesterone)inearlypostmenopausalwomen,andtoobservetheimpactofsmokingonboneinuntreatedwomen (i)ToexaminetherelationshipsbetweenBMDandcalciumintake(dietary)andtoexaminetheinteraction(smokingandcalciumintake)onBMD
g a
n
Table3:Tobaccosmoki SampleSize/Age/Sex/TypeofSample MD),BoneMineralContent(BMC),(i)N=26iliacbonemarrowsamplescollectedduringpelvicsurgery:13nonsmokers,13smokers±(ii)Theaverageofage(Mean±SD):36.011.87fornonsmokers±39.012.91forsmokers(iii)16weremales,and10werefemales (i)N=270:192nonsmokers,78smokers±(ii)Theaverageofage(Mean±SD):53.51.9fornonsmokers±53.11.6forsmokers(iii)AllparticipantswerepostmenopausalCaucasianwomen (i)N=14,116:6,882never-smokers,3,532formersmokers,3,702currentsmokers(ii)Themedianageoftheparticipantswas44years(iii)6,830weremales,and7,286werefemales
B
(
Design s)oneMineralDensity Cross-sectionalstudy PosthocexploratorystudybasedondatafromRCTstudy Cross-sectionalstudy[sampleNHANES]III)
eB
ticlnd
Ara
(132oking [17] 2009 9]
Citation Section1:Bone1.A:TobaccoSm Beythetal.,2015 Bjarnasonetal.,[18] Breitling,2015[1
JournalofEnvironmentalandPublicHealth 7
Findings (i)BMDandrelativefractureriskdidnotdifferbetweennever-smokersandformerandcurrentsmokers(ii)Amongcurrentsmokers,BMD(femoralneck)decreasedascigaretteconsumptionincreasedindose-responseeffect(P=0.037)(iii)BMDwasnotsignificantlylowerinyoungwomenwhohadsmokedforlongduration(P=0.07)orstartedsmokingearly(P=0.64)(iv)Aftersmokingcessation,lowerBMDpersistedupto24months,becomingcomparabletonever-smokersafter24months≤(i)ComparedtothosewithBMD-2SD,patientswith>BMD-2.0SDwerefoundtobeyounger,hadshorter<timesincemenopause,andhadhigherBMI(P0.05)(ii)Thefallepisodeswerereportedin57.8%oftheparticipantswithoutanysignificantdifferencesbetweenthetwogroupsofBMD(iii)Theposturalbalanceassessedviastabilometricparameterswasnotdifferedbetweenthetwogroups(P>0.05)(iv)Theriskoffallincreasedwithcurrentsmoking(OR=2.19,95%CI:1.22-3.21),age,andcorrectedvisualdeficit.However,hormonetherapyusewassignificantlycorrelatedwithreducedriskforfalls(OR=0.48,95%CI:0.26-0.88)(i)Comparedtonever-smokers,patientswithCOPD[]hadlowerfat-freemass(FFM)P=0.02andfat-free[]massindex(FFMI)P=0.008(ii)Six-minutewalkdistance(6MWD)waslowerinCOPDandsmokersthannever-smokers(P=0.01)(iii)Comparedtonever-smokers,smokershadworse<SF-36scoreforfunctionalcapacity(P0.001)(iv)Comparedtosmokersandnever-smokers,COPDpatienthadlowerSF-36scoreforphysicalfunctioning<<(P0.001)androle-emotional(P0.001)(v)BothCOPDdiagnosisandsmokinginverselyassociatedwithFFMI,6MWDandhealthstatus
Continued. StudyPurpose (i)Toevaluatetheassociationbetweensmokingandbonemass(BMDandfracturerisk)in25-year-oldwomen (i)ToevaluateassociationofBMDwithposturalbalanceinpostmenopausalwomenanditsrelationtoriskforfallsandtoinvestigateifsmokingincreasetheriskforfall. (i)ToinvestigatethejointeffectofsmokingandCOPDonthehealthstatus,bodycomposition,andexercisecapacity
3:
e
Tabl SampleSize/Age/Sex/TypeofSample (i)N=1,054:591never-smokers,187formersmokers,276currentsmokers(ii)Allparticipantswere25-year-oldwomen (i)N=225womeninamenorrhea:group1:140with>T-score-2.0SD(116nonsmoker,24currentsmokers)≤andgroup2:85withT-score-2SD(72nonsmokers,13currentsmokers)(ii)Theaverageofagewas54(50-57)forpatientsgroup1,anditwas58(52-64)forgroup2(iii)Allparticipantswerepostmenopausalwomen (i)N=96:32never-smokers,32>smokers(10pack-year),and32mild/moderateCOPD(currentorformersmokers)(ii)Theaverageofage(Mean,range):(49.5,46-58)fornever-smokers,(53,5-55)forsmokers,and(64.5,58-74.5)forCOPDpatients(iii)28weremales,and68werefemales
y y y
studm]ort stud stud
Design ss-sectional[samplefroEAK-25coh ss-sectional ss-sectional
ro P ro ro
C C C
]
20] [21 2]
[ 2 2
Citation Callreusetal.,2013 Cangussuetal.,201 Carametal.,2016[
8 JournalofEnvironmentalandPublicHealth
Findings (i)Theratesofosteopeniaandosteoporosisinsmokersandnonsmokerswere75%and52.5%,respectively(ii)TheT-scoresweresignificantlylowerinsmokers<thaninnonsmokers(median:-2.7versus-1.4,P0.001)(iii)Activitiesofantioxidantenzymes(superoxidedismutase,glutathioneperoxidase,andparaoxonase)werelowerandthelevelsofoxidativestressproducts(malondialdehyde,nitricoxide)werehigherinsmokers<thaninnonsmokers(P0.001)(iv)Inthesmokinggroup,therewasasignificantcorrelationbetweendecreasedT-scoreandoxidativestressparameters (i)Comparedtononsmokers,smokersremarkablyhadlowerreductioninthegeneexpressionofBMP-2,BMP-4,andBMP-6,demonstratingtheeffectofsmokingonperiostealmRNAtranscriptionforBMPs(ii)Comparedtofracturedgroup,nonfracturegroupsexhibitedahighergeneexpressionofBMP-2,BMP-4and,BMP-7 (i)ComparedtononsmokersandCOPDpatients,smokershadhigherfrequenciesofRANKL-CD4(+)<andCD8(+)Tcells(AllP0.001).(ii)COPDpatientshadsignificantlyhigherproportionofCD(+)TcellsexpressedRANKLandIL-17thanthatofnonsmokers(P=0.010).(iii)AllgroupshadsimilarfrequencyforRANKLexpressioninTh17(P=0.508).(iv)TherewereaninversecorrelationbetweenthefrequencyofRANKL(+)CD4(+)TcellsandBMDofthelumbarvertebrae(r=-0.229,P=0.01)andfemoral<neck(r=-0.350,P0.001).
Continued. StudyPurpose (i)ToinvestigatetheimpactofsmokingontheoxidativestatusinpostmenopausalwomenandtoassesstherelationshipbetweenBMDandoxidant/antioxidantparameters (i)Toevaluatetheeffectofsmokingontheexpressionofthebonemorphogeneticproteins(BMPs)ofhumanperiosteum (i)Toevaluatetheexpressionofreceptoractivatorofnuclearfactor-BligandinCD4(+)/CD8(+)TcellsandTh17cellsandtheroleofthesecellsinCOPDandsmokerpopulationinboneloss
3:
Table SampleSize/Age/Sex/TypeofSample (i)N=60:30nonsmokers,and30smokers±(ii)Theaverageofage(Mean±SD):51.23.4fornonsmokers,±49.73.5forsmokers(iii)Allparticipantswerepostmenopausalwomen(iv)Participantswererandomlyselected (i)N=105:45fracturedbone(26nonsmokers,19smokers),and60nonfracturedbone(39nonsmokers,21smokers)(ii)Theaverageofage(Mean,Rang):49(21to87)forfractured,and52(19to82)fornonfractured(iii)62weremales,and43werefemales (i)N=131:36nonsmokers,38smokershadnormallungfunctionand57hadCOPD±(ii)Theaverageofage(Mean±SD):74.09.49nonsmokers,±±72.4412.27smokers,and77.710.89(iii)Allparticipantsweremale
y y y
d d d
u u u
st st st
Design ectional ectional ectional
s s s
- - -
s s s
s s s
o o o
r r r
C C C
2
2009[23] etal.,201 2016[25]
on etal., anidis etal.,
Citati Cetin Chass[24] Chen
JournalofEnvironmentalandPublicHealth 9
Findings (i)Percentagewithin-pairdifference(WPD)thatwascalculatedbasedonthedifferencesbetweensmokersandnonsmokerswerefoundtobesignificantforBMDoffemoralneck(-5.6%,95%CI:-9.0to-2.2,P=0.002),≤totalhip(-6.2%,95%CI:-9.4to-2.9,P0.001),andwhole-bodyBMC(-4.1%,95%CI:-7.2to-1.1,P=0.012).However,itwasfoundtobenotsignificantforlumbarspine(-3.5%,95%CI:(-7.0to0.0,P=0.058),andforearm(-0.8%,95%CI:-2.6to-1.0,P=0.290).(ii)WPDforfatmasswasalsolowerinsmokingtwins(-12.8%,95%CI:-20.7to-4.8,P=0.005),andleanmassmarginallysignificant(-2.8,95%CI:-5.9to0.3,P=0.083)(i)Theprevalenceofvertebralfractureamongthecohortwas8.8%(100).Currentsmokershadhigherrateofvertebralfracturethanthatofformersmokers(11.3%versus5.8%,P=0.001),butitwasnotdifferentbasedonCOPDstatus(9.6%versus8.3%,P=0.430)(ii)Theadjustedoddsratio(AOR)forfracturewas“AOR=1.79.95%CI:1.13-2.84”incurrentsmokersand“adjustedOR=1.08,95%CI:0.69-1.67”inCOPDparticipants.BothsmokingandCOPDwereindependentlyassociatedwithBMDadjustedforageandBMI(iii)BMDassessedbyHounsfieldUnits(HU)waslowerincurrentthaninformersmokers(103.2HUversus108.7HU,P=0.006)andwaslowerinCOPDpatientsthanpatientswithoutCOPD(100.7HUversus<108.9HU,P0.001)(i)ThelowerratesoflumbarspineandtotalhipBMDofages13-19wereassociatedwithhigherfrequencyofsmoking(ii)TherewasanassociationbetweenhighdepressivesymptomsandlowerlumbarspineBMDacross11-19yearsofage(iii)Alcoholintakeandanxietyhadnoeffectonboneoutcome,anddepressivesymptomshadnoeffectontotalbodyBMC
ng n ol95,
Continued. StudyPurpose (i)Toexaminewhethermechanismofbonelossinpairtwinscouldberelatedtosmoki (i)ToinvestigatetheassociatioofsmokingandCOPDwithBMDandvertebralfracture. (i)Toexaminetheimpactofdepressiveandanxietysymptoms,smoking,andalcohuseonboneaccrualingirls11-1yearswithagecohortof11,13,1and17years
3:
e
Tabl SampleSize/Age/Sex/TypeofSample (i)N=69twin±(ii)Averageofage(MeanSD):±538.9witharangeof(40-76)years(iii)13weremales,and56werefemales ≥(i)N=1,140:609current(16pack-year)and531formersmokers(ii)437participantshadCOPD±(iii)Theaverageofage(Mean±SD):62.55.2(iv)Allparticipantsweremales. (i)N=262:171nonsmokers,91smokers±(ii)Theaverageofage(Mean±SD)attime1:14.352.16years(iii)Allparticipantswerefemales(iv)32%black,and62%white
y y
d d
Design ross-sectionalstu ross-sectionalstu[samplefromthe]NELSONtrial Crosssequentialdesign
C C
al.,2009[26] al.,2014[27] 2013[28]
et et al.,
Citation Christie DeJong Dornet
10 JournalofEnvironmentalandPublicHealth
Findings (i)ThehigherstateofdepressivesymptomswasassociatedwithlowerBMCandBMD(ii)ParticipantswithlowestuseofsmokinghadhigherBMD(hip,femoralneck),however;nodifferenceswereobservedbyalcoholuse(iii)Comparedwithalcohol(regular,nonusers),theregularusersofbothcigarettesandalcoholhadastrongernegativeassociationbetweendepressiveoranxietysymptomsandtotalbodyBMC(i)HigherdepressivesymptomswerecorrelatedwithlowertotalbodyBMCandBMDbutnotassociatedwithhiporspineBMCandBMD.(ii)Inwhitewomen,thelowerlevelsoftotalbodyBMCandhipBMCandBMDwereassociatedwithhighscoreofanxiety.(iii)Therewerenodifferencesinage-adjustedBMCorBMDbetweenever-smokersandnever-smokers.However,ever-smokershadhigherdepressiveandanxietysymptomsthannever-smokers.(iv)Therewasnosignificantinteractionbetweensmokingstatusanddepressionoranxietystatus.(v)HighlevelofanxietywasassociatedwithlowerBMCingroupofever-smoking(i)TheBMDoftheramuswassimilartothefemur;howeveritwassignificantlylowerthantheBMDoflumbarspine.(ii)BMDofanteriormaxillawaslowerthanBMDvaluesoffemurandramus.(iii)TherewasastrongrelationshipbetweenramusBMDandspineandhipBMD,buttherewerenorelationshipsbetweenBMDofotherjaw’sareasandBMDskeletalsites.(iv)TherewasaninverseassociationbetweenincreasingageandBMDofbothhipandtheramus.However,therewasnosignificantassociationbetweenBMDofhip,spine,andjawandyearsedentulousorcigaretteyears
Continued. StudyPurpose (i)Toexaminetheassociationbetweendepressiveandanxietysymptoms,smoking,andalcoholuseonbonehealthwhethertheassociationbetweendepressiveandanxietysymptomsvariedbysmokingoralcoholuseindividuallyorbycombineduse (i)Toinvestigatetherelationshipsbetweenanxiety,depression,smoking,andBMDamongadolescentgirls (i)ToinvestigatetheassociationbetweenjawsBMDandotherskeletalsiteBMDandtoinvestigatetheinfluenceofsmokingontheBMD
3:
e
Tabl SampleSize/Age/Sex/TypeofSample(i)N=262:171nonsmokers,91smokers±(ii)Theaverageofage(Mean±SD):14.92.2years(iii)Allparticipantswerefemales(iv)ThemajoritywereCaucasian(61.8%)orAfricanAmerican(32.8%)withsomemixedrace/other(5.4%) (i)N=207:107never-smokers,94ever-smokers±(ii)Theaverageofage(Mean±SD):14.02.2years(iii)Allparticipantswerefemales.(iv)62.2%white,32.3%AfricanAmerican(32.3%),and5.5%mixedrace/other (i)N=18:5nonsmokers,13smokers±(ii)Theaverageofage(Mean±SD):67.112.6(iii)9weremales,and9werefemales
y y
d d
Design Crosssequentialdesign oss-sectionalstu oss-sectionalstu
r r
C C
2011[29] 2008[30] 2007[31]
al., al., al.,
Citation Dornet Dornet Drageet