Does Smoking Cause Low Back Pain?

According to the Centers for Disease Control and Prevention (CDC), an estimated 14% of Americans are current smokers, and therefore at risk for a number of smoking-related conditions. Low back pain is one such condition that has a strong association with smoking.

Specific findings in research show:

• The more frequently one smokes, the greater the risk of back pain¹Hurtubise J, McLellan K, Durr K, Onasanya O, Nwabuko D, Ndisang JF. The Different Facets of Dyslipidemia and Hypertension in Atherosclerosis. Curr Atheroscler Rep. 2016;18(12):82. doi:10.1007/s11883-016-0632-z
• Smokers with low back pain also tend to have pain in the leg, usually extending below the knee²Dionne CE, Laurin D, Desrosiers T, et al. Vitamin C is not the Missing Link Between Cigarette Smoking and Spinal Pain. Spine (Phila Pa 1976). 2018;43(12):E712-E721. doi:10.1097/BRS.0000000000002466

Smoking may change the level of nutrients, such as cholesterol and vitamins, in the blood and the health of organs, such as the heart and the lungs. While these metabolic changes may help explain the link between smoking and a degenerating spine, it remains to be seen if smoking is a cause of back pain.

Smoking Alters Blood Flow and May Lead to Back Pain

Consequences of smoking may indirectly contribute to the development of degenerative lumbar spine problems. These consequences include, but are not limited to¹Hurtubise J, McLellan K, Durr K, Onasanya O, Nwabuko D, Ndisang JF. The Different Facets of Dyslipidemia and Hypertension in Atherosclerosis. Curr Atheroscler Rep. 2016;18(12):82. doi:10.1007/s11883-016-0632-z^,3Virdis A, Giannarelli C, Neves MF, Taddei S, Ghiadoni L. Cigarette smoking and hypertension. Curr Pharm Des. 2010;16(23):2518-2525. doi:10.2174/138161210792062920^,4Libby P, Buring JE, Badimon L, et al. Atherosclerosis. Nat Rev Dis Primers. 2019;5(1):56. Published 2019 Aug 16. doi:10.1038/s41572-019-0106-z^,5Moradinazar M, Pasdar Y, Najafi F, et al. Association between dyslipidemia and blood lipids concentration with smoking habits in the Kurdish population of Iran. BMC Public Health. 2020;20(1):673. Published 2020 May 13. doi:10.1186/s12889-020-08809-z:

• Hypertension, or high blood pressure. A history of cigarette smoking impairs the ability of the endothelium (the thin membrane of cells lining the blood vessels) to regulate blood pressure, causing hypertension (elevated blood pressure) in some individuals.
• Abnormally high blood cholesterol. High levels of cholesterol, also known as hyperlipidemia, can go undetected but increase the risk of developing coronary artery disease.
• Atherosclerosis, or narrowing of the arteries. Atherosclerosis is aggravated by hypertension and abnormal cholesterol levels.

Atherosclerosis causes decreased blood flow to organs and tissues and may result in ischemia. Atherosclerosis in the aorta (a main artery of the heart) and ischemia in the leg have long been considered potential causes of low back pain and intervertebral disc degeneration.⁶Kurunlahti M, Tervonen O, Vanharanta H, Ilkko E, Suramo I. Association of atherosclerosis with low back pain and the degree of disc degeneration. Spine (Phila Pa 1976). 1999;24(20):2080-2084. doi:10.1097/00007632-199910150-00003^,7Gahier M, Hersant J, Hamel JF, et al. A Simple Scale for Screening Lower-Extremity Arterial Disease as a Possible Cause of Low Back Pain: a Cross-sectional Study Among 542 Subjects. J Gen Intern Med. 2020;35(7):1963-1970. doi:10.1007/s11606-020-05670-z^,8Kauppila LI, McAlindon T, Evans S, Wilson PW, Kiel D, Felson DT. Disc degeneration/back pain and calcification of the abdominal aorta. A 25-year follow-up study in Framingham. Spine (Phila Pa 1976). 1997;22(14):1642-1649. doi:10.1097/00007632-199707150-00023

Passive smoking,⁹Attard R, Dingli P, Doggen CJM, Cassar K, Farrugia R, Wettinger SB. The impact of passive and active smoking on inflammation, lipid profile and the risk of myocardial infarction. Open Heart. 2017;4(2):e000620. Published 2017 Aug 8. doi:10.1136/openhrt-2017-000620 also called second-hand smoking, and waterpipe tobacco smoking,¹⁰Hallit S, Hallit R, Haddad C, et al. Previous, current, and cumulative dose effect of waterpipe smoking on LDL and total cholesterol. Environ Sci Pollut Res Int. 2019;26(8):8194-8201. doi:10.1007/s11356-019-04311-1^,11Al Ali R, Vukadinović D, Maziak W, et al. Cardiovascular effects of waterpipe smoking: a systematic review and meta-analysis. Rev Cardiovasc Med. 2020;21(3):453-468. doi:10.31083/j.rcm.2020.03.135 commonly known as hookah, similarly contribute to abnormal blood pressure and cholesterol. The combination of cigarette smoking and waterpipe smoking may increase cholesterol levels higher than either type of smoking alone.¹²Hallit S, Zoghbi M, Hallit R, et al. Effect of exclusive cigarette smoking and in combination with waterpipe smoking on lipoproteins. J Epidemiol Glob Health. 2017;7(4):269-275. doi:10.1016/j.jegh.2017.08.006

Smoking Weakens the Spine’s Health

Smoking reduces the nutrient content of the blood that is delivered to the intervertebral discs and joints of the spine. Studies have drawn conclusions about whether or not the following effects of smoking play a role in back pain:

• Low vitamin D. Smoking alters the speed of vitamin D production,¹³Hansdottir S, Monick MM, Lovan N. Powers LS, Hunninghake, GW. Smoking disrupts vitamin D metabolism in the lungs [abstract]. Am J Respir Crit Care Med 2010;181:A1425 the amount of vitamin D circulating in the blood,¹⁴Ren W, Gu Y, Zhu L, et al. The effect of cigarette smoking on vitamin D level and depression in male patients with acute ischemic stroke. Compr Psychiatry. 2016;65:9-14. doi:10.1016/j.comppsych.2015.09.006 and the number of vitamin D receptors.¹⁵Haley KJ, Manoli SE, Tantisira KG, Litonjua AA, Nguyen P, Kobzik L, Weiss ST. Maternal smoking causes abnormal expression of the vitamin D receptor [abstract]. Am J Respir Crit Care Med 2009;179:A5874 Gradually, these effects may lead to vitamin D deficiency. Moderate deficiency of vitamin D has the potential to decrease bone density, which may contribute to the development of bone fractures.¹⁶Reid IR. Vitamin D Effect on Bone Mineral Density and Fractures. Endocrinol Metab Clin North Am. 2017;46(4):935-945. doi:10.1016/j.ecl.2017.07.005 The association between vitamin D deficiency and low back pain is well-established,¹⁷Gokcek E, Kaydu A. Assessment of Relationship between Vitamin D Deficiency and Pain Severity in Patients with Low Back Pain: A Retrospective, Observational Study [published correction appears in Anesth Essays Res. 2018 Oct-Dec;12(4):970]. Anesth Essays Res. 2018;12(3):680-684. doi:10.4103/aer.AER_96_18 but may only exist for certain subgroups such as women less than 60 years old¹⁸Xu HW, Yi YY, Zhang SB, et al. Does vitamin D status influence lumbar disc degeneration and low back pain in postmenopausal women? A retrospective single-center study. Menopause. 2020;27(5):586-592. doi:10.1097/GME.0000000000001499 or individuals with severe vitamin D deficiency.¹⁹Kanaujia V, Yadav RK, Verma S, Jain S, Patra B, Neyaz O. Correlation between Vitamin D deficiency and nonspecific chronic low back pain: A retrospective observational study. J Family Med Prim Care. 2021;10(2):893-897. doi:10.4103/jfmpc.jfmpc_1478_20
• Low vitamin C. Smokers generally metabolize vitamin C faster and have lower vitamin C levels in the blood as a result of the rapid metabolism.²⁰Schectman G, Byrd JC, Gruchow HW. The influence of smoking on vitamin C status in adults. Am J Public Health. 1989;79(2):158-162. doi:10.2105/ajph.79.2.158 While vitamin C has been a factor of interest in low back pain research, vitamin C deficiency does not explain the link between smoking and back pain.

More research is needed to explore the possible ways that smoking leads to prolonged and more frequent episodes of back pain. Targeted treatments, such as vitamin C supplements, can be tailored to current or former smokers with back pain or at risk of developing back pain, once the association is better understood.

Smoking Promotes the Development of Chronic Back Pain

Smoking also has certain effects on brain circuitry. Back pain is more likely to become chronic in smokers, possibly due to the cooperation of specific areas of the brain— the nucleus accumbens and the medial prefrontal cortex.²¹Petre B, Torbey S, Griffith JW, et al. Smoking increases risk of pain chronification through shared corticostriatal circuitry. Hum Brain Mapp. 2015;36(2):683-694. doi:10.1002/hbm.22656 These regions of the brain are known for their role in many cognitive functions, such as reward, addiction, and habit formation. The connection between these brain regions weakens after quitting smoking.

Back Pain After Quitting Smoking

The habit of smoking is an important obstacle to overcome, and one way that smoking cessation may pay off is with a reduced risk of back pain.

Former daily smokers may experience generalized body pain, including back pain, that continues or begins after smoking cessation.²²Perski O, Garnett C, Shahab L, Brown J, West R. Associations between smoking status and bodily pain in a cross-sectional survey of UK respondents. Addict Behav. 2020;102:106229. doi:10.1016/j.addbeh.2019.106229 After quitting, nicotine withdrawal causes the level of serotonin in the brain to decrease. With lower serotonin levels, the sensitivity to pain increases.²³Wurtman RJ, Wurtman JJ. Brain serotonin, carbohydrate-craving, obesity and depression. Obes Res. 1995;3 Suppl 4:477S-480S. doi:10.1002/j.1550-8528.1995.tb00215.x Smokers with chronic pain may be advised to quit smoking gradually or to alleviate withdrawal symptoms using nicotine patches.

The neurological and vascular effects of smoking on the back can be reduced by quitting, but cannot be fully reversed. Both current and former smokers are at risk for numerous conditions, including low back pain and degenerative disc disease, because of the lingering effects of smoking.

Smoking and Low Back Pain Among Certain Groups

Factors such as age, gender, and history of spinal conditions may turn the dial up on the influence that smoking has on the spine. Research studies of hundreds of individuals have supported the following findings:

• Adolescents who smoke were up to 2.4 times as likely to experience low back pain compared to nonsmoking adolescents.²⁴Feldman DE, Rossignol M, Shrier I, Abenhaim L. Smoking. A risk factor for development of low back pain in adolescents. Spine (Phila Pa 1976). 1999;24(23):2492-2496. doi:10.1097/00007632-199912010-00011
• Adult smokers were about 30% more likely to have low back pain compared to nonsmoking adults.²⁵Shiri R, Karppinen J, Leino-Arjas P, Solovieva S, Viikari-Juntura E. The association between smoking and low back pain: a meta-analysis. Am J Med. 2010;123(1):. doi:10.1016/j.amjmed.2009.05.028
• Men who smoke were 18% more likely to have low back pain, 25% more likely to have disc degeneration, 33% more likely to have spinal instability, 49% more likely to have spondylolisthesis, and 52% more likely to have spinal stenosis compared to nonsmoking men.²⁶Kwon JW, Ha JW, Lee TS, Moon SH, Lee HM, Park Y. Comparison of the Prevalence of Low Back Pain and Related Spinal Diseases among Smokers and Nonsmokers: Using Korean National Health Insurance Database. Clin Orthop Surg. 2020;12(2):200-208. doi:10.4055/cios19095
• Women who smoke were 50% more likely to experience chronic back pain compared to women who never smoked.²⁷Schmelzer AC, Salt E, Wiggins A, Crofford LJ, Bush H, Mannino DM. Role of Stress and Smoking as Modifiable Risk Factors for Nonpersistent and Persistent Back Pain in Women. Clin J Pain. 2016;32(3):232-237. doi:10.1097/AJP.0000000000000245
• Smokers with a history of adolescent idiopathic scoliosis are more likely to have back pain than smokers without the condition.²⁸Scott SC, Goldberg MS, Mayo NE, Stock SR, Poîtras B. The association between cigarette smoking and back pain in adults. Spine (Phila Pa 1976). 1999;24(11):1090-1098. doi:10.1097/00007632-199906010-00008

Both back pain and associated leg pain are less common in former smokers than in current smokers,¹¹Al Ali R, Vukadinović D, Maziak W, et al. Cardiovascular effects of waterpipe smoking: a systematic review and meta-analysis. Rev Cardiovasc Med. 2020;21(3):453-468. doi:10.31083/j.rcm.2020.03.135 so quitting smoking may alleviate back pain and may also improve outcomes after back surgery.²⁹Jazini E, Glassman SD, Bisson EF, Potts EA, Carreon LY. Do Former Smokers Exhibit a Distinct Profile Before and After Lumbar Spine Surgery?. Spine (Phila Pa 1976). 2018;43(3):201-206. doi:10.1097/BRS.0000000000002293