Smoking and Low Back Pain

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The Association between Smoking and Low

Back Pain: A Meta-analysis
Article in The American journal of medicine January 2010

DOI: 10.1016/j.amjmed.2009.05.028 Source: PubMed
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CLINICAL RESEARCH STUDY
The Association between Smoking and Low Back Pain:

A Meta-analysis
Rahman Shiri, MD, PhD,a Jaro Karppinen, MD, PhD,a,b Pivi Leino-Arjas, MD, PhD,a Svetlana Solovieva, PhD,a
Eira Viikari-Juntura, MD, PhDa
a
Centre of Expertise for Health and Work Ability, Finnish Institute of Occupational Health, Helsinki, Finland; bDepartment of Physical
Medicine and Rehabilitation, University of Oulu, Oulu, Finland.
ABSTRACT
OBJECTIVE: To assess the association between smoking and low back pain with meta-analysis.
METHODS: We conducted a systematic search of the MEDLINE and EMBASE databases until February
2009. Eighty-one studies were reviewed and 40 (27 cross-sectional and 13 cohort) studies were included
in the meta-analyses.
RESULTS: In cross-sectional studies, current smoking was associated with increased prevalence of low back
pain in the past month (pooled odds ratio [OR] 1.30, 95% confidence interval [CI], 1.16-1.45), low back
pain in the past 12 months (OR 1.33, 95% CI, 1.26-1.41), seeking care for low back pain (OR 1.49, 95%
CI, 1.38-1.60), chronic low back pain (OR 1.79, 95% CI, 1.27-2.50) and disabling low back pain (OR 2.14,
95% CI, 1.11-4.13). Former smokers had a higher prevalence of low back pain compared with never
smokers, but a lower prevalence of low back pain than current smokers. In cohort studies, both former (OR
1.32, 95% CI, 0.99-1.77) and current (OR 1.31, 95% CI, 1.11-1.55) smokers had an increased incidence
of low back pain compared with never smokers. The association between current smoking and the
incidence of low back pain was stronger in adolescents (OR 1.82, 95% CI, 1.42-2.33) than in adults (OR
1.16, 95% CI, 1.02-1.32).
CONCLUSIONS: Our findings indicate that both current and former smokers have a higher prevalence and
incidence of low back pain than never smokers, but the association is fairly modest. The association
between current smoking and the incidence of low back pain is stronger in adolescents than in adults.
2010 Elsevier Inc. All rights reserved. The American Journal of Medicine (2010) 123, 87.e7-87.e35
KEYWORDS: Incidence; Prevalence; Publication bias; Tobacco
Low back pain is a worldwide health problem, affecting ranges between 25% and 60%, and the 1-month prevalence
between 50% and 80% of people at some time in their is around 30%.1,2 Low back pain is associated with reduced
lives.1,2 Its annual prevalence in the general populations quality of life, sickness absence, loss of worker productiv-
ity, and high health care costs.2-5
The etiology of low back pain is not fully known. Studies
Funding: None.
Conflict of Interest: The authors declare that they have no competing
suggest that modifiable risk factors may play a role in the
interests. development of low back pain.6,7 However, the available
Authorship: All authors had a role in writing the manuscript. All evidence on the role of smoking in low back pain is incon-
authors contributed to the design of the review, as well as interpretation of sistent.8 To date, 2 reviews on the association between
the findings and preparing the report. R. Shiri and S. Solovieva carried out
smoking and low back pain have been published.8,9 One of
the MEDLINE searches. R. Shiri carried out the EMBASE searches. All
authors assessed the quality of the studies. R. Shiri carried out the meta- these suggested an association between cigarette smoking
analyses and drafted the manuscript. All authors critically revised the and low back pain,9 while the other reported unclear
manuscript and approved the final version for submission. findings.8
Requests for reprints should be addressed to Rahman Shiri, MD, PhD, These 2 reviews on the relation between smoking and
Centre of Expertise for Health and Work Ability, Finnish Institute of
Occupational Health, Topeliuksenkatu 41 a A, Helsinki FIN-00250, Fin-
low back pain covered studies published between 1974 and
land. mid-1997. Moreover, no meta-analysis has been performed.
E-mail address: rahman.shiri@ttl.fi Our aim was to provide a systematic literature review of the
0002-9343/$ -see front matter 2010 Elsevier Inc. All rights reserved.
doi:10.1016/j.amjmed.2009.05.028
87.e8 The American Journal of Medicine, Vol 123, No 1, January 2010
association between smoking and low back pain and to Exposures collaborative group.13 Chronic low back pain
estimate the magnitude of such an association with was defined as pain that lasts for longer than 7-12 weeks2 or
meta-analysis. pain for more than 30 days in the past 12 months.13
We did random-effects meta-analyses. Results from a
random-effects model are usually more conservative than
METHODS the fixed-effect model.12 Hetero-
Search Strategy geneity was assessed by the Coch-
Studies of interest were identified rans chi-squared (Q-test) and I2
CLINICAL SIGNIFICANCE
by searches of the MEDLINE and statistic.14,15 Heterogeneity refers
EMBASE databases from 1966 Smoking might increase the risk of low to any kind of variability in the as-
until February 2009 using pre- back pain. sociation between smoking and low
defined keywords. In addition to back pain among different studies.
Smoking might have stronger adverse Significant heterogeneity shows that
smoking, our search covered a
larger set of cardiovascular or life- effects on the lumbar spine in adoles- this variability is not due to chance
style risk factors. 10,11
Our search cents than adults. alone. Values of I2 statistic range
was limited to human populations. from 0% to 100% and show the
Smoking cessation might reduce the
All languages were accepted. We proportion of total variation across
risk of seeking care for low back pain studies that are not due to chance.
excluded reviews, case reports, and chronic low back pain.
letters, editorials, and guidelines. Values of 25%, 50%, and 75% cor-
We also searched reference lists of respond to low, moderate, and high
included studies. heterogeneity.15
The small-study effect and the effect of low-quality stud-
Selection of Studies ies were assessed by cumulative meta-analysis and by sub-
Two authors examined independently all titles and ab- group analysis. For cumulative meta-analysis, the studies
stracts. We scrutinized the full text of relevant articles and were ranked in descending order, first by number of mod-
determined whether they met the inclusion criteria. We erate biases and then by sample size. Meta-regression was
included original articles on human populations with a co- used to determine whether study-level covariates account
hort, case-control, or cross-sectional design. Studies solely for the observed heterogeneity.16
on clinical populations, case-control studies with controls Publication bias was examined with funnel plots. A fun-
derived from the patient populations, studies with sample nel plot is a scatter plot of included studies in the meta-
size 30, and studies with response rate 60% or not analysis, with the magnitude of smoking effect on the hor-
reported, were excluded (Figure 1). Studies on specific back izontal axis, and the weight of the study, such as the inverse
disorders,11 on musculoskeletal or spinal pain without spec- standard error or sample size, on the vertical axis. The
ification to the back, and studies on the prognosis of low funnel plot is based on the fact that the precision in assess-
back pain were excluded. ing the association between smoking and low back pain will
increase as the sample size of studies increases. An asym-
Quality Assessment metrical appearance of dots in the funnel plot can be due to
Two reviewers assessed independently the quality of the the presence of publication bias.17 Asymmetry of funnel
studies using a modification of the Cochrane quality criteria plots was assessed by 3 statistical methods: rank correlation
for the systematic assessment of nonexperimental studies.12 method (Beggs test),18 regression analysis (Eggers test),19
Disagreements were solved through discussion. and the trim-and-fill method.20 In the trim-and-fill method,
We assessed the occurrence and severity of 4 possible we used the fixed-effect model for trimming and the ran-
sources of bias: selection, performance, detection, and at- dom-effects model for filling to obtain the adjusted pooled
trition (Appendix 1). Studies with any definite biases were estimates. We assessed publication bias for cross-sectional
excluded from the review. Only studies with no or minor and cohort studies as well as for each low back pain out-
selection bias were included in the meta-analysis. come. Stata software, version 10 (StataCorp, College Sta-
tion, Tex), was used to perform meta-analysis.
Meta-analysis
Studies that reported a risk estimate (odds ratio or relative
risk) for smoking were eligible for the meta-analysis. A RESULTS
minimum requirement was adjustment for age and sex. We identified 250 relevant study reports on the associations
When the study population was of either sex, represented a between cardiovascular risk factors and low back pain for
narrow age group, or included stratified analysis by age and detailed assessment (Figure 1). We included 81 studies on
sex, the study also was included. the relation between smoking and low back pain for sys-
We used combinable low back pain outcomes suggested tematic review (Appendixes 2,3). Finally, 40 (27 cross-
by the Meta-Analysis of Pain in the Lower Back and Work sectional and 13 cohort) studies qualified for meta-analysis.
Shiri et al Association between Smoking and Low Back Pain 87.e9
Figure 1 Flow chart of the search strategy and selection of studies.
Cross-sectional Studies 5 assessed a dose-response relation between the number

Compared with those who never smoked, ever, former, and of cigarettes smoked per day and chronic low back
current smokers had a higher prevalence of low back pain in pain.30,31,40,42,54 Of them, 4 showed a dose-response
the past month, in the past 12 months, seeking care for low relation.30,40,42,54
back pain, and chronic low back pain (Tables 1-3). The
prevalence of low back pain in the past month did not differ Cohort Studies
between former and current smokers, whereas current The meta-analysis of prospective studies showed an in-
smokers had a higher prevalence of low back pain in the creased incidence of low back pain in ever, former, and
past 12 months, seeking care for low back pain, or chronic current smokers compared with never smokers (Table 4).
low back pain than former smokers (Tables 2,3). Current The association between current smoking and low back pain
smoking had the strongest association with disabling low was stronger in adolescents than in adults. All studies in
back pain. adolescents56-58 showed a dose-response relation between
Of 8 studies included in the meta-analysis on the asso- the number of cigarettes smoked per week or per day and
ciation between current smoking and chronic low back pain, the incidence of low back pain.
Table 1 Pooled Odds Ratio of Low Back Pain for Ever Smokers versus Never Smokers among Adults, Prevalence (Cross-sectional
Studies)
Heterogeneity No. of
Sample Moderate Cumulative OR
First Author Population Country Year Size OR 95% CI P Value I2 (95% CI) Biases (95% CI)
Low back pain in the past month

Schneider22 General Germany 2005 6235 1.25 1.14-1.37 0 1.25 (1.14-1.37)
Nagasu26 Occupational Japan 2007 5835 1.48 1.23-1.77 0 1.34 (1.13-1.57)
Ghaffari24 Occupational Iran 2007 3838 1.18 0.95-1.47 0 1.29 (1.15-1.45)
Heistaro27 General Finland 1998 29,043 1.21 1.15-1.27 1 1.25 (1.16-1.33)
Croft25 General UK 1994 9003 1.35 1.22-1.49 1 1.27 (1.19-1.36)
Leino-Arjas28 General Finland 1998 7544 1.22 1.13-1.33 1 1.26 (1.19-1.32)
Pooled 61,498 1.26 1.19-1.32 .17 35 (0-74)
Low back pain in the past 12 months
Pietri35 Occupational France 1992 1709 1.40 1.10-1.70 0 1.40 (1.10-1.70)
Skov33 Occupational Denmark 1996 1306 1.40 1.12-1.74 0 1.40 (1.20-1.60)
Wright34 General UK 1995 24,000 1.30 1.23-1.36 1 1.31 (1.25-1.37)
Pooled 27,015 1.31 1.25-1.37 .67 0 (0-90)
Adjusted for publication bias 1.30 1.24-1.36
Seeking care for low back pain
Wright34 General UK 1995 24,000 1.35 1.26-1.44 1
Leino-Arjas28 General Finland 1998 7544 1.24 1.10-1.39 1
Pooled 31,544 1.31 1.21-1.42 .21
Chronic low back pain
Adults
Leclerc41 General France 2008 15,534 1.21 1.12-1.32 0 1.21 (1.12-1.32)
Bjrck-van Dijken43 General Sweden 2008 5798 1.29 1.11-1.49 0 1.23 (1.14-1.32)
Helivaara40 General Finland 1991 5673 1.40 1.22-1.61 0 1.28 (1.17-1.40)
Silva39 General Brazil 2004 3182 2.07 1.43-3.00 0 1.35 (1.18-1.55)
Andersson42 General Sweden 1998 1624 1.62 1.28-2.05 0 1.40 (1.22-1.60)
Pooled 31,811 1.40 1.22-1.60 .009 70 (24-88)
Adolescents
Hestbaek54 Twins Denmark 2006 9608 1.77 1.44-2.17 0
Pooled (adults adolescents) 35,621 1.47 1.27-1.69 .001 77 (48-90)
OR odds ratio; CI confidence interval.
No association was found between smoking and sickness the incidence of low back pain was symmetrical (Figure 2).
absence due to low back disorder (Table 4). Beggs test showed no evidence of publication bias
(P .16). However, Eggers test showed an evidence of a
Sex-specific Analyses possible publication bias (P .079). No missing study was
Former and current smoking was associated with increased imputed by the trim-and-fill method. When Eggers test was
prevalence of low back pain in both sexes (Tables 5-7). applied to 9 studies on 1-year incidence of low back pain,
Male former smokers had a higher incidence of low back the test showed no publication bias (P .26).
pain than never smokers. Male former smokers had a higher
prevalence of chronic low back pain and higher incidence of Sensitivity Analysis
low back pain than female former smokers. No other sex Adjusting for publication bias did not affect the association
differences were observed. between current smoking and low back pain. It attenuated
only the pooled estimate of low back pain in the past month
Publication Bias (Table 3). For ever smoking, adjustment attenuated the
The funnel plot of the cross-sectional studies on the asso- pooled estimate of chronic low back pain and for former
ciation between ever (one study) or current (26 studies) smoking, the estimates of low back pain in the past 12
smoking and any low back pain was asymmetrical (Figure months and chronic low back pain (Tables 1, 2).
2). The results suggest that some medium-sized and small In cumulative meta-analyses the pooled estimates were
studies with negative findings were not published. Both not affected by the small or low-quality studies (Tables 1-4).
Beggs (P .070) and Eggers (P .009) tests showed ev- In meta-regression, heterogeneity across studies on low
idence of publication bias. The trim-and-fill method im- back pain in the past month was not associated with the
puted 8 missing studies. study population, publication year (before or after the year
The funnel plot of the cohort studies on the association 2000), recall period of low back pain (1 to 4 weeks),
between ever (1 study) or current (12 studies) smoking and adjustment for potential confounders, the proportion of cur-
Table 2 Pooled Odds Ratios of Low Back Pain for Former Smokers versus Never Smokers among Adults, Prevalence (Cross-sectional
Studies)
Moderate Cumulative OR
First Author Population Country Year Sample OR 95% CI P Value I2 (95% CI) Biases (95% CI)

Ghaffari24 Occupational Iran 2007 3838 0.70 0.40-1.20 0 1.18 (0.92.1.50)
Croft25 General UK 1994 9003 1.33 1.16-1.53 1 1.27 (1.17-1.37)
Pooled 61,498 1.27 1.20-1.35 .39 3 (0-75)
Skov33 Occupational Denmark 1996 1306 1.51 1.09-2.10 0
Pooled 25,306 1.27 1.05-1.55 .18
Pooled 31,544 1.13 1.03-1.24 .81
Pooled 31,811 1.28 1.16-1.40 .49 0 (0-79)
rent smokers, or the presence of moderate bias. The pooled 1.23-1.41), and the incidence of low back pain in adults 1.18
estimate in occupational populations, however, was higher (95% CI, 1.02-1.36). All studies on the incidence of low
than that for studies in general populations (odds ratio [OR] back pain in adolescents controlled the obtained risk esti-
1.46 vs 1.34). There was only minor heterogeneity across mates for potential confounders.
studies published after the year 2000 (I2 8%). Country and
the prevalence of low back pain were significant determi-
nants of heterogeneity. The pooled estimate was lower in DISCUSSION
Finland than in the other countries. The pooled OR was 1.51 This meta-analysis showed an association between smoking
(95% confidence interval [CI], 1.28-1.78; I2 53%) for stud- and low back pain. The association was strongest for
ies with a prevalence of low back pain 30%, and 1.26 chronic low back pain and disabling low back pain. Former
(95% CI, 1.14-1.39; I2 59%) for studies with a prevalence of smokers were at a lower prevalence of low back pain than
low back pain 30%. current smokers. The association between smoking and the
Heterogeneity across studies on chronic low back pain incidence of low back pain was stronger in adolescents than
was not associated with publication year, the proportion of in adults.
current smokers, or the prevalence of low back pain. Study The observed association between smoking and low back
population, country, and adjustment for potential confound- pain was modest. The multifactorial etiology of low back
ers were determinants of heterogeneity. The pooled OR was pain needs to be considered in the interpretation of the
higher in Denmark (OR 2.34), in a twin population (OR findings. Most causal factors of a multifactorial disease have
2.36), and in studies that did not control the obtained OR for a relatively weak effect.100 The slight sex difference in the
physical work load factors or psychosocial factors (OR association may be due to chance.
2.79). The pooled estimate was 1.43 (95% CI, 1.21-1.70) in Some studies have reported an association between
5 studies in adults that controlled the obtained ORs for smoking and low back pain only in people with heavy
physical work load or psychosocial factors. physical work.45,62 People in physically demanding jobs
For other low back pain outcomes, the pooled estimates may smoke more. Thus, physical exposures at work could
did not differ when the meta-analyses were restricted to confound the association between smoking and low back
those studies that controlled the obtained ORs for common pain. Smokers also have a poorer mental health status than
confounders. For current smoking, the pooled estimate of nonsmokers.101 Therefore, smoking might be a surrogate
low back pain in the past month was 1.41 (95% CI, 1.23- marker of an underlying psychological problem that causes
1.63), low back pain in the past 12 months 1.31 (95% CI, low back pain. Most of the studies included in this meta-
Table 3 Pooled Odds Ratios of Low Back Pain for Current Smokers versus Never Smokers among Adults and Adolescents, Prevalence
(Cross-sectional Studies)
Moderate Cumulative OR
First Author Population Country Year Sample OR 95% CI P Value I2 (95% CI) Biases (95% CI)

Croft25 General UK 1994 9003 1.40 1.20-1.60 1 1.30 (1.17-1.45)
Brage23 General Norway 1996 6681 1.84 1.50-2.25 1 1.36 (1.21-1.52)
Miyamoto21 Occupational Japan 2008 1334 1.65 1.07-2.53 1 1.37 (1.23-1.53)
Pooled 69,513 1.37 1.23-1.53 .001 74 (47-87)
Adults
Leboeuf-Yde31 Twins Denmark 1998 29,424 1.40 1.30-1.60 0 1.40 (1.30-1.60)
Leboeuf-Yde29,30 General Denmark 1997 1370 1.30 1.00-1.60 0 1.38 (1.26-1.52)
Skov33 Occupational Denmark 1996 1306 1.31 0.98-1.76 0 1.38 (1.26-1.51)
Strine7 General US 2007 29,828 1.30 1.20-1.40 1 1.33 (1.25-1.41)
Wright34 General UK 1995 24,000 1.37 1.28-1.45 1 1.35 (1.29-1.41)
Oksuz32 General Turkey 2006 4990 1.10 0.90-1.30 1 1.33 (1.26-1.40)
Karahan37 Occupational Turkey 2009 1510 1.52 1.19-1.95 1 1.34 (1.27-1.41)
Raanaas36 Occupational Norway 2008 823 0.99 0.73-134 1 1.32 (1.24-1.40)
Pooled 93,251 1.32 1.24-1.40 .13 37 (0-72)
Adolescents
Pooled (adults adolescents) 102,748 1.33 1.26-1.41 .16 32 (0.68)
Pooled 31,544 1.49 1.38-1.60 .36
Adults
Leboeuf-Yde31 Twins Denmark 1998 29,424 3.00 2.80-3.30 0 3.00 (2.70-3.30)
Leboeuf-Yde29,30 General Denmark 1997 1370 2.30 1.60-3.30 0 1.78 (1.21-2.62)
Pooled 62,605 1.78 1.21-2.62 .001 97 (96-98)
Adolescents
Pooled (adults adolescents) 72,213 1.79 1.27-2.50 .001 97 (95-98)
Disabling low back pain
Harreby55 Children Denmark 1999 1389 3.03 2.14-4.30 0
Liira44 General Canada 1996 18,920 1.55 1.20-2.00 1
Pooled (adults adolescents) 20,309 2.14 1.11-4.13 .002
analysis, especially prospective studies, controlled for po- of causality in humans is the cohort study. We found an
tential confounders. The results remained consistent when association between smoking and the incidence of low back
meta-analyses were limited to the studies that controlled the pain. The association was stronger in adolescents than in
obtained risk estimates for physical or psychosocial work adults. Adolescents might be more vulnerable than adults to
loads. Therefore, our observed association between smok- the adverse effects of smoking.102 They also have a lower
ing and low back pain is unlikely due to workload factors or prevalence of low back pain, better enabling studies on true
individual psychological factors. incidence of low back pain.
The temporal relationship is an essential aspect of cau- The reviewed studies had some major limitations. The
sality. For cigarette smoking to be a cause of low back pain, outcomes in many studies did not include information on
it has to precede low back pain onset. A causal association the frequency and severity of low back pain, and different
between smoking and low back pain cannot be established recall periods and case definitions were used. A limited
by randomized controlled trials due to ethical restraints. number of prospective studies on the role of smoking in low
Therefore, the most feasible study design for the assessment back pain have been published. In the few studies with
Table 4 Pooled Odds Ratios of Low Back Pain for Ever, Former, or Current Smokers versus Never Smokers among Adults and
Adolescents, Incidence (Cohort Studies)
Sample Moderate Cumulative OR
First Author Population Country Year Size OR 95% CI P Value I2 (95% CI) Biases (95% CI)
Ever smoking
Andersen48 Occupational Denmark 2007 1513 1.03 0.77-1.38 0 1.03 (0.77-1.38)
Leino-Arjas47 Occupational Finland 2006 546 1.59 1.14-2.23 0 1.27 (0.83-1.94)
Miranda49 Occupational Finland 2008 1676 1.17 1.01-1.37 1 1.21 (0.99-1.48)
Pietri35 Occupational France 1992 627 1.30 0.80-2.10 1 1.21 (1.04-1.42)
Pooled 4362 1.21 1.04-1.42 .26 24 (0-88)
Sickness absence (1 day)
Hemingway50 Occupational UK 1999 4886 1.08 0.94-1.24 0 1.08 (0.94-1.24)
Van den Heuvel51 Occupational Netherlands 2004 629 0.77 0.46-1.28 1 1.25 (0.73-2.15)
Pooled 9353 1.25 0.73-2.15 .008 80 (35-94)
Former smoking
Pooled 3735 1.32 0.99-1.77 .12 52 (0-86)
Hemingway50 Occupational UK 1999 4886 1.09 0.91-1.31 0
Ghaffari24 Occupational Iran 2007 3838 0.90 0.10-7.40 0
Van den Heuvel51 Occupational Netherlands 2004 629 0.73 0.33-1.58 1
Pooled 9353 1.07 0.89-1.27 .61 0 (0-90)
Current smoking
Adults
Power46 General UK 2001 2773 1.25 1.03-1.51 1 1.20 (1.02-1.40)
Eriksen45 General Norway 1999 562 1.11 0.68-1.82 1 1.16 (1.02-1.32)
Pooled 7070 1.16 1.02-1.32 .76 0 (0-79)
Adolescents
Mikkonen57 Adolescents Finland 2008 813 1.60 1.02-2.53 0 1.60 (1.02-2.53)
Feldman6,56 Children Canada 2001 377 2.20 1.38-3.50 0 1.87 (1.35-2.59)
Mustard58 Children Canada 2005 1039 1.75 1.19-2.57 2 1.82 (1.42-2.33)
Pooled 2229 1.82 1.42-2.33 .61 0 (0-90)
Pooled (adults adolescents) 9299 1.31 1.11-1.55 .075 46 (0-76)
Hemingway50 Occupational UK 1999 4886 1.07 0.87-1.31 0 1.07 (0.87-1.31)
Van den Heuvel51 Occupational Netherlands 2004 629 0.80 0.41-1.57 1 1.34 (0.70-2.59)
Pooled 9353 1.34 0.70-2.59 .007 80 (35-94)
Sickness absence (7 days)
Hemingway50 Occupational UK 1999 4886 1.20 0.81-1.78 0
Tubach52 Occupational France 2002 2236 2.04 1.22-3.40 0
Pooled 7122 1.52 0.91-2.56 .108
detailed information on number of cigarettes smoked per pooled estimates for publication bias using the trim-and-fill
day, meta-analysis of the dose-response relationship was method, which spuriously adjusts for publication bias when
not feasible because different cut-points for number of cig- the studies are heterogeneous.103,104 The pooled estimates
arettes were used. were attenuated after adjustment for publication bias mostly
There may be a publication bias in favor of positive in the studies with moderate to high heterogeneity, suggest-
results between smoking and low back pain. Publication ing that the true positive association between smoking and
bias arises when studies with a statistically significant pos- low back pain was underestimated. Funnel plot asymmetry
itive association are more likely to be reported or published may be caused by a number of factors other than publication
than studies with a negative or null association. Language of bias.19 All statistical methods for assessment of publication
publication also influences accessibility. Publication bias is bias are unable to distinguish publication bias from other
more likely to affect small studies, which tend to show causes of funnel plot asymmetry.104 We found that the study
larger risk estimates than larger studies. We adjusted the population, year of publication, and the prevalence of low
Table 5 Pooled Odds Ratio of Low Back Pain for Ever, Former, or Current Smokers versus Never Smokers in Males
Moderate
First Author Population Country Year Sample OR 95% CI P Value I2 (95% CI) Biases
Prevalence (cross-sectional studies)

Former smoking
Nagasu26 Occupational Japan 2007 1010 1.41 0.94-2.11 0
Heistaro27 General Finland 1998 14,257 1.30 1.18-1.43 1
Croft25 General UK 1994 3905 1.45 1.15-1.83 1
Pooled 22,801 1.34 1.23-1.45 .77 0 (0-85)
Leclerc41 General France 2008 7292 1.19 1.00-1.41 0
Bjrck-van Dijken43 General Sweden 2008 2850 1.44 1.11-1.86 0
Helivaara40 General Finland 1991 2727 1.54 1.08-2.21 0
Pooled 12,869 1.31 1.12-1.54 .28 19 (0-92)
Current smoking
Croft25 General UK 1994 3905 1.29 1.12-1.74 1
Pooled 22,801 1.30 1.21-1.39 .45 0 (0-85)
Oksuz32 General Turkey 2006 2164 1.20 1.00-1.50 1
Pooled 6769 1.30 1.14-1.49 .29
Mattila38 Conscripts Finland 2008 7040 1.20 1.10-1.40 1
Pooled 10,669 1.30 1.07-1.57 .114
Pooled 12,869 1.35 1.09-1.66 .13 50 (0-85)
Incidence (Cohort studies)
Ever smoking
Andersen48 Occupational Denmark 2007 596 1.07 0.71-1.62 0
Leino-Arjas47 Occupational Finland 2006 353 1.59 1.06-2.37 0
Miranda49 Occupational Finland 2008 1541 1.20 0.97-1.49 1
Pooled 2490 1.24 1.04-1.48 .35 2 (0-90)
Former smoking
Pooled 2490 1.44 1.04-1.98 .23 31 (0-93)
Current smoking
Mikkonen57 Adolescents Finland 2008 410 1.38 0.71-2.67 0
Pooled 2900 1.11 0.88-1.41 .90 0 (0-85)
back pain were associated with heterogeneity, which sug- The mechanisms of low back pain are only partly known.
gests differences in the etiology of low back pain in differ- Smoking may lead to reduced perfusion and malnutrition of
ent countries and populations. the intervertebral discs via vasoconstriction,105 and in the
Former smokers had a lower risk of seeking care for low long run, via atherosclerosis.106-108 Impaired blood supply
back pain or chronic low back pain than current smokers, to spinal structures may cause degenerative lesions in the
suggesting that the effects of smoking may be at least partly intervertebral discs109 and interfere with healing. Smoking
reversible. We have, however, insufficient information is a risk factor for osteoporosis,110,111 which may lead to
about former smokers with regard to their exposure history, low back pain.112 Smoking increases the level of circu-
including the duration and level of exposure, and time since lating pro-inflammatory cytokines,113,114 which signal
stopping smoking. the central nervous system, leading to amplification of
Table 6 Pooled Odds Ratios of Low Back Pain for Ever, Former, or Current Smokers versus Never Smokers in Females
Moderate
First Author Population Country Year Sample OR 95% CI P Value I2 (95% CI) Biases
Prevalence (Cross-sectional studies)

Former smoking
Croft25 General UK 1994 5098 1.27 1.06-1.51 1
Pooled 28,624 1.24 1.13-1.36 .80 0 (0-85)
Pooled 14,136 1.13 0.90-1.43 .106 55 (0-87)
Current smoking
Croft25 General UK 1994 5098 1.38 1.18-1.62 1
Pooled 28,624 1.25 1.01-1.55 .001 86 (66-94)
Ghandour53 Adolescents US 2004 8250 1.40 1.10-1.90 1
Oksuz32 General Turkey 2006 2826 1.00 0.80-1.30 1
Pooled 15,968 1.27 1.02-1.57 .05 66 (0-90)
Pooled 14,136 1.20 1.06-1.36 .38 0 (0-90)
Incidence (Cohort studies)
Ever smoking
Pooled 1553 1.08 0.84-1.40 .37 0 (0-90)
Former smoking
Pooled 1553 1.03 0.71-1.48 .56 0 (0-90)
Current smoking
Adults
Mikkonen57 Adolescents Finland 2008 403 1.83 0.98-3.43 0
Pooled 1956 1.27 0.93-1.74 .44 0 (0-85)
pain.115 Smoking changes the gene expression in interver- stronger in adolescents than in adults. Research is needed to
tebral discs; it down-regulates collagen genes and up-regu- investigate whether smoking prevention or cessation is as-
lates aggrecan and the tissue inhibitor of metalloprotein- sociated with reduced incidence or severity of low back
ase-1 genes.116 pain.
CONCLUSIONS
Both current and former smokers have a higher prevalence ACKNOWLEDGMENTS
and incidence of low back pain than never smokers, but the We thank Helena Liira for her assistance in selecting rele-
association is fairly modest. The association is strongest for vant studies. We thank Johan Hviid Andersen, Christina
chronic or disabling low back pain. The association between Bjrck-van Dijken, Lise Hestbk, and Helena Miranda for
current smoking and the incidence of low back pain is sending us additional results.
Table 7 Summary of Observed Association between Smoking and Low Back Pain
All Males Females
Smoking OR 95% CI OR 95% CI OR 95% CI

Prevalence (cross-sectional studies)
Former smoking 1.27 1.20-1.35 1.34 1.23-1.45 1.24 1.13-1.36
Current smoking 1.30 1.16-1.45 1.30 1.21-1.39 1.25 1.01-1.55
Former smoking 1.20 1.00-1.44
Current smoking 1.33 1.26-1.41 1.30 1.14-1.49 1.27 1.02-1.57
Former smoking 1.13 1.03-1.24
Current smoking 1.49 1.38-1.60 1.30 1.07-1.57
Former smoking 1.24 1.11-1.38 1.31 1.12-1.54 1.13 0.90-1.43
Current smoking 1.79 1.27-2.50 1.35 1.09-1.66 1.20 1.06-1.36
Incidence (cohort studies)
Ever smoking 1.21 1.04-1.42 1.24 1.04-1.48 1.08 0.84-1.40
Former smoking 1.32 0.99-1.77 1.44 1.04-1.98 1.03 0.71-1.48
Current smoking 1.31 1.11-1.55 1.11 0.88-1.41 1.27 0.93-1.74
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Appendix 1 Quality Assessment
Type of Bias Criteria Classification

Selection bias Major No or minor: Defined target population represents the
Selection of study population general population or subgroup of the general
Representativeness (response rate, difference between population (eg, women or men, certain age group,
participants and nonparticipants, and control for geographical area, certain occupational group) and
variables in case difference found between response rate is above 60%.
participants and nonparticipants) Moderate: Defined target population represents a
Minor narrow subgroup of the general population and
Awareness of study hypothesis response rate is 80%-100%.
Possibility of change in the status of a risk factor as Severe: Defined target population represents a narrow
a result of low back pain subgroup of the general population and response
rate is 60%-80%.
Definite: Study population consists of self-selected
volunteers if suspicion of payment to nonpatients.
Performance bias Major No: Validated and systematic exposure assessment,
Validity and objectivity of exposure assessment blinding of assessors of exposure towards the
Minor outcome.
Recall bias Minor: No information on the number of cigarettes
Blinding of assessors of exposure towards the smoked per day or on the number of years smoked.
outcome Moderate: Only one dichotomized question was used
for the assessment of smoking, and never-smokers
were not distinguished from former smokers.
Definite: Nonsystematic exposure assessment,
assessors of exposure not blinded towards the
outcome.
Detection bias Major No or minor: Clear definition of outcome and
Clear definition of outcome standardized method of assessing outcome.
Minor Moderate: Clear definition of outcome and not
Standardized method of assessing outcome standardized method of assessing outcome.
Blinding of assessors of outcome towards exposure Definite: Unclear definition of outcome or
nonsystematic assessment of outcome.
Attrition bias Major No: Participation rate 50%-100% for follow-up time
Completeness of follow-up 5 years, or comparison done for lost to follow-up
Magnitude of missing data about variables of interest and less than 20% of
missing data.
Possible: Participation rate 30-50% for follow-up time
5 years, and no comparison done for lost to
follow-up about variables of interest and missing
data between 20% and 40%.
Definite: Participation rate 30% for follow-up time
5 years or more than 40% of missing data.
Shiri et al
Appendix 2 Studies Included in Meta-analyses on the Association between Smoking and Low Back Pain
Assessment of Quality: Biases
Association between Smoking and Low Back Pain

Author, Year Age Range Sample Size Adjustment for Other
and Country Study Population (Years) Sex (in Analysis) Smoking Outcome Performance Detection Attrition Results OR (95% CI) Covariates
Adults
Cross-sectional studies
Miyamoto 2008, Taxi drivers 24-79, mean Both 1334 Daily smokers vs Low back pain in the Moderate No or No OR 1.65 (1.07-2.53) History of low back pain,
Japan21 51.5 nonsmokers past 7 days minor history of other
diseases, fatigue,
sleeplessness, regular
exercise, long working
hours, burdensomeness
Schneider 2005, General 18-79 Both 6235 Never, former, occasional, Back pain during the Minor No or No OR 1.254 (1.091-1.442) for Age, sex, socioeconomic
Germany22 population current smokers past 7 days minor ex-smokers, 1.177 (0.93- status, occupational
1.488) for occasional, 1.269 factors, body mass
(1.10-1.465) for current index and
smokers psychosocial factors
Brage 1996, General 16-66 Both 6681 Never, former, current Back pain in the past 2 Minor Moderate No OR for current vs. never Sex, age, co-morbidity,
Norway23 population smokers. weeks smoking 1.84 (1.5-2.25) mental distress and
work-related physical
factors
Ghaffari 2007, Car manufacturing Not reported. 86.4% 3838 Never, former, current Low back pain in the Minor No or No OR 0.7 (0.4-1.2) for former Adjusted for age, sex,
Iran24 company majority men smokers. past 7 days minor and 1.3 (1.0-1.6) for physical work loads,
30 years current smoking psychosocial factors
and war participation
Croft 1994, General 18 or older Both 9003 (3905 Never, former, current Low back pain in the No Moderate No Overall OR for current smoking Sex-specific ORs were
UK25 population men and smokers; number of past month 1.4 (1.2-1.6). ORs for adjusted for age
5098 cigarettes per day women: 1.27 (1.06-1.51),
women) 1.38 (1.18-1.62). ORs for
men: 1.45 (1.15-1.83), 1.29
(1.12-1.74). A dose-
response relation with
number of cigarettes
smoked per day, which was
clearer for women than men.
Nagasu 2007, Professional cooks Mean 41.4 for Both, 83% 5835 (1010 Never, former, current Low back pain in the Minor No or No Overall OR for former smoking Sex-specific ORs were
Japan26 men, 47.5 women men and smokers. past month minor 1.35 (1.01-1.79), it was adjusted for age.
for women 4825 1.41 (0.94-2.11) for men Overall ORs were
women) and 1.31 (0.98-1.73) for adjusted for sex,
women. Overall OR for psychological factors,
current smoking 1.57 (1.24- height of cooking
1.98). It was 1.59 (1.15- equipment, kitchen
2.02) for men and 1.61 environment and work
(1.29-2.00) for women. activities.
87.e21
87.e22
Appendix 2 Continued
Heistaro 1998, General 30-59 Both 29,043 (men Never, former, current Low back pain in the Minor Moderate No Overall OR 1.27 (1.17-1.37) Sex, age, education,
Finland27 population 14,257, smokers. past month for former and 1.16 (1.09- income, workload,
women 1.24) for current smoking. leisure time physical
14786) Men 1.30 (1.18-1.43) and activity and BMI
1.26 (1.15-1.36). Women
1.26 (1.09-1.45) and 0.99
(0.89-1.10) for current.
Leino-Arjas General 20-64 Both 7544 (men Smoking classified 6 Back pain in the past No Moderate No An association in men only. Age, marital status,
1998, population 3629, groups: (1) never, (2) month Among 3629 men ORs: 1.46 height, BMI, mental
Finland28 women quit 12 m, (3) quit (1.19-1.80), 1.18 (0.77- stress, occupational
3915) 12 m, (4) 1.82), 1.15 (0.84-1.57), class and physical
nonregular, (5) current 1.34 (1.10-1.63) and 1.35 activity
1-20 cigarettes/day, (1.05-1.74).
(6) current 21
cigarettes/d.
Strine 2007, General 18 or older Both 29828 Current smokers vs Low back pain for at Moderate No or No OR 1.3 (1.2-1.4) Age, sex, race/ethnicity,
US7 population nonsmokers least a day in the past minor education, marital
The American Journal of Medicine, Vol 123, No 1, January 2010

3 months status, employment
status, number and
type of comorbid
condition
Leboeuf-Yde General 30-50 Both 1370 Never smokers, former Low back pain at least a No No or No OR for current smoking 1.3 Unadjusted. OR remained
1996,29 population smokers, current day or for 30 days in minor (1.0-1.6) for low back pain significant after
1997,30 smokers 1-10 cig/day, the past 12 months 1 day, 1.0 (0.7-1.3) for adjustment for age,
Denmark 11-20 cig/day, current low back pain 8-30 days. sex, marital status and
smokers 20 cig/day physical activity at
work.
Leboeuf-Yde Twins 12-41 Both 29424 Never, former, current Low back pain for 1-7 No No or No OR 1.4 (1.3-1.6) for low back Unadjusted. Results did
1998, smokers. Number of days or 8-30 days in minor pain 1-7 days, and 2.1 not change when
Denmark31 cigarettes smoked and the past 12 months (2.0-2.2) for 8-30. No dose- analysis stratified by
number of years response relations with age, sex or BMI.
smoked. number of cigarettes
smoked and number of
years smoked. Low back
pain also was high in ex-
smokers regardless of
number of years since
smoking cessation. No
association between
smoking and low back pain
in monozygotic twins.
Shiri et al

Oksuz 2006, General 18-70, mean Both 4990 (2164 Current smokers vs Low back pain for more Moderate No or No OR 1.2 (1.0-1.5) for men 1.0 Sex-specific ORs adjusted
Turkey32 population 39.5 men and nonsmokers than a day in the past minor (0.8-1.3) for women. for age, BMI,
2826 12 months Overall 1.1 (0.9-1.3) education and living
women) location. Overall OR
adjusted for above
variables and sex,
occupation and
physical stress
Skov 1996, Salespeople Mean age Both 1306 Never, former, current Low back pain in the Minor No or No OR 1.51 (1.09-2.10) for former Social contact with
Denmark33 42.0 9.9 smokers past 12 months minor and 1.31 (0.98-1.76) for colleagues, annual
years (men) current smoking driving distance,
and sedentary work,
36.5 7.8 tendency to feel
years overworked, height
(women)
Wright 1995, General 18 or older Both 38,011, Never, former, current Sciatica, lumbago or No No or Possible ORs were 1.20 (1.11-1.30), Age, sex, height, alcohol
UK34 population 23,500- smokers (pipe, cigars recurring backache in minor 1.27 (1.16-1.40), and 1.45 consumption, BMI,
24,800 for or 1-14 cigarettes/ the past 12 months (1.33-1.58). physical activity, diet,
multivariable day), current smokers living alone, and
(15 cigarettes/day) psychological
problems
Pietri 1992, Commercial Mean age 38.7 Both 1709 (men Never, former, current Low back pain in the Minor No or No OR 1.4 (1.1-1.7) for current/ Age, sex, driving,
France35 travellers, for men, 1368, smokers. past 12 months minor past smoking vs. never comfort of the car
salesperson 37.6 for women 341) smoking seat, carrying loads,
women standing, and
psychosomatic factors
Raanaas 2008, Taxi drivers Mean age 43.3 Both, 823 Often/very frequent vs Low back pain in the Moderate No or No OR 0.99 (.73-1.34) Age, sex, ethnic origin,
Norway36 majority never/seldom past 12 months minor driving hours per
were week, BMI, physical
men activity and violence
exposure
Karahan 2009, Hospital staff Mean age 28 Both, 1510 Current smokers vs Low back pain for at Moderate No or No OR 1.52 (1.19-1.95) Sex, occupation, working
Turkey37 majority nonsmokers least a day in the past minor years, exercise,
were 12 months perceived stress in
women work environment and
(69%) physical work load
factors
Leino-Arjas General 20-64 Both 7544 (3915 Smoking classified 6 Back pain with medical No Moderate No In men OR was 1.40 (1.06- Age, marital status,
1998, population men and groups: 1) never, 2) consultation in the 1.83) for current smoking height, BMI, mental
Finland28 3629 quit 12 m, 3) quit past 12 months 1-20 cigarettes/day and stress, occupational
women) 12 m, 4) nonregular, 1.54 (1.11-2.14) for current class and physical
5) current 1-20 21 cigarettes. In women activity
cigarettes/day, 6) corresponding ORs were
current 21 1.23 (0.93-1.62) and 1.69
cigarettes/d. (0.85-3.35).
87.e23
87.e24
Wright 1995, General 18 or older Both 34,141 Never, former, current Consultation for sciatica, No No or Possible ORs 1.14 (1.03-1.26), 1.49 Age, sex, height, alcohol
UK34 population (23,500- smokers (pipe, cigars lumbago or recurring minor (1.32-1.68), 1.52 (1.36- consumption, BMI,
24,800 for or 1-14 cigarettes/ backache in the past 1.70) physical activity, diet,
multivariable day), current smokers 12 months living alone, and
analysis) (15 cigarettes/day) psychological
problems
Mattila 2008, Conscripts 18-29, median Men 7040 Daily smoking, use of Lifetime low back pain Moderate No or No Age-adjusted OR 1.2 (1.1-1.4) Age
Finland38 19 smokeless tobacco prompting a visit to a minor for daily smoking. Adjusted Age, self-perceived
physician OR 1.4 (1.2-1.7) for health status,
smokeless tobacco use number of diseases
and physical activity.
Silva 2004, General 20 or older Both 3182 Never, former, current Chronic low back pain Minor No or No OR: 1.64 (0.88-3.05), 2.36 Age, sex, marital status,
Brazil39 population smokers. (pain longer than 7 minor (1.49-3.74) education, BMI, work-
weeks) related physical
factors
Helivaara General 30-64 Both 5673 (2727 Never, former, current Chronic nonspecific low No No or No OR: 1, 1.2 (1.0-1.6), 1.3 (1.0- Age, sex, physical work
1991, population men and smokers (pipe, cigars back pain minor 1.7), 1.5 (1.1-2.1). In load, occupational
Finland40 2946 or 1-19 cigarettes/ those aged 30-49, former mental stress,
women) day), current smokers and current smoking was traumatic back injury,

(20 cigarettes/day) associated with low back smoking and alcohol
pain only in men and not consumption
in women. In those aged
50-64 only smoking 20
cigarettes/day associated
with low back pain in both
men and women.
Leboeuf-Yde General 30-50 Both 1370 Never smokers, former Low back pain for more No No or No OR for current smoking 2.3 Unadjusted. OR remained
199629 and population smokers, current than 30 days in the minor (95% CI, 1.6-3.3). A dose- significant after
1997,30 smokers 1-10 cig/day, past 12 months response relation. stratifying for age,
Denmark 11-20 cig/day, current sex, marital status and
smokers 20 cig/day. physical activity at
work.
Leboeuf-Yde Twins 12-41 Both 29,424 Never, former, current Low back pain more than No No or No OR for current smoking 3.0 Unadjusted. Results did
1998, smokers. Number of 30 days in the past 12 minor (2.8-3.3). No dose-response not change when
Denmark31 cigarettes smoked and months relations with number of analysis stratified by
number of years cigarettes smoked and age, sex, or BMI.
smoked. number of years smoked.
Low back pain also was
high in ex-smokers
regardless of number of
years since smoking
cessation. No association
between smoking and low
back pain in monozygotic
twins.
Shiri et al
Leclerc 2009, General 30-69 Both 15,534 (7292 Never, former, current Low back pain more than Minor No or No OR 1.19 (1.00-1.41) and 1.24 Age, education, personal
France41 population men and smokers 30 days in the past 12 minor (1.06-1.46) for men. ORs factors, physical
8242 months 1.33 (1.11-1.60) and 1.14 constraints at work
women) (0.98-1.32) for women.
Andersson General 25-74 Both 1624 Never, former, current Chronic low back pain No No or No OR 1.66 (1.19-2.32) for former Age, sex, education,
1998, population smokers (1-9, 10-19, (moderate to severe minor and 1.58 (1.13-2.20) for socioeconomic level,
Sweden42 20 cigarettes/day) pain longer than 6 current smoking. A dose sleep disturbance,
months) radiating response relation with daily depression and high
pain to the legs smoking. work strain
Bjrck-van General 25-79 Both 5798 (2850 Never, former, current Low back pain lasted No No or No ORs were 1.44 (1.11-1.86) and Age, education, physical
Dijken 2008, population men, 2948 smokers. Number of continuously for more minor 1.17 (0.81-1.70) for men activity at work,
Sweden43 women) cigarettes smoked. than 6 months and 1.10 (0.85-1.43) and occurrence of physical
1.43 (1.07-1.92) for demanding work, low
women. physical activity
during leisure time
and BMI
Liira 1996, General 16-64 Both 18920 Nonsmokers, occasional, Long-term back problems Moderate No or No OR 1.55 (1.20-2.00) for Age, sex, occupational
Canada44 population current smokers. (serious back pain or minor smokers vs nonsmokers class, work-related
back problem led to a physical exposure
long-term health
problem or to a
limitation in activity)
Cohort studies
1-year incidence of low back pain
Eriksen 1999, General 20-72 at Both 562 Daily smokers vs Low back pain in the Moderate No or No Overall ns. OR 1.11 (0.68- Sex, age, marital status,
Norway45 population baseline, nonsmokers past 12 months minor 1.82). Interaction with physical activity, pain
4-year heavy physical work. OR of other low back pain,
follow-up low back pain 5.53 (1.93- monotonous
15.84) in smokers and 1.12 movements in the job,
(0.48-2.59) in nonsmokers and emotional
with both lifting and symptoms
standing.
87.e25
87.e26
Power 2001, General 23 at entry, Both 5781 (2773 for Smoking classified into 5 1-year incidence of back No No or Possible Only early and continued OR for early and
Great population 10-year multivariable groups: 1) never pain lasted for more minor smoking was associated continued smoking
Britain46 follow-up analysis) smoked, 2) never than a day at ages 32 with back pain OR 1.63 was adjusted for sex,
smoked moderately or to 33 (1.23-2.17). BMI, social class,
heavily (10 OR 1.03 (0.77-1.38) for early ergonomic and
cigarettes/d), 3) early and quit smoking, and 0.97 psychosocial factors.
moderate or heavy (0.59-1.59) for late ORs for early and quit
smoking (at or before initiation. smoking and for late
23 years) and cessation initiation were
by 33, 4) early unadjusted.
moderate or heavy
smoking continuing at
33 years, 5) late
initiation (started
moderate or heavy
smoking between 23
and 33).
Leino-Arjas Metal industry 18-64 at Both 544 (353 men Never, former, current Frequent local low back Minor No or No In men, OR 2.15 (1.23-3.76) Sex-specific analysis

2006, employees baseline, and 191 smokers. pain (rather often or minor for former and 1.15 (0.87- controlled for age and
Finland47 28-year women) continuously) in past 2.74) for current smoking. occupational class
follow-up 12 months In women, OR 1.63 (0.63-
4.20) and 1.60 (0.71-3.57).
Pietri 1992, Commercial Mean age 38.7 Both 627 (men 514, Never, former, current 1-year incidence of low Minor No or Possible OR 1.3 (0.8-2.1) for current/ Age, sex, driving,
France35 travelers, for men, women 113) smokers. back pain minor past smoking vs never comfort of the car
salesperson 37.6 for smoking seat, carrying loads,
women, standing, and
1-year psychosomatic factors
follow-up
Andersen 2007, Workers from Mean 45 10, Both 1513 Never, former, current Bother some to very Minor No or No ORs were 1.13 (0.62-2.05) and Age, occupational group,
Denmark48 industrial and 2-year smokers. much by low back pain minor 1.02 (0.58-1.81) for men intervention group,
service follow-up in the past 12 months and 1.01 (0.59-1.74) and lifting, standing and
companies 0.99 (0.55-1.79) for job control
women.
Miranda 2008, Forest industry 16.4-65.0 Both, 2256 (1676 for Never, former, current 1-year incidence of low Minor No or Possible An association in subjects Age, sex, heavy lifting,
Finland49 workers majority multivariable smokers. back pain 7 days minor aged 50 or older awkward postures,
were analysis) whole-body vibration,
men body mass index and
physical exercise
Sickness absence due to low back pain
Ghaffari 2007, Car manufacturing Not reported. 86.4% 3838 Never, former, current 1-year incidence of Minor No or No OR 0.9 (0.1-7.4) for former Adjusted for age, sex,
Iran24 company majority men smokers. sickness absence due minor and 3.1 (1.6-6.2) for physical work loads,
30 years to low back pain (1 current. psychosocial factors
day) and war participation
Shiri et al

Hemingway Nonindustrial civil 35-55, 4-year Both 4886 (3506 Never, former, current Sickness absence due to No No or No ns in men. A significant Age, BMI, employment
1999, servants follow-up men, 1380 smokers 15 pyrs, back pain (7 days minor association in women for grade, baseline back
England50 women) current smokers 15-29 or 7 days) sickness absence for 7 days pain
pyrs, current smokers or less.
30 pyrs
Van den Heuvel Working Not reported, Both 629 Never, former, current Sickness absence due to Minor No or Possible OR 0.73 (0.33-1.58) and 0.80 Sex, age, BMI, physical
2004, The population 3-year smokers back pain (1 days) minor (0.41-1.57) activity, work-related
Netherlands51 follow-up in the past 12 months physical load factors,
psychosocial factors
and pain
characteristics at
baseline
Tubach 2002, Workers of 35-50, 4-year Both 2236 Nonsmokers, current Low back pain for more Minor No or No ORs 1.2 (0.5-3.1) for light Sex, physical loads
France52 national follow-up smokers 1-10 cig, than 30 days and minor smoking, 1.2 (0.5-2.9) for factors, pain at
electricity and current smokers 11-20 sickness absence 8 medium and 5.5 (2.3-13.0) baseline, social
gas company cig, current smokers days in the past 12 for heavy smoking support at work,, and
21 cig. months psychological demand
Adolescents
Ghandour 2004, School children Grade 6-10 Girls 8250 Smokers vs nonsmokers Back pain at least once a Moderate No or No OR 1.4 (1.1-1.9) Age, race/ethnicity,
US53 week in the past 6 minor mothers education,
months parent support,
teacher support,
student support, bully
experience, alcohol
use, coffee intake,
physical activity
Hestbaek 2006, Twins 11-22 Both 9497 (4605 Nonsmokers, smokers 1- Low back pain in the No No or No For current smoking OR was Age and BMI
Denmark54 boys and 10 cig/day, smokers past 12 months minor 1.38 (1.17-1.63) in boys
4892 girls) 11-20 cig/day, smokers and 1.41 (1.21-1.64) in
20 cig/day girls
Hestbaek 2006, Twins 11-22 Both 9608 Nonsmokers, smokers 1- Low back pain for more No No or No OR 1.77 (1.44-2.17) for ever Sex, age, BMI and
Denmark54 10 cig/day, smokers than 30 days in the minor smoking. Smoking 4 groups: alcohol consumption
11-20 cig/day, smokers past 12 months 1, 1.38 (1.02-1.88), 2.00
20 cig/day. (1.53-2.63), 6.38 (2.66-
15.35).
Harreby 1999, School children 13-16 Both 1389 Daily smoking vs less Severe low back pain No No or No OR 3.03 (2.14-4.30) Sex and heavy job in
Denmark55 frequent smoking. (recurrent or minor leisure time
Number of cigarettes continuous pain in
smoked daily. moderate to severe
degree)
87.e27
87.e28
Cohort studies
Feldman 199956 School children 12-14 (grade Both 377 Nonsmokers, current Low back pain at least No No or No OR 2.20 (1.38-3.50) for Age, sex, height, sports
and 2001,6 7-9), 1-year smokers 1-25 once a week in the minor current vs nonsmokers. OR activity, work activity,
Canada follow-up cigarettes/week, past 6 months 2.28 (1.15-4.51) for light mental health status,
current smokers 25 to moderate smoking and high growth spurt,
cigarettes/week 3.78 (0.82-17.51) for poor abdominal
moderate to heavy strength and poor
smoking. muscular flexibility
Mikkonen 2008, Adolescents 16 at baseline, Both 813 Regular smokers vs never Low back pain in the No No or No For regular smoking OR was Parents socioeconomic
Finland57 2-year or occasional smokers, past 6 months minor 1.38 (0.71-2.67) in boys status, physical

follow-up number of cigarettes and 1.83 (0.98-3.43) in activity, body mass
per day (1-9 or over 9 girls. OR was 1.72 (0.85- index, and depressive
cigarettes/day) 3.50) for 1-9 cig/d and mood
1.71 (0.72-4.01) for 9
cig/d in boys. In girls 1.32
(0.73-2.41) and 2.80 (1.11-
7.09).
Mustard 2005, School children 4-16 at Both 1039 Nonsmokers, current Low back pain in the Minor Moderate Possible ORs 1.63 (0.92-2.91) and 1.85 Age, sex, education,
Canada58 baseline, smokers 1-9 cigarettes/ past 12 months (1.10-3.10) parental education,
21-34 at day), current smokers body mass index, job
follow-up, (10 cigarettes/day). demands, psychosocial
18-year Smoking was assessed work conditions, work
follow-up at follow-up. social support, job
satisfaction, mental
health, social support,
factional limitations
OR odds ratio; CI confidence interval; BMI body mass index; pyrs pack-years; NS non-significant.
Shiri et al
Appendix 3 Studies Not Included in Meta-analyses on the Association between Smoking and Low Back Pain
Author, Year and Age Range Sample Size Adjustment for
Country Study Population (Years) Sex (in Analysis) Smoking Outcome Selection Performance Detection Attrition Results OR (95% CI) Other Covariates

Adults
Bergenudd 1994, General 55 Both 575 (men Smokers vs nonsmokers Current back pain No or Moderate No or No ns Overweight, sleeping
Sweden59 population 323, minor minor disturbance, job
women satisfaction, and
252) occupational
workload
Ueno 1999, Construction 20-70 Men 2289 Smoking classified 4 groups: Current low back pain No or No No or No OR for any low back Unadjusted
Japan60 workers 1) never, 2) former, 3) minor minor pain: 0.95 (0.73-
current 20 cigarettes/ 1.25), 1.13 (0.87-
day, 4) current 20 1.47), 1.14
cigarettes/day (0.87-1.52).
OR for relatively severe
low back pain: 1.05
(0.71-1.58), 0.97
(0.66-1.45), 1.47
(1.00-2.16).
Kostova 2001, Operators, repair Not reported Both 898 Nonsmokers vs current Current low back pain Moderate No No No OR 0.82 (0.59-1.15) for Unadjusted
Bulgaria61 staffs, shop smokers, smoking 20 for a week or more current smoking. OR
managers, years vs. 20 years, 1.24 (0.76-2.02) for
administrators, smoking 20 cigarettes/ smoking over 20 years.
laboratory day vs 20 cigarettes/ OR 0.83 (0.43-1.57)
assistants, day for smoking over 20
other cigarettes/day.
Brynhildsen General 55-56 Women 1103 Smokers vs nonsmokers Current back pain (in No or Moderate No or No Overall no association. An Unadjusted
1998, population the past week) minor minor interaction between
Sweden62 smoking and an
occupation requiring
heavy lifting or
physical stress
(P .01)
Svensson 1983, General 40-47 Men 716 Former or current vs never Current low back pain No or Minor No or No No association. Number Unadjusted
Sweden63 population smokers; number of years or low back pain minor minor of years of smoking
of smoking occurring at least associated with severe
once a month, current pain
current severe pain
(ongoing either
daily or recurring
2 times a week)
Landry 2008, Hospital workers 20 or older Both 344 Smokers vs nonsmokers Low back pain in the Moderate Moderate No or No ns Unadjusted
Kuwait64 past 24 h minor
Lagerstrm Nursing 18-64 Women 688 Smokers vs nonsmokers Current low back Moderate Moderate No or No OR 1.17 (0.84-3.47) for Unadjusted
1995, personnel pain, severe low minor any low back pain and
Sweden65 back pain (6 on 1.07 (0.87-1.65) for
the scale of 0-9) severe low back pain.
87.e29
87.e30
Mazicioglu 2006, Pregnant women Mean age 27.1 Women 1357 Never, former, current Current low back pain Moderate Minor No or No OR .82 (0.39-1.73) for Previous pain,
Turkey66 (SD 9.9) smokers minor nonsmokers, 0.45 weight, assistant
(0.19-1.03) for former in daily activities,
smokers. Current Oswestry back
smokers were used as a pain scale.
reference group.
Miyamoto 2000, Truck drivers 19-61, mean 97% men 153 (148 Smokers vs nonsmokers Low back pain in the No or Moderate No or No OR 1.8 (0.7-4.5) Unadjusted
Japan67 age 41.6 men, 5 past month minor minor
women)
Hartvigsen Twins 70-102 Both 4484 Never, former, current Back pain, acute low No or Minor No or No ns. OR not reported Sex-specific
2003,68 smokers. back pain or lumbago minor minor unadjusted
2004,69 in the past month
Denmark
Tiwari 2003, Cotton textile 68% were 25- Not 514 Smokers vs nonsmokers Low back pain in the Moderate Moderate Moderate No OR 2.19 (1.23-3.89) Unadjusted
India70 workers 35 years reported past 6 months

Deyo 1989, US71 General 25 or older Both 10404 Never, former, current Low back pain in the No or No No or No Dose-response relations Age, education,
population smokers. Packs per day past 12 months minor minor between current level employment
classified into 5 groups of smoking and pack- status, BMI,
and pack-years into 6 years of smoking, and chronic cough,
groups. low back pain. OR 1.05 level of daily
for each increasing activity
pack-decade. In both
sexes these dose-
responses were
apparent only in those
under age 45. Smoking
cessation reduced the
risk of low back pain.
Ghaffari 2006, Car- Not reported. 96% men 10941 Smokers vs nonsmokers Low back pain in the No or Moderate No or No ns. OR not reported Adjusted for age,
Iran72 manufacturing majority past 7 days minor minor physical and
industry 30 years psychosocial
factors
Videman 2005, Nursing students Mean age 22.6 Women 174 Ever smokers vs nonsmokers Back pain in the past 12 Moderate Moderate No or No OR 1.2 (0.4-3.7) for Previous back pain,
Finland73 (SD 4.5), a months minor sudden back pain and patient handling
7.5-year 2.0 (0.7-5.9) for back skill, sit-ups,
follow-up pain other than sciatic twisted-bent work
or sudden pain. position, and
hysteria score.
Shiri et al

Niedhammer Nurses Mean age 30 Women 310 Current smokers vs Lumbar pain in the past Moderate Moderate No or No OR 1.23, not significant Age, sports
1994, France74 nonsmokers 12 months minor (CIs not reported) activities,
previous
musculoskeletal
disorders, physical
work load,
symptoms of
psychological
disorders, and
psychosocial
factors at work
Lehto 1991, Dentists 33-65, mean Both 131,42 men Smokers vs nonsmokers Low back pain in the No or Moderate No or No ns Sex-specific
Finland75 46 89 women past 12 months minor minor unadjusted
interferes with daily
activities
Alcouffe 1999, Workers of small 15-73, mean Both 6827 Smokers vs nonsmokers Low back pain in the No or Moderate No or No OR 1.15 (1.01-1.32) for Sex-specific
France76 companies 37.8 for past 12 minor minor men 1.21 (1.03-1.41) unadjusted
men 37 for months radiating for women and 1.17
women pain to the legs (1.06-1.30) overall.
Holmstrm 1992, Construction 18-65, mean Men 1773 (1772 Never, former, current Low back pain at least a No or Minor No or No OR for current smoking Unadjusted
Sweden77 workers 39.5 (12.5) men, 1 smokers day in the past 12 minor minor 1.07 (0.97-1.18).
woman) months radiating
pain to the legs.
Toroptsova 1995, Employees of 18-65, mean Both 583 Smokers vs nonsmokers. Low back pain lasting No or Moderate No or No No association. There was Unadjusted
Russia78 machine 41.2 Smokers 10 vs 10 longer than a day in minor minor a tendency toward a
building cigarettes/day the past 12 months higher low back pain
factory in the group of heavy
smokers.
Cecchi 2006, General 65 or older Both 1008 Former or current vs never Frequent low back pain No or Moderate No or No ns Unadjusted
Italy79 population smokers in the past 12 minor minor
months
Omokhodion Office workers 20-60 Both 840 Never, former, current Low back pain in the No or Minor No or No Association between Unadjusted
200280 and smokers past 12 months minor minor current smoking and
2003,81 low back pain.
Nigeria Prevalence was 57% in
current smokers vs
36% in never smokers.
OR not reported.
Jefferson 1996, Employees of an Not reported Not 306 Smokers vs nonsmokers Low back pain in the No or Moderate No or No ns Unadjusted
Canada82 aircraft engine reported past 12 months minor minor
factory
87.e31
87.e32

Kopec 2004, General 18 or older, Both 10,007 Never, former, current Consultation for a back No or Minor No or No ns. Number of years Smoking did not
Canada83 population 2-year smokers. Number of years pain lasted 6 months minor minor smoked was associated remain significant
follow-up smoked or longer. with back pain in men in the backward
in unadjusted model elimination
only. procedure.
Wijnhoven, General 20-59 Women 11428 Current vs former/never Chronic low back pain No or Moderate No or No OR 1.14 (0.98-1.32) Age, working status,
2006, the population smokers (12 weeks) in the minor minor education,
84
Netherlands past 12 months overweight,
hormonal and
reproductive
factors
Bejia 2005, Hospital 18-60, mean Both 350 Smokers vs nonsmokers Chronic low back pain Moderate Moderate No or No No association (OR not Age, sex, BMI,
Tunisia85 employees 37 (7.8) (3 months) minor reported). marital status,
sports activity,
psychological
problems, low
back pain past

medical history,
and extra
professional
activity
Hagen 2002, Working 25-59 years, a Both 24,538 Current smokers vs Disability retirement No or Moderate Moderate No OR 1.4 (1.2-1.7) Sex, age, body mass
Norway86 population 7-year nonsmokers from back pain minor index, physically
follow-up demanding work,
perceived general
health, diabetes,
angina pectoris,
and worn out
Holmstrm 1992, Construction 18-65, mean Men 1773 (1772 Never, former, current Severe low back pain No or Minor No or No OR for current smoking Unadjusted
Sweden77 workers 39.5 (12.5) men, 1 smokers. (often or very often minor minor 2.67 (2.0-3.4)
woman) for 8-30 days and
with very severe
functional
impairment)
Case control study
Videman 1995, Former elite 65 Men 937 620 Smokers vs nonsmokers Low back pain in the Moderate Moderate Moderate No OR 1.3 (CI not reported). Age
Finland87 athletes past years interfering It was statistically
(cases), with working significant.
eligible men
for military
service
(controls)
Shiri et al
Cohort studies
Symmons 1991, General 45-64 at Women 241 Current smokers vs Current back pain or No or Minor Moderate No No association. OR for Unadjusted
the population baseline, incidence, nonsmokers experienced minor incidence 0.78 (0.47-
Netherlands88 9-year 236 continuous back pain 1.30) and for
follow-up recurrent for 2 weeks during recurrence 1.03 (0.85-
follow-up 1.25)
Manninen 1995, Farmers 45-54, 12-year Both 363, 193 Never, former, current Low back pain in the Moderate No No or Possible ns. OR in men 1, 0.63 Sex-specific analyses
Finland89 follow-up men, 170 smokers. Pack-years past 12 months minor (0.22-1.78), 0.71 controlled for age,
women classified into 4 groups (0.24-2.11) height, mental
(0-7.2, 7.3-15.0, 15.1- stress, smoking,
30.0, 30.0). farm production
and occupational
class
Battie 1989, Aircraft 21-67 at Both 3020 Current smokers vs Incidence of back pain No or Moderate No or No Smoking increased the Age and sex
US90 manufacturing baseline, nonsmokers or injury minor minor incidence of back
employees 4-year problems (RR 1.4, CI
follow-up not reported)
Biering-Srensen General 30-60 at Both 920 Daily smokers vs Incidence of low back No or Moderate No or No Smoking associated with Sex, age, epigastric
1986, population baseline, nonsmokers pain in the past 12 minor minor a higher incidence of pain, colic, poor
Denmark91 1-year months, and low back pain. No health,
follow-up recurrence/persistence association with hospitalization,
recurrence or distance from
persistence low back home to work
pain.
Niedhammer Nurses Mean age 30, Women 208 Current smokers vs Lumbar pain in the past Moderate Moderate No or No ns Age, sports
1994, France74 a 5-year nonsmokers 12 months minor activities, physical
follow-up work load,
symptoms of
psychological
disorders,
psychosocial
factors at work
and commuting
Vessey 1999, Women attending 25-39 at Women 17032 Nonsmokers, smokers Referral to hospital due Moderate Moderate No or No ns Unadjusted
UK92 family baseline, to unspecified minor
planning 26-year backache
clinics follow-up
87.e33
87.e34
Adolescents
Spahn 2004, School children Mean age 14.5 Both 2368 Never, occasional, regular Low back pain in the No or No No or No A significant association. Unadjusted
Germany93 (0.7) smokers. past 3 months minor minor Prevalence of low back
pain was 32.6% in
never smokers, 34.2%
in occasional and
39.5% in regular
smokers.
Vikat, 2000 General 14-18 Both 10302 Smoking classified 6 groups: Low back pain at least No or No No or No ORs: CIs are not reported Age, sex, timing of
Finland94 population, 1) never smoked, 2) only once a week in the minor minor 1) 1 (reference group) puberty, family
adolescent once, 3) 2-50 cigarettes past 6 months 2) 1.4 (significant) background,
ever, 4) more than 50 3) 1.2 physical activity,
cigarettes ever, 5) less 4) 1.6 (significant) school enrolment
than 10 cigarettes daily, 5) 2.0 (significant) and success, long-
6) 10 or more cigarettes 6) 2.2 (significant) term illness and
daily psychosomatic

symptoms
Kristjansdottir School children 11-16 Both 2173 Smoking was measured by Recurrent back pain (at No or Minor No or No Smoking was associated Age, chronic disease
2002, how often subjects least weekly) minor minor in the univariable or handicap,
Iceland95 smoked per week model, but did not tiredness, physical
(0 never to 6 once remain significant at fitness, coffee
or more every day). the stepwise regression drink, and
model. parental support
were included in
the stepwise
model.
Bejia 2005, School children 11-19 Both 622 Smokers vs nonsmokers chronic low back pain Moderate Moderate No or No No association Unadjusted
Tunisia96 (pain lasted 3 minor
months and
occurred once a
week)
Shipp 2007, US97 Farm workers Majority 14-18 Both 306 Current use of tobacco Severe back pain in the Moderate Minor Moderate No OR 2.79 (1.23-6.31) Sex, history of back
years (cigarettes, cigars, or past 9 months (lasted injury, physical
chew) every day for 1 work load factors
weeks or resulted in and feeling tense
loss of 4 hours from or stressed or
regular activity or anxious.
resulted in medical
treatment)
Shiri et al
View publication stats

Cohort studies
Hestbaek 2006, Twins 11-22 at Both 6554 Nonsmokers, smokers 1-10 Low back pain for more No or No No or No OR 1.88 (1.32-2.69) for Sex, age, BMI and
Denmark54 baseline, cig/day, smokers 11-20 than 30 days in the minor minor current smoking. alcohol
8-year cig/day, smokers 20 past 12 months Smoking 4 groups: 1, consumption
follow-up cig/day 1.76 (1.10-2.82), 2.12
(1.30-3.46), -.
Harreby 1996, School children 14 at baseline, Both 481 Daily smoking vs less Low back pain for more No or No No or No An association between Unadjusted
Denmark98 25-year frequent smoking. than 30 days in the minor minor current smoking and
follow-up Number of cigarettes past year low back pain in men
smoked daily. only. OR not reported
Hospitalization due to low back pain
Mattila 2008, Adolescents 14-18 at Both 57408 Daily smoking vs not daily Low back pain No or Minor No or No OR 1.4 (1.1-1.7) Age, sex, family
Finland99 baseline, hospitalization minor minor composition,
14-41 at sports activities,
follow-up, timing of puberty,
average number of health
follow-up complaints,
11.1 years drinking and
(0-23 years) school success
ns nonsignificant; OR odds ratio; BMI body mass index; CI confidence interval; RR relative risk.
87.e35

Smoking and Low Back Pain

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The Association between Smoking and Low

Article in The American journal of medicine January 2010

Rahman Shiri Jaro Karppinen

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Pivi Leino-Arjas Svetlana Solovieva

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Helsinki Health Study View project

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The Association between Smoking and Low Back Pain:

KEYWORDS: Incidence; Prevalence; Publication bias; Tobacco

Figure 1 Flow chart of the search strategy and selection of studies.

Cross-sectional Studies 5 assessed a dose-response relation between the number

Low back pain in the past month

OR odds ratio; CI confidence interval.

Low back pain in the past month

OR odds ratio; CI confidence interval.

Low back pain in the past month

OR odds ratio; CI confidence interval.

OR odds ratio; CI confidence interval.

Prevalence (cross-sectional studies)

OR odds ratio; CI confidence interval.

Prevalence (Cross-sectional studies)

OR odds ratio; CI confidence interval.

All Males Females

Smoking OR 95% CI OR 95% CI OR 95% CI

Appendix 1 Quality Assessment

Type of Bias Criteria Classification

Association between Smoking and Low Back Pain

The American Journal of Medicine, Vol 123, No 1, January 2010

Association between Smoking and Low Back Pain

The American Journal of Medicine, Vol 123, No 1, January 2010

The American Journal of Medicine, Vol 123, No 1, January 2010

Association between Smoking and Low Back Pain

The American Journal of Medicine, Vol 123, No 1, January 2010

Association between Smoking and Low Back Pain

The American Journal of Medicine, Vol 123, No 1, January 2010

Association between Smoking and Low Back Pain

Seeking care for low back pain

The American Journal of Medicine, Vol 123, No 1, January 2010

The American Journal of Medicine, Vol 123, No 1, January 2010

Association between Smoking and Low Back Pain

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