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• W78931034 abstract "Editor—Law and Hacksaw’s meta-analysis of cigarette smoking, bone mineral density, and risk of hip fracture seems to be incomplete.1 At least three relevant studies,2–4 including our own,4 were not included. One of these studies,3 however, would need reanalysis of the data. In our study a random sample of 1227 premenopausal women aged 45-49 (including 311 smokers) had their bone mineral density measured with dual energy x ray absorptiometry, and several risk factors were then related to bone mineral density. This study was more than three times bigger than the largest study of premenopausal women included in the meta-analysis. Although smoking was significantly associated with low bone mineral density at all sites, this difference was abolished after adjustment for current body weight. There was, however, a suggestion of a link between low bone mineral density and smoking during pregnancy.4Using the search terms “tobacco” and “smoking” may be inefficient and lead to bias. Studies that looked at a range of risk factors for osteoporosis may not use the key words of smoking or tobacco because they were not shown to be important risk factors. Hence, Law and Hacksaw may be more likely to have identified papers that showed a negative effect of smoking on bone mass and missed those in which no association was found,3,4 thus exaggerating the risk of smoking on fracture risk. Better search terms might have included “lifestyle” or “risk factors.” Even if the conclusion of the meta-analysis is correct, women may not always follow advice to stop smoking. In a randomised trial of bone density screening among perimenopausal women, those with low bone mineral density increased their use of hormone replacement therapy to reduce their risk of fracture.5 We have re-examined our data and compared those women who thought that they had low hip bone mineral density with those who thought that they had high hip bone mineral density; there was no difference in smoking levels two years after screening (21% v 20%, respectively; 95% confidence interval of difference −10% to 12%). Hence, even among women who believed themselves to be at high risk of osteoporosis (and most women had individual preventive advice from their general practitioners as well as general lifestyle advice from the screening unit) there was no significant change in smoking patterns. Thus the meta-analysis may be prone to selection bias and overestimate the effects of smoking on risk of fracture; even women who believe that they are at high risk of fracture and who smoke may not give up." @default.
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• W78931034 title "Meta-analysis of cigarette smoking, bone mineral density, and risk of hip fracture" @default.
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• W78931034 doi "https://doi.org/10.1136/bmj.316.7136.1017" @default.
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