The association of smoking with back pain remains controversial. Since 80 percent of mankind will develop back pain at some time during life, and since the cause of back pain is multifactorial, direct linkage to smoking is subject to debate.
Several investigators have noted a correlation between cigarette smoking and general low back pain.4 29 54 64 A dose-response relationship to cigarettes smoked and degree of pain has also been identified.25 37 Most authors agree that confounding factors such as genetic predisposition, lifestyle and occupational differences may be operating in these studies. Battie, et al, attempted to isolate the habit of smoking in a study of identical twins who were disconcordant for smoking and found an 18 percent greater incidence of disc degeneration in smokers when compared to nonsmokers. Furthermore, the distribution of disc degeneration was somewhat unusual among smokers, with a higher incidence of disc deterioration in the upper lumbar spine rather than the lower lumbar spine. This pattern suggests that systemic factors in addition to the usual mechanical factors are operating to cause disc degeneration among smokers.8
The reasons for the higher incidence of back pain among smokers is theoretical at present. Since smokers have diminished bone density, microfracturing of the vertebral bodies has been proposed.103 Repetitive damage due to the transitory increases in intradiscal pressure associated with chronic coughing also has been hypothesized.54 75 Malnutrition of the disc due to diminished blood flow and interference with oxygen transport at the cellular level are also potential mechanisms.8 37 47 Since smoking impairs fibrinolysis, fibrin deposition which leads to inflammation and scarring also has been implicated.50
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