Effect of Secondhand Smoking, Determined by Urinary Cotinine Level on Bone Health

Ji Hyun Moon, Mi Hee Kong, Hyeon Ju Kim


Background: We evaluated the relationship between secondhand smoke (SHS) inhalation, as verifed by urinary cotinine levels, and bone health.

Methods: We analyzed the nationwide, population‑based, cross‑sectional health survey. We included 1936 men aged 50 years or older who checked bone mineral density (BMD) from the Korean National Health and Nutrition Examination Survey (2008–2010). Current smokers assessed by urinary cotinine levels higher than 500 ng/mL were excluded (n = 616). Exposure to SHS was determined using a 50 ng/mL urinary cotinine threshold.

Results: The estimated prevalence of SHS exposure in our cohort was 13.9%. After adjusting for age and body mass index (BMI), T‑scores at total femur (P < 0.001), femoral neck (P < 0.001), and lumbar spine (P = 0.004) were lower in SHS exposure versus nonexposure groups. Impaired bone health (osteopenia or osteoporosis) at femoral neck or lumbar spine was evident in 61.7% and 48.6% of SHS exposure and nonexposure cases, respectively (P = 0.004). Moreover, after adjusting for age, BMI, and health habits, the odds ratio for impaired bone health in the SHS exposure group was 1.89 (95% confdence interval: 1.31–2.74).

Conclusions: Our fndings suggest that SHS exposure, determined by urinary cotinine levels, is negatively associated with BMD and is a leading cause of impaired bone health in Korean men.

Keywords: Biomarker, bone density, cotinine, tobacco smoke pollution

Full Text:



Park EJ, Joo IW, Jang MJ, Kim YT, Oh K, Oh HJ. Prevalence of

osteoporosis in the Korean population based on Korea National

Health and Nutrition Examination Survey (KNHANES),

‑2011. Yonsei Med J 2014;55:1049‑57.

Bliuc D, Nguyen ND, Milch VE, Nguyen TV, Eisman JA,

Center JR. Mortality risk associated with low‑trauma

osteoporotic fracture and subsequent fracture in men and women.

JAMA 2009;301:513‑21.

Holt G, Smith R, Duncan K, Hutchison JD, Gregori A. Gender

differences in epidemiology and outcome after hip fracture:

Evidence from the Scottish Hip Fracture Audit. J Bone Joint

Surg Br 2008;90:480‑3.

Shetty S, Kapoor N, Naik D, Asha HS, Prabu S, Thomas N, et al.

Osteoporosis in healthy South Indian males and the influence of

life style factors and Vitamin D status on bone mineral density.

J Osteoporos 2014;2014:723238.

Schick S, Glantz S. Philip Morris toxicological experiments with

fresh sidestream smoke: More toxic than mainstream smoke. Tob

Control 2005;14:396‑404.

Comhair SA, Gaston BM, Ricci KS, Hammel J, Dweik RA,

Teague WG, et al. Detrimental effects of environmental tobacco

smoke in relation to asthma severity. PLoS One 2011;6:e18574.

Wang Y, Ji J, Liu YJ, Deng X, He QQ. Passive smoking and risk

of type 2 diabetes: A meta‑analysis of prospective cohort studies.

PLoS One 2013;8:e69915.

Glantz SA, Parmley WW. Passive smoking and heart disease.

Epidemiology, physiology, and biochemistry. Circulation


Kim YW, Lee CH, Park YS, Kim YI, Ahn CM, Kim JO, et al.

Effect of exposure to second‑hand smoke on the quality of life:

A nationwide population‑based study from South Korea. PLoS

One 2015;10:e0138731.

Kanis JA, Johnell O, Oden A, Johansson H, De Laet C,

Eisman JA, et al. Smoking and fracture risk: A meta‑analysis.

Osteoporos Int 2005;16:155‑62.

Law MR, Hackshaw AK. A meta‑analysis of cigarette smoking,

bone mineral density and risk of hip fracture: Recognition of a

major effect. BMJ 1997;315:841‑6.

Wong SL, Shields M, Leatherdale S, Malaison E, Hammond D.

Assessment of validity of self‑reported smoking status. Health

Rep 2012;23:47‑53.

Zielinska‑Danch W, Wardas W, Sobczak A, Szoltysek‑Boldys I.

Estimation of urinary cotinine cut‑off points distinguishing

non‑smokers, passive and active smokers. Biomarkers


Apseloff G, Ashton HM, Friedman H, Gerber N. The importance

of measuring cotinine levels to identify smokers in clinical trials.

Clin Pharmacol Ther 1994;56:460‑2.

Lee S, Yoon DH, Kim KN, Shin DA, Ha Y. Association between

urine cotinine levels and bone mineral density in lumbar spine

and femoral neck among adult males. Spine (Phila Pa 1976)


Khosla T, Lowe CR. Obesity and smoking habits. Br Med J


Ramp WK, Lenz LG, Galvin RJ. Nicotine inhibits collagen

synthesis and alkaline phosphatase activity, but stimulates

DNA synthesis in osteoblast‑like cells. Proc Soc Exp Biol Med


Krall EA, Dawson‑Hughes B. Smoking increases bone loss

and decreases intestinal calcium absorption. J Bone Miner Res


Ajiro Y, Tokuhashi Y, Matsuzaki H, Nakajima S, Ogawa T.

Impact of passive smoking on the bones of rats. Orthopedics


Hapidin H, Othman F, Soelaiman IN, Shuid AN, Luke DA,

Mohamed N. Negative effects of nicotine on bone‑resorbing

cytokines and bone histomorphometric parameters in male rats.

J Bone Miner Metab 2007;25:93‑8.

Brot C, Jorgensen NR, Sorensen OH. The influence of smoking

on Vitamin D status and calcium metabolism. Eur J Clin Nutr


Wilcox RG, Hughes J, Roland J. Verification of smoking history

in patients after infarction using urinary nicotine and cotinine

measurements. Br Med J 1979;2:1026‑8.

Kim KH, Lee CM, Park SM, Cho B, Chang Y, Park SG,

et al. Secondhand smoke exposure and osteoporosis in

never‑smoking postmenopausal women: The Fourth Korea

National Health and Nutrition Examination Survey. Osteoporos

Int 2013;24:523‑32.

Myong JP, Kim HR, Choi SE, Koo JW. Dose‑related effect of

urinary cotinine levels on bone mineral density among Korean

females. Osteoporos Int 2013;24:1339‑46.