🎧 Listen to this guideAudio version coming soon. Mr Sadek will read this guide for you.
Key points
- People who smoke are more likely to have low back pain and sciatica than people who have never smoked. The link is real but modest.
- Smoking is one of the lifestyle factors linked with wear and tear of the discs in the lower back.
- If you need a spinal fusion operation, smoking roughly doubles the chance that the bones fail to join, and is linked with worse recovery.
- Stopping helps. Former smokers have a lower risk than current smokers, and stopping with proper support before surgery can reduce complications.
- Free NHS stop smoking services offer one-to-one support and stop smoking medicines, and give you the best chance of quitting for good.
Smoking and back pain: is there really a link?
Most people know that smoking harms the heart and lungs. Fewer people realise it matters for the spine too. Here is what the evidence actually says, including where it is weaker than you might expect.
A meta-analysis that combined 40 studies found that current smokers were more likely than never-smokers to have had low back pain in the past month or year, and more likely to have chronic or disabling back pain.[1] People who had given up sat in the middle: more back pain than people who had never smoked, but less than people who still smoked.[1] The link was stronger in teenagers than in adults.[1]
The authors describe the association as “fairly modest”, and that is a fair summary.[1] Smoking is not the main cause of most back pain. But it is one of the few risk factors you can actually change.
Sciatica
A separate meta-analysis of 28 studies looked at sciatica, the nerve pain that travels down the leg. Current smokers had a higher risk of sciatica and of needing hospital care or surgery for a slipped (herniated) disc.[2] Former smokers had only a slightly higher risk than never-smokers, which suggests that stopping reduces, though may not completely remove, the extra risk.[2]
What does smoking do to the discs?
The discs between your vertebrae have a poor blood supply and rely on nutrients seeping in from the bone next to them. Exactly how smoking affects them is not fully understood, and most of the human evidence comes from studies that show a link rather than prove cause and effect.
A systematic review of risk factors for degenerative disc disease in the lower back listed smoking among the factors you can change, alongside a high body mass index (BMI), diabetes, high blood pressure and high cholesterol.[3] Age, family history and previous back injury also matter, and these cannot be changed.[3] Disc wear is common with age and often causes no symptoms, so this is about reducing risk rather than a guarantee either way.
Smoking and spinal surgery
This is where the evidence is strongest, and why spinal surgeons ask so much about smoking.
Some spinal operations, such as a spinal fusion, aim to make two or more vertebrae grow together into one solid bone. If that does not happen, it is called a non-union or pseudarthrosis. It can leave ongoing pain and sometimes means further surgery.
A 2022 meta-analysis of 20 studies, including more than 3,000 patients, found that smokers had nearly twice the risk of non-union after spinal fusion compared with non-smokers (risk ratio 1.91).[4] The extra risk was seen whatever type of bone graft was used, and for both single-level and multilevel fusions.[4]
A larger review published in 2026, combining 29 studies, found similar results. Smokers had a higher rate of non-union, less improvement in pain and disability scores, were less likely to return to work and, after lower back fusion, were less satisfied with the result.[5] Importantly, people who had stopped smoking at least a year before their operation did no worse than non-smokers on non-union or pain scores.[5]
If you smoke and are being considered for spinal surgery, tell your surgeon. Many spinal surgeons will strongly advise stopping before a planned fusion operation. Please be honest about vaping and other nicotine products too, so your team can give you the right advice.
Stopping before an operation
A Cochrane review of 13 trials looked at helping people stop smoking before any type of surgery.[6] Intensive programmes, starting four to eight weeks before the operation with weekly counselling and nicotine replacement therapy, made people much more likely to have stopped by the time of surgery. In two small trials they also reduced complications after surgery, including wound problems.[6] Brief advice on its own had a smaller effect on smoking and no clear effect on complications.[6] The overall quality of evidence was moderate.
The practical message: if surgery is on the cards, start getting support to stop as early as you can, and use proper help rather than relying on willpower alone.
Getting help to stop
NHS stop smoking services are free. They usually offer a one-to-one adviser, sometimes group or online sessions, and access to stop smoking treatments such as nicotine patches and gum or tablets including varenicline, cytisinicline and bupropion.[7] Support usually lasts up to 12 weeks.[7] Your GP, pharmacist or health visitor can refer you, or you can contact your local service directly.[7]
- England: Smokefree National Helpline, 0300 123 1044
- Scotland: Quit Your Way Scotland, 0800 84 84 84
- Wales: Help Me Quit, 0800 085 2219
- Northern Ireland: search for your local stop smoking service on the NHS website or ask your GP or pharmacist
The NHS also notes that there is evidence e-cigarettes can help people stop smoking. They are not available on prescription, but some local services offer a free starter pack and advice on using one to quit.[7]
Practical tips
- Set a quit date and tell people around you.
- Use a stop smoking treatment rather than going cold turkey. Your adviser can help you choose the right one, or combination, for you.
- Plan for your triggers, such as the first coffee of the day or a stressful moment, and decide in advance what you will do instead.
- A short walk can help a craving pass, and it is good for your back as well.
- If you slip up, do not give up. Many people take several attempts before they stop for good.
Will stopping help my back pain?
It may, but nobody can promise that. The studies above show associations, and many other things affect back pain, including activity, sleep, stress, work and general health. What we can say is that former smokers have less back pain and sciatica than current smokers, and do better after spinal fusion when they have stopped well beforehand.[1][2][5] Add the benefits for your heart, lungs and circulation, and stopping is one of the most useful things you can do for your long-term health.
Seek urgent medical help (A&E or 999) if you have:
- Numbness around your bottom or genitals, or new problems controlling your bladder or bowels (possible cauda equina syndrome)
- Weakness or numbness in both legs, or weakness that is getting worse
- Back pain with fever, feeling very unwell, unexplained weight loss or a history of cancer
- After spinal surgery: a red, hot or leaking wound, fever, or new or worsening leg weakness
References
- Shiri R, et al. The association between smoking and low back pain: a meta-analysis. Am J Med. 2010;123(1):87.e7-35. Link
- Shiri R, et al. The Effect of Smoking on the Risk of Sciatica: A Meta-analysis. Am J Med. 2016;129(1):64-73.e20. Link
- Hoffeld K, et al. Patient-related risk factors and lifestyle factors for lumbar degenerative disc disease: a systematic review. Neurochirurgie. 2023;69(5):101482. Link
- Nunna RS, et al. The Risk of Nonunion in Smokers Revisited: A Systematic Review and Meta-Analysis. Global Spine J. 2022;12(3):526-539. Link
- Arnold PM, et al. Adverse Impact of Smoking on Spine Fusion and Patient-Reported Outcomes: A Systematic Review and Meta-Analysis. Global Spine J. 2026;16(2):1329-1348. Link
- Thomsen T, et al. Interventions for preoperative smoking cessation. Cochrane Database Syst Rev. 2014;(3):CD002294. Link
- NHS. NHS stop smoking services help you quit. NHS website. Link
This guide is general information and is not a substitute for advice about your own situation. Please speak to your GP, physiotherapist or specialist before starting a new treatment.
Leave a comment