Open Access Research article

Smoking and primary total hip or knee replacement due to osteoarthritis in 54,288 elderly men and women

George Mnatzaganian1*, Philip Ryan23, Christopher M Reid4, David C Davidson5 and Janet E Hiller12

Author Affiliations

1 Faculty of Health Sciences, Australian Catholic University, Room 8.70, Level 8, 250 Victoria Parade, East Melbourne, Victoria, VIC, 3065, Australia

2 Discipline of Public Health, School of Population Health, The University of Adelaide, Adelaide, South Australia, Australia

3 Data Management & Analysis Centre, The University of Adelaide, Adelaide, South Australia, Australia

4 Centre of Cardiovascular Research & Education in Therapeutics, Monash University, Melbourne, Australia

5 Royal Adelaide Hospital, Emeritus consultant orthopaedic surgeon, Adelaide, South Australia, Australia

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BMC Musculoskeletal Disorders 2013, 14:262  doi:10.1186/1471-2474-14-262

Published: 5 September 2013



The reported association of smoking with risk of undergoing a total joint replacement (TJR) due to osteoarthritis (OA) is not consistent. We evaluated the independent association between smoking and primary TJR in a large cohort.


The electronic records of 54,288 men and women, who were initially recruited for the Second Australian National Blood Pressure study, were linked to the Australian Orthopaedic Association National Joint Replacement Registry to detect total hip replacement (THR) or total knee replacement (TKR) due to osteoarthritis. Competing risk regressions that accounted for the competing risk of death estimated the subhazard ratios for TJR. One-way and probabilistic sensitivity analyses were undertaken to represent uncertainty in the classification of smoking exposure and socioeconomic disadvantage scores.


An independent inverse association was found between smoking and risk of THR and TKR observed in both men and women. Compared to non-smokers, male and female smokers were respectively 40% and 30% less likely to undergo a TJR. This significant association persisted after controlling for age, co-morbidities, body mass index (BMI), physical exercise, and socioeconomic disadvantage. The overweight and obese were significantly more likely to undergo TJR compared to those with normal weight. A dose–response relationship between BMI and TJR was observed (P < 0.001). Socioeconomic status was not independently associated with risk of either THR or TKR.


The strengths of the inverse association between smoking and TJR, the temporal relationship of the association, together with the consistency in the findings warrant further investigation about the role of smoking in the pathogenesis of osteoarthritis causing TJR.

Total joint replacement; Smoking; Socioeconomic status; Exposure misclassification; Sensitivity analysis