Smoking is a significant risk factor for future fractures, as shown by a meta-analysis of data from 59,232 participants across ten international cohorts. The study found that current smokers had a significantly increased risk of any fracture (RR=1.25; 95% CI=1.15–1.36) and osteoporotic fracture (RR=1.29; 95% CI=1.13–1.28). The risk was highest for hip fractures (RR=1.84; 95% CI=1.52–2.22), though this was slightly reduced after adjusting for bone mineral density (BMD). The risk was higher in men than in women for all fracture types, but not for hip fractures. Low BMD accounted for only 23% of the increased hip fracture risk associated with smoking. Adjustment for body mass index had a small effect on risk for all fracture outcomes. The risk of osteoporotic fracture increased with age, while the risk of hip fracture decreased with age. A smoking history was associated with a significantly increased fracture risk compared to individuals with no smoking history, though the risk ratios were lower than for current smokers. The study concludes that a history of smoking results in a fracture risk that is substantially greater than that explained by BMD measurements. This risk factor can be used in case-finding strategies on an international basis. The study highlights the importance of considering smoking as a risk factor for fractures, especially in the context of BMD and age. The findings support the inclusion of smoking as a risk factor in assessment guidelines, with different intervention thresholds for smokers and non-smokers. The study also emphasizes the need to understand the interrelationships between risk factors to develop effective intervention strategies.Smoking is a significant risk factor for future fractures, as shown by a meta-analysis of data from 59,232 participants across ten international cohorts. The study found that current smokers had a significantly increased risk of any fracture (RR=1.25; 95% CI=1.15–1.36) and osteoporotic fracture (RR=1.29; 95% CI=1.13–1.28). The risk was highest for hip fractures (RR=1.84; 95% CI=1.52–2.22), though this was slightly reduced after adjusting for bone mineral density (BMD). The risk was higher in men than in women for all fracture types, but not for hip fractures. Low BMD accounted for only 23% of the increased hip fracture risk associated with smoking. Adjustment for body mass index had a small effect on risk for all fracture outcomes. The risk of osteoporotic fracture increased with age, while the risk of hip fracture decreased with age. A smoking history was associated with a significantly increased fracture risk compared to individuals with no smoking history, though the risk ratios were lower than for current smokers. The study concludes that a history of smoking results in a fracture risk that is substantially greater than that explained by BMD measurements. This risk factor can be used in case-finding strategies on an international basis. The study highlights the importance of considering smoking as a risk factor for fractures, especially in the context of BMD and age. The findings support the inclusion of smoking as a risk factor in assessment guidelines, with different intervention thresholds for smokers and non-smokers. The study also emphasizes the need to understand the interrelationships between risk factors to develop effective intervention strategies.