3.18 Other conditions with possible links to smoking


Last updated: May 2021
Suggested citation: Hurley, S, Winnall, WR, Greenhalgh, EM & Winstanley, MH. 3.18 Other conditions with possible links to smoking. In Greenhalgh, EM, Scollo, MM and Winstanley, MH [editors].  Tobacco in Australia: Facts and issues. Melbourne: Cancer Council Victoria; 2021. Available from  http://www.tobaccoinaustralia.org.au/3-18-other-conditions-with-possible-links-to-smoking


This section provides information about the many other conditions (in addition to those discussed in other sections of Chapter 3) that may be associated with smoking. The list of conditions discussed in this section is comprehensive but not exhaustive; because cigarette smoke can adversely affect most, if not all, organs of the body, the list of diseases that may be caused by tobacco is still growing.

Generally, causality between smoking and the conditions discussed in this section has not been established. Before a causal link is confirmed by expert bodies such as the US Surgeon General’s office, a plausible biological mechanism and multiple prospective studies reporting the association are required. These studies need large numbers of subjects, unbiased/prospective design and controlling for confounding factors.

3.18.1 Mental illnesses

People with mood disorders or mental illness have a higher prevalence of smoking than the general population, and account for a large proportion of smokers.1, 2 In Australia, smoking rates among those with mental illness are about twice as high as for people without mental illness. Smokers are more likely than non-smokers to have anxiety,3 depression,3-7, bipolar disorder,8 bruxism (teeth clenching and grinding),9 panic attacks,10, 11 suicide attempts,3, 12 symptoms of psychosis7 and schizophrenia.13-15

The underlying reasons for the relationship between smoking and mental illness are complex, and are described in greater detail in Section 7.12. This section also summarises research on barriers to quitting (Section 7.12.4) and interventions for reducing smoking for people with mental illness (Section 7.12.5).

3.18.2 Neurological diseases

Multiple sclerosis (MS) is a disease in which the myelin sheaths surrounding nerve cells in the brain and spinal cord become damaged and are gradually destroyed, through an autoimmune process. Smoking is considered a risk factor for multiple sclerosis, as well as a number of other autoimmune diseases.16 However, the US Surgeon General’s reports on the health effects of smoking have not reported sufficient evidence for any causative statements regarding smoking and multiple sclerosis.

A 2011 meta-analysis investigating the possible association of smoking and MS pooled data on more than 3,000 cases from 14 studies.17 The study found that smokers had about 50% higher risk of MS than non-smokers. These results were supported by a review of 14 studies, also from 2011.18

Smoking has also been reported to accelerate the clinical progression of MS, and the progression of the typical disease lesions visible on magnetic resonance images.19-22 However, a review article in 2011 looking at smoking and the onset and progression of MS found that while most of the studies on onset supported a positive association, the evidence on progression was more limited and mixed.18 More recently, numerous studies have found that smokers with MS have a higher risk of disease progression or severity, including increased respiratory problems,23 reduced grey matter fraction in the brain,24 worsening disability,25, 26 greater disease severity,27 worse long-term cognitive function28 and higher frequency of relapse.29

The biological mechanisms by which smoking might be causing or worsening MS are unclear. However, evidence from basic research has led to some hypotheses regarding potential mechanisms. Smoke contains nitric oxide, which may play a role in the degradation of nerve tissue.26, 30, 31 Free radicals, cyanates, and carbon monoxide in cigarette smoke may also be toxic to nerve cells.32 Smokers experience long-term inflammation and changes to the regulation of inflammatory cells that may play a role in causing autoimmune diseases such as MS.26 People who smoke have a higher risk of cardiovascular diseases, which also increases their risk of MS progression.26, 33 Further research is necessary to test whether these effects of smoking contribute to the progression of MS.

Amyotrophic lateral sclerosis (ALS) is a progressive neurodegenerative condition; a type of motor neurone disease. ALS leads to a dramatic loss of motor function that is usually rapid and lethal. A 2010 meta-analysis of 15 case–control and five cohort studies found that smoking increased the risk of ALS in women, but not in men.34 However a 2011 pooled analysis of data from more than half a million men and more than half a million women enrolled in five prospective cohort studies in the US found that smoking increases the risk of ALS by about 40% for both men and women.35 This large study therefore strongly supports the existence of an association between smoking and ALS. The risk in smokers increased with decreasing age at smoking initiation. Smoking has also been reported to decrease survival rates in women with ALS.36 Although smokers have a higher risk of ALS, the question of whether smoking is causative for ALS remains unanswered. Two studies that have assessed this association by reducing the effects of confounding have had conflicting conclusions.37, 38

There is increasing evidence for an association between smoking and hearing loss. A case–control study in the US, which included more than 3,000 cases, found only a very small, marginally statistically significant increase in risk associated with smoking.39 A prospective study of over 50,000 Japanese people found that smokers had a 1.6-fold increased risk of hearing loss, especially at the high frequency, in a dose-response manner. Smoking cessation reduced this excess risk.40 During the Nurses’ Health study II, 2,760 cases of hearing loss were reported. Compared with never smokers in this study, the risk of hearing loss for past smokers with 20 or more pack-years of smoking was 1.30-fold higher, and the risk for current smokers was 1.21-fold higher. Similar to the Japanese cohort, the excess risk decreased with smoking cessation.41 A 2020 systematic review found that smoking sensorineural hearing loss that is more pronounced in the long term and at high frequencies.42 Smoking, therefore, may be a causal factor in hearing loss, but future research is necessary to make this conclusion.

Smoking may be a precipitating factor for migraine43, 44 and smokers may be at increased risk of developing cranial autonomic symptoms (for example, facial sweating) during an attack.45 However, there is some doubt as to whether smoking is a cause of migraines.46

An analysis of the Nurses’ Health Study II in the US reported an increased risk of seizures associated with smoking.47

3.18.3 Kidney disease

Smoking has physiological effects on the kidneys. It has been reported to increase the glomerular filtration rate,48, 49 possibly by relaxing renal arteries.48 An increased glomerular filtration rate is a sign of kidney disease. There is evidence that smoking increases the risk of developing chronic kidney disease. For example, a 10-year follow-up study of more than 100,000 Japanese people found that smoking increased the risk of developing proteinuria and renal dysfunction.50 In a prospective study of Japanese people, current smokers had a 1.39-fold increased risk of new-onset of chronic kidney disease. This association was stronger for younger smokers.51 Similar results were found in a Korean study.52 The association of smoking with end-stage kidney disease (ESKD) was examined in a retrospective study of over 23 million people using data from the Korean National Health Insurance Service.53 Current smokers had a significant 1.39-fold increased risk of developing ESKD compared to non-smokers. The risk of ESKD increased with the smoking duration, number of cigarettes smoked and the pack-years.53

A case–control study in Syria found that smokers had a higher risk of hypertensive nephropathy and diabetic nephropathy, but the risk of other types of chronic kidney disease were not increased by smoking.54 A systematic review that included nine studies of smokers found that smokers were more likely to get kidney stone disease than non-smokers.55 

3.18.4 Other conditions

Numerous studies have indicated that smokers are more likely to suffer gout, a type of inflammatory arthritis. However, there is currently little evidence that smoking is a cause of gout.56

Smokers are also 1.49-fold more likely to have suffered from major bleeding compared to non-smokers. This includes intracranial bleeding, airway bleeding, gastrointestinal bleeding and urinary bleeding.57

A study from Japan has found that women who are current or ex-smokers are more likely to suffer from overactive bladder.58  


Relevant news and research

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56. Lee YH. Assessing the causal association between smoking behavior and risk of gout using a Mendelian randomization study. Clinical Rheumatology, 2018; 37(11):3099-105. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30003442

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58. Kawahara T, Ito H, Yao M, and Uemura H. Impact of smoking habit on overactive bladder symptoms and incontinence in women. International Journal of Urology, 2020; 27(12):1078-86. Available from: https://www.ncbi.nlm.nih.gov/pubmed/32875688