In reply: On behalf of the writing group, I wish to thank Carey and Plehwe for their perceptive comment on the effects of cigarette smoking on bone health. The focus of our supplement was the prevention of fragility fractures, and unfortunately there is no evidence that smoking cessation reduces fracture rate. However, the authors are correct to emphasise the negative impact of cigarette smoking on fracture healing, bone graft incorporation and bone density, the last factor being a strong predictor of fragility fracture.

The meta-analysis that Carey and Plehwe refer to1 showed that hip bone mineral density (BMD) in current smokers was one-third of a standard deviation below that of people who had never smoked. This meta-analysis and another recent study2 showed that these effects are greatest in men and are dose-dependent. Prospective studies also show that smokers have higher rates of bone loss than non-smokers. Extrapolations from these BMD data suggest smoking increases the lifetime risk of vertebral fracture by 13% in women and 32% in men, while hip fractures are increased by 31% and 40%, respectively.

In response to the question of what steps are being taken to publicise the effects of smoking on bone health, we would like emphasise that

• further prospective studies are urgently required to assess the effect of smoking cessation on fracture risk, BMD and bone turnover; and

• the message that smoking has a negative impact on BMD should be incorporated into public education campaigns run by government and non-government organisations for both osteoporosis prevention and smoking cessation.

This area of bone health is eminently suited to successful intervention.