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Smoking and Musculoskeletal Healing

How smoking and nicotine affect bone healing, fracture union, spinal fusion, tendon and wound healing, and surgical complications — and the benefits of stopping before surgery.

Overview

Smoking significantly impairs musculoskeletal healing across diverse orthopaedic procedures, increasing risks for nonunion, implant failure, and perioperative complications. In lumbar arthrodesis, contemporary techniques and biologic augmentation may mitigate the adverse effects of smoking on radiographic fusion after combined TLIF and posterolateral (270°) arthrodesis [1]. However, in rotator cuff repair, pack-years and duration of cessation serve as independent predictors of tendon healing [2]. Heated tobacco users exhibit worse clinical outcomes regarding rotator cuff healing than nonsmokers, a profile similar to conventional cigarette smokers [5].

Smoking is associated with a higher risk for complications than smokeless tobacco use [6]. Smokeless tobacco use is associated with worse outcomes following total knee arthroplasty [6] and increased perioperative complications and revision surgery after anterior cruciate ligament reconstruction (ACLR) [16, 17]. Active smokers face an increased risk of both medical and surgical complications undergoing elective knee or hip arthroplasty [4].

Preoperative screening must account for specific forms of tobacco use to identify patients at risk. Surgeons should consider asking all patients with scaphoid fractures if they use smokeless tobacco or smoke to identify patients at risk for nonunions [3]. Preoperative screening for patients undergoing ACLR should consider specific forms of tobacco use [16, 17]. Orthopaedic surgeons should consider evaluating non-tobacco nicotine dependence within their surgical optimization protocol for total knee arthroplasty [13].

How It Works

Mechanisms of Injury: Nicotine exerts a dose-dependent effect on bone healing, bone growth, and implant integration [18]. All forms of tobacco products adversely affect rotator cuff healing, with heated tobacco use having a similar deleterious effect as cigarette smoking [14]. Heated tobacco users have worse clinical outcomes regarding rotator cuff healing compared to nonsmokers, similar to conventional cigarette smokers [5].

Spinal Fusion Outcomes: Contemporary surgical techniques and biologic augmentation may mitigate the adverse effects of smoking on radiographic fusion after combined TLIF and posterolateral lumbar (270°) arthrodesis [1]. Conversely, cigarette smoking was not associated with impaired radiographic fusion after TLIF with adjunctive posterolateral arthrodesis performed using a standardized technique [12].

Shoulder and Rotator Cuff Healing: Patient factors influencing lesser tuberosity healing in stemmed and stemless anatomic shoulder arthroplasty include tobacco use and greater body mass index [7]. Smoking is a modifiable risk factor that should be addressed to improve outcomes and reduce costs associated with complications in patients undergoing shoulder arthroplasty [10]. Pack-years and duration of smoking cessation serve as independent predictors of tendon healing after arthroscopic rotator cuff repair [2].

Arthroplasty Complications: Active smokers are at an increased risk of both medical and surgical complications during elective knee or hip arthroplasty [4]. Smokeless tobacco use is associated with higher rates of medical- and joint-related complications following primary total hip arthroplasty [11].

Extremity and Trauma Healing: Smoking is associated with higher residual pain and poorer functional outcomes at midterm follow-up after autologous osteochondral transplantation for osteochondral lesions of the talus [8]. Surgeons should include smokeless tobacco use in patient intake history to identify patients at risk for nonunions following scaphoid fractures [3]. Cessation of smoking is highly advised for meniscus repair performed in the presence of concurrent ligamentous injury to reduce factors contributing to failure [9].

What the Evidence Shows

Spinal Fusion: Contemporary techniques and biologic augmentation may mitigate the adverse effects of smoking on radiographic fusion after combined TLIF and posterolateral lumbar (270°) arthrodesis [1]. Conversely, cigarette smoking was not associated with impaired radiographic fusion after TLIF with adjunctive posterolateral arthrodesis performed using a standardized technique [12].

Shoulder Arthroplasty and Repair: Patient factors influencing lesser tuberosity healing in stemmed and stemless anatomic shoulder arthroplasty include greater BMI and tobacco use [7]. Current smokers may have poorer functional outcomes after reverse total shoulder arthroplasty compared to former smokers and nonsmokers, despite no significant difference in complication or revision surgery incidence [15]. Smoking is a modifiable risk factor that should be addressed to improve outcomes and reduce costs associated with complications and joint replacement in patients undergoing shoulder arthroplasty [10].

Rotator Cuff Repair: Pack-years and duration of cessation serve as independent predictors of tendon healing after arthroscopic rotator cuff repair [2]. Heated tobacco users have worse clinical outcomes regarding rotator cuff healing compared to nonsmokers, similar to conventional cigarette smokers [5]. Heated tobacco use has a similar deleterious effect on rotator cuff repair healing as cigarette smoking [14]. Current smokers and former smokers who quit within 6 months of rotator cuff repair are at an elevated risk of postoperative infection and revision surgery at 90 days, 1 year, and 2 years postoperatively compared with never smokers [22].

Knee Arthroplasty and Meniscus Repair: Active smokers are at an increased risk of both medical and surgical complications following elective knee or hip arthroplasty [4]. Smokeless tobacco use is associated with worse outcomes following total knee arthroplasty [6]. Smoking within 30 days of total knee arthroplasty was associated with greater postoperative pain and lower odds of achieving an acceptable pain state compared to former and never-smokers [20]. Cessation of smoking is highly advised for meniscus repair performed in the presence of concurrent ligamentous injury to reduce factors contributing to failure [9].

Hip Arthroplasty: Smokeless tobacco use is associated with higher rates of medical- and joint-related complications following primary total hip arthroplasty [11].

Other Procedures: Surgeons should ask patients with scaphoid fractures about smokeless tobacco or cigarette use to identify those at risk for nonunions [3]. Smoking is associated with higher residual pain and poorer functional outcomes at midterm follow-up after autologous osteochondral transplantation for osteochondral lesions of the talus [8]. Non-smokers were significantly more likely to achieve superior functional outcomes following ACL reconstruction compared to smokers, despite comparable graft failure rates [21].

Nicotine Dependence: Orthopaedic surgeons should consider evaluating non-tobacco nicotine dependence within their surgical optimization protocol [13].

Practical Considerations

Smoking Cessation and Optimization: Smoking is a modifiable risk factor that should be addressed to improve outcomes and reduce costs associated with complications and joint replacement in patients undergoing shoulder arthroplasty [10]. Cessation of smoking is highly advised for meniscus repair performed in the presence of concurrent ligamentous injury [9]. Orthopaedic surgeons should consider evaluating non-tobacco nicotine dependence within their surgical optimization protocol [13].

Preoperative Risk Assessment: Surgeons should ask all patients with scaphoid fractures if they use smokeless tobacco or smoke to identify patients at risk for nonunions [3]. Pack-years and duration of cessation serve as independent predictors of tendon healing after arthroscopic rotator cuff repair [2]. Patient factors that influence tuberosity healing in stemmed and stemless anatomic shoulder arthroplasty include greater BMI and tobacco use [7].

Complication Profiles by Modality: Active smokers are at an increased risk of both medical and surgical complications in elective knee or hip arthroplasty [4]. Smokeless tobacco use is associated with higher rates of medical- and joint-related complications following primary total hip arthroplasty [11]. Smokeless tobacco use is associated with increased perioperative complications and revision surgery after anterior cruciate ligament reconstruction [16, 17]. Smoking is associated with a higher risk for complications than smokeless tobacco use [6].

Outcomes by Procedure: Current smokers may have poorer functional outcomes after reverse total shoulder arthroplasty compared to former smokers and nonsmokers, despite no significant difference in complication or revision surgery incidence [15]. Heated tobacco users have worse clinical outcomes with respect to rotator cuff healing than nonsmokers, similar to conventional cigarette smokers [5]. Smokeless tobacco use is associated with worse outcomes following total knee arthroplasty [6]. Smoking is associated with higher residual pain and poorer functional outcomes at midterm follow-up after autologous osteochondral transplantation for osteochondral lesions of the talus [8].

Fusion and Technical Considerations: Contemporary techniques and biologic augmentation may mitigate the adverse effects of smoking on radiographic fusion after combined TLIF and posterolateral lumbar (270°) arthrodesis [1]. Cigarette smoking was not associated with impaired radiographic fusion after TLIF with adjunctive posterolateral arthrodesis performed using a standardized technique [12]. Current or recent smokers may benefit from an inpatient setting of minimum 2 nights for outpatient total shoulder arthroplasty [19].

Key Evidence

  • [L3] Contemporary techniques and biologic augmentation may mitigate the adverse effects of smoking in this setting. (10.1097/corr.0000000000003999)
  • [L3] Pack-years and duration of cessation serve as independent predictors of tendon healing. (10.1177/03635465261422620)
  • [L3] Surgeons should consider asking all patients with scaphoid fractures if they use smokeless tobacco or smoke and consider adding this to the patient's intake history to further identify patients at risk for nonunions. (10.5435/jaaos-d-23-00188)
  • [L1] The literature reveals that active smokers are at an increased risk of both medical and surgical complications. (10.1016/j.arth.2024.10.035)
  • [L3] Heated tobacco users, like conventional cigarette smokers, have worse clinical outcomes with respect to rotator cuff healing than nonsmokers. (10.2106/jbjs.23.00804)
  • [L3] However, smoking is associated with higher risk for complications than smokeless tobacco use. (10.1016/j.arth.2023.01.035)
  • [L3] In addition to the surgical technique, patient factors that influence tuberosity healing include a greater BMI and tobacco use. (10.3390/jcm12030834)
  • [L3] However, smoking is associated with higher residual pain and poorer functional outcomes at midterm follow-up, despite no significant differences in activity levels based on Tegner scores. (10.1186/s13018-025-06428-1)
  • [L2] Nevertheless, MAT and meniscus repair performed in the presence of concurrent ligamentous injury require reduction of factors that may contribute to failure, and cessation of smoking is highly advised. (10.1530/eor-24-0097)
  • [L1] Smoking is a modifiable risk factor that should be addressed to improve outcomes and reduce the costs associated with complications and joint replacement in patients undergoing shoulder arthroplasty. (10.1177/17585732251327368)
  • [L3] Smokeless tobacco use is associated with higher rates of medical- and joint-related complications following primary THA. (10.1016/j.arth.2023.05.041)
  • [L2] Cigarette smoking was not associated with impaired radiographic fusion after TLIF with adjunctive posterolateral arthrodesis performed using a standardized technique. (10.1097/corr.0000000000003844)
  • [L3] Orthopaedic surgeons should consider evaluating non-tobacco nicotine dependence within their surgical optimization protocol. (10.5435/jaaos-d-23-01053)
  • [L4] This novel study shows that heated tobacco use has a similar deleterious effect on rotator cuff repair healing as cigarette smoking. (10.2106/jbjs.24.00192)
  • [L3] Current smokers may have poorer functional outcomes after rTSA compared to former smokers and nonsmokers, despite the incidence of complications and revision surgery not differing significantly between cohorts. (10.1016/j.jse.2024.07.052)
  • [L3] These findings highlight the importance of considering specific forms of tobacco use in preoperative screening for patients undergoing ACLR. (10.1177/2325967125s00229)
  • [L3] These findings highlight the importance of considering specific forms of tobacco use in preoperative screening for patients undergoing ACLR. (10.1177/03635465241303487)
  • [L2] Nicotine has a dose-dependent effect on bone healing, bone growth, and implant integration, as demonstrated in various animal and in vitro studies. (10.1186/s13018-026-06733-3)
  • [L3] Current or recent smokers may benefit from an inpatient setting of minimum 2 nights. (10.1016/j.jseint.2023.07.009)
  • [L3] Smoking within 30 days of TKA was associated with greater postoperative pain and lower odds of achieving an acceptable pain state compared to former and never-smokers. (10.1016/j.arth.2026.04.018)
  • [L1] Nonetheless, non-smokers were significantly more likely to achieve superior functional outcomes following ACL reconstruction. (10.1002/ksa.70146)
  • [L3] Current smokers and former smokers who quit smoking within 6 months of rotator cuff repair are at an elevated risk of postoperative infection and revision surgery at 90 days, 1 year, and 2 years postoperatively compared with never smokers. (10.1016/j.jse.2023.03.007)

References

[1] Editor’s Spotlight/Take 5: Cigarette Smoking Was Not Associated With Lower Odds of Radiographic Fusion After Combined TLIF and Posterolateral Lumbar (270°) Arthrodesis: A CT-based Retrospective Cohort Evaluation. Clinical Orthopaedics & Related Research. 2026. DOI: 10.1097/corr.0000000000003999

[2] Duration of Smoking Cessation Needed to Achieve Retear Rates Comparable to Those of Nonsmokers After Arthroscopic Rotator Cuff Repair. The American Journal of Sports Medicine. 2026. DOI: 10.1177/03635465261422620

[3] The Snuffbox: The Effect of Smokeless Tobacco Use on Scaphoid Fracture Healing. Journal of the American Academy of Orthopaedic Surgeons. 2023. DOI: 10.5435/jaaos-d-23-00188

[4] Should Smoking Cessation Be Recommended and Required for Patients Undergoing Elective Knee or Hip Arthroplasty?. The Journal of Arthroplasty. 2025. DOI: 10.1016/j.arth.2024.10.035

[5] Heated Tobacco Products Have Detrimental Effects on Rotator Cuff Healing, Similar to Conventional Cigarettes. Journal of Bone and Joint Surgery. 2024. DOI: 10.2106/jbjs.23.00804

[6] Smokeless Tobacco Use is Associated With Worse Outcomes Following Total Knee Arthroplasty. The Journal of Arthroplasty. 2023. DOI: 10.1016/j.arth.2023.01.035

[7] Lesser Tuberosity Osteotomy Healing in Stemmed and Stemless Anatomic Shoulder Arthroplasty Is Higher with a Tensionable Construct and Affected by Body Mass Index and Tobacco Use. Journal of Clinical Medicine. 2023. DOI: 10.3390/jcm12030834

[8] Smoking is associated with inferior postoperative outcomes after autologous osteochondral transplantation for osteochondral lesions of the talus: a minimum 5-year clinical follow-up study. Journal of Orthopaedic Surgery and Research. 2025. DOI: 10.1186/s13018-025-06428-1

[9] The impact of smoking on meniscus surgery: a systematic review. EFORT Open Reviews. 2025. DOI: 10.1530/eor-24-0097

[10] Influence of smoking on shoulder arthroplasty outcomes: A meta-analysis of postoperative complications. Shoulder & Elbow. 2025. DOI: 10.1177/17585732251327368

[11] Smokeless Tobacco Use is Associated With Worse Medical and Surgical Outcomes Following Total Hip Arthroplasty. The Journal of Arthroplasty. 2024. DOI: 10.1016/j.arth.2023.05.041

[12] Cigarette Smoking Was Not Associated With Lower Odds of Radiographic Fusion After Combined TLIF and Posterolateral Lumbar (270°) Arthrodesis: A CT-based Retrospective Cohort Evaluation. Clinical Orthopaedics & Related Research. 2026. DOI: 10.1097/corr.0000000000003844

[13] Non-Tobacco Nicotine Dependence and Rates of Postoperative Complications in Total Knee Arthroplasty: A Propensity-Matched Comparison. Journal of the American Academy of Orthopaedic Surgeons. 2024. DOI: 10.5435/jaaos-d-23-01053

[14] All Forms of Tobacco Products Adversely Affect Rotator Cuff Healing. Journal of Bone and Joint Surgery. 2024. DOI: 10.2106/jbjs.24.00192

[15] The effect of smoking on outcomes of reverse total shoulder arthroplasty. Journal of Shoulder and Elbow Surgery. 2025. DOI: 10.1016/j.jse.2024.07.052

[16] Poster 132: Smokeless Tobacco Use is Associated with Increased Perioperative Complications and Revision Surgery After Anterior Cruciate Ligament Reconstruction. Orthopaedic Journal of Sports Medicine. 2025. DOI: 10.1177/2325967125s00229

[17] Association of Smokeless Tobacco Use With Perioperative Complications and Revision Surgery After Anterior Cruciate Ligament Reconstruction. The American Journal of Sports Medicine. 2025. DOI: 10.1177/03635465241303487

[18] The effect of non-tobacco nicotine on bone healing: a systematic review and application to total joint arthroplasty. Journal of Orthopaedic Surgery and Research. 2026. DOI: 10.1186/s13018-026-06733-3

[19] Smoking is an independent risk factor for complications in outpatient total shoulder arthroplasty. JSES International. 2023. DOI: 10.1016/j.jseint.2023.07.009

[20] Impact of Smoking Status on Early Outcomes and Healthcare Utilization Following Primary Total Knee Arthroplasty: A Retrospective Cohort Study. The Journal of Arthroplasty. 2026. DOI: 10.1016/j.arth.2026.04.018

[21] Tobacco's toll: Comparable anterior cruciate ligament graft failure rates and inferior functional outcomes in smokers compared to non‐smokers: A systematic review and meta‐analysis. Knee Surgery, Sports Traumatology, Arthroscopy. 2025. DOI: 10.1002/ksa.70146

[22] Does timing matter? The effect of preoperative smoking cessation on the risk of infection or revision following rotator cuff repair. Journal of Shoulder and Elbow Surgery. 2023. DOI: 10.1016/j.jse.2023.03.007

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