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Smoking and Musculoskeletal Healing

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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.

Updated Sep 202622 citations
A person smoking.
Smoking narrows blood vessels and slows bone and wound healing, raising the risk of complications after surgery. Kieran Hirpara 4.0

What it is

Smoking affects more than your lungs and heart. It also slows down how well your body heals after bone, joint, tendon and ligament surgery. This page explains why, and what it means for your operation.

Nicotine, the addictive chemical in tobacco, narrows the small blood vessels that carry oxygen and nutrients to healing tissue. It has a dose-dependent effect on bone healing, bone growth and implant integration [1]. That means the more nicotine your body gets, the more it can interfere with healing. Bone needs a steady blood supply to knit together, and implants need healthy bone to bed into.

The effects show up across many types of surgery. Smokers face a higher risk of medical and surgical complications after elective hip or knee replacement [2]. After rotator cuff repair, heated tobacco products have a similar harmful effect on tendon healing as cigarettes [3]. Smokeless tobacco is linked to more complications after ACL reconstruction [4, 5] and after hip replacement [6]. For ankle and heel fracture surgery, smoking raises the risk of infection in the wound [7]. Nicotine dependence before upper arm fracture surgery carries a 60-110% increased risk of complications such as infection, wound breakdown, nonunion (a fracture that fails to heal) and reoperation [8].

The good news is that smoking is a modifiable risk factor [9, 10]. That means it is something you can change. Quitting matters. Former smokers who quit more than 6 months before rotator cuff repair show no detectable rise in infection or revision surgery compared with people who have never smoked [11]. Your doctor can talk with you about stopping, and about nicotine replacement options, well before your operation date.

Does it work?

The honest answer is that surgery can still work for smokers, but the evidence shows it often works less well. Studies of shoulder replacement found that current smokers may have poorer function afterwards than people who never smoked or who quit [12]. The rate of complications and revision surgery was similar between the groups [12]. So the implant itself may hold up, but how your shoulder feels and moves may not reach the same level.

Nicotine on its own, without tobacco, also matters. Research on shoulder replacement found that nicotine dependence from sources other than smoking was linked to more wound breakdowns and infections in the first 90 days, and more loosening and joint infections at 2 years [13]. After keyhole rotator cuff repair, people with nicotine dependence needed more follow-up cuff repairs and more procedures to free up a stiff shoulder or clean out the joint, at both 2 and 5 years [14].

The same pattern appears elsewhere. After ACL reconstruction, people who had never smoked were more likely to gain good knee function than smokers [15]. For knee replacement, smoking seems to affect the early recovery period rather than pain levels alone [16]. For fracture surgery, nicotine's effect on bone healing depends on the dose, and this has been shown in animal and laboratory studies [1]. Surgeons are advised to ask every patient with a scaphoid fracture, a small wrist bone, whether they smoke or use smokeless tobacco, because both raise the chance of the fracture failing to heal [17].

Some of this evidence is stronger than others. Much of it comes from large patient records rather than trials where people are randomly split into groups. A few findings are mixed. One study found smoking carried a higher risk of complications than smokeless tobacco after knee replacement [18], which suggests no tobacco product is clearly safe around surgery.

What this means for you is simple. Quitting before your operation gives your body the best chance to heal well, and the earlier you stop, the better.

What are the risks?

The main risks are the ones already described: slower healing, wound problems and infection. But there are some details worth knowing.

Nicotine from any source, not just cigarettes, raises the chance of wound breakdown, infection and serious spread of infection in the first 90 days after shoulder replacement [13]. It also raises the chance of the implant loosening or becoming infected at 2 years [13]. This includes nicotine from pouches, gum or other products that contain no tobacco at all.

Some risks depend on where you are having surgery. Smoking raises the risk of infection in the wound after ankle and heel bone fracture surgery [7]. After knee replacement, smoking seems to affect the early recovery period most [16]. For fractures of the scaphoid, a small bone in the wrist, both smoking and smokeless tobacco use are flagged as signs that the bone may fail to heal [17].

Not every risk is confirmed. One study of a specific type of lower spine operation found smoking did not slow bone fusion when a standard technique was used [19]. Newer techniques and bone-healing additives may offset some of smoking's effects in that setting [20]. So the picture is not the same for every operation.

The clearest risk is the one you can change. Nicotine is a modifiable risk factor in rotator cuff surgery [10]. Quitting more than 6 months before rotator cuff repair shows no detectable rise in infection or revision surgery compared with people who have never smoked [11].

Is it right for you?

There is no simple yes or no here. Smoking does not rule you out of surgery, but it changes the conversation you and your doctor need to have. The evidence shows that tobacco and nicotine affect healing across many operations, from wrist fractures to shoulder and knee replacements. So the question is less about whether you can have surgery, and more about how to give your body the best chance of healing well.

That is why screening matters. Surgeons are advised to ask every patient with a scaphoid fracture whether they smoke or use smokeless tobacco [17], and to ask about all forms of tobacco use before ACL reconstruction [4, 5]. Nicotine from sources other than tobacco is part of that check too [21]. If you use any of these, telling your doctor early means you can plan around it, including quitting well before your operation date.

Some situations need extra care. If you are a current or recent smoker having shoulder replacement, research suggests a hospital stay of at least 2 nights may help in the early recovery period [22]. And after knee replacement, smoking seems to affect the early recovery most [16], so closer follow-up in those first weeks can make a difference.

This is a shared decision. Bring up your smoking or nicotine use honestly, ask what it means for your specific operation, and weigh the risks described in the section above against the benefit you hope to gain. Your doctor can help you decide on timing, and whether quitting first makes sense for you.

The bottom line

If you smoke or use nicotine in any form, it is worth stopping before your operation. Quitting is the one risk factor you can change, and the earlier you stop, the better. Surgery can still work for smokers, but your body gets a better chance to heal without nicotine slowing it down. The main caveat: nicotine from any source, including pouches and gum, affects healing too, so stopping tobacco alone may not be enough.

Reviewed by Kieran Hirpara · 13 June 2026.

Want the clinical detail? Read the clinician version.

Talk to your treating clinician for advice specific to you.

For an appointment with the CQ Hand + Upper Limb team, ask your GP about a referral or visit www.cqupperlimb.com.

References
  1. 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. 10.1186/s13018-026-06733-3
  2. Should Smoking Cessation Be Recommended and Required for Patients Undergoing Elective Knee or Hip Arthroplasty?. *The Journal of Arthroplasty*. 2025. 10.1016/j.arth.2024.10.035
  3. All Forms of Tobacco Products Adversely Affect Rotator Cuff Healing. *Journal of Bone and Joint Surgery*. 2024. 10.2106/jbjs.24.00192
  4. 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. 10.1177/2325967125s00229
  5. Association of Smokeless Tobacco Use With Perioperative Complications and Revision Surgery After Anterior Cruciate Ligament Reconstruction. *The American Journal of Sports Medicine*. 2025. 10.1177/03635465241303487
  6. Smokeless Tobacco Use is Associated With Worse Medical and Surgical Outcomes Following Total Hip Arthroplasty. *The Journal of Arthroplasty*. 2024. 10.1016/j.arth.2023.05.041
  7. Adverse effect of smoking on surgical site infection following ankle and calcaneal fracture fixation: a meta-analysis. *EFORT Open Reviews*. 2024. 10.1530/EOR-23-0139
  8. The impact of nicotine dependence on postoperative complications following humeral shaft fracture repair. *JSES Reviews, Reports, and Techniques*. 2026. 10.1016/j.xrrt.2026.100732
  9. Influence of smoking on shoulder arthroplasty outcomes: A meta-analysis of postoperative complications. *Shoulder & Elbow*. 2025. 10.1177/17585732251327368
  10. Editorial Commentary : Tobacco or Not—All Nicotine Products Negatively Impact Rotator Cuff Surgery. *Arthroscopy*. 2026. 10.1002/arj.70199
  11. 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. 10.1016/j.jse.2023.03.007
  12. The effect of smoking on outcomes of reverse total shoulder arthroplasty. *Journal of Shoulder and Elbow Surgery*. 2025. 10.1016/j.jse.2024.07.052
  13. Nontobacco Nicotine Dependence and Rates of Periprosthetic Joint Infection and Other Postoperative Complications in Shoulder Arthroplasty: A Retrospective Analysis. *Journal of the American Academy of Orthopaedic Surgeons*. 2024. 10.5435/jaaos-d-24-00706
  14. Nontobacco Nicotine Dependence Is Associated With Perioperative Complications and Repeat Surgery After Arthroscopic Rotator Cuff Repair. *Arthroscopy*. 2026. 10.1002/arj.70189
  15. 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. 10.1002/ksa.70146
  16. Impact of Smoking Status on Early Outcomes and Healthcare Utilization Following Primary Total Knee Arthroplasty: A Retrospective Cohort Study. *The Journal of Arthroplasty*. 2026. 10.1016/j.arth.2026.04.018
  17. The Snuffbox: The Effect of Smokeless Tobacco Use on Scaphoid Fracture Healing. *Journal of the American Academy of Orthopaedic Surgeons*. 2023. 10.5435/jaaos-d-23-00188
  18. Smokeless Tobacco Use is Associated With Worse Outcomes Following Total Knee Arthroplasty. *The Journal of Arthroplasty*. 2023. 10.1016/j.arth.2023.01.035
  19. 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. 10.1097/corr.0000000000003844
  20. 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. 10.1097/corr.0000000000003999
  21. 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. 10.5435/jaaos-d-23-01053
  22. Smoking is an independent risk factor for complications in outpatient total shoulder arthroplasty. *JSES International*. 2023. 10.1016/j.jseint.2023.07.009
Evidence & references

This is the clinical evidence summary written for health professionals. It is technical, and it lists the research this page was built from. You do not need to read it to understand your treatment or to make a decision about it.

Overview

  • Contemporary techniques and biologic augmentation may mitigate the adverse effects of smoking on radiographic fusion after combined TLIF and posterolateral lumbar arthrodesis [1].
  • Heated tobacco use has a similar deleterious effect on rotator cuff repair healing as cigarette smoking [2].
  • Pack-years and duration of cessation serve as independent predictors of tendon healing after arthroscopic rotator cuff repair [3].
  • Surgeons should consider asking all patients with scaphoid fractures if they use smokeless tobacco or smoke to identify patients at risk for nonunions [4].
  • Active smokers are at an increased risk of both medical and surgical complications following elective knee or hip arthroplasty [5].
  • Patient factors that influence lesser tuberosity osteotomy healing in stemmed and stemless anatomic shoulder arthroplasty include a greater BMI and tobacco use [6].
  • Heated tobacco users have worse clinical outcomes with respect to rotator cuff healing than nonsmokers, similar to conventional cigarette smokers [7].
  • Smoking is associated with a higher risk for complications than smokeless tobacco use following total knee arthroplasty [8].
  • Current smokers may have poorer functional outcomes after reverse total shoulder arthroplasty compared to former smokers and nonsmokers, despite no significant differences in the incidence of complications and revision surgery between cohorts [9].
  • Smokeless tobacco use is associated with increased perioperative complications and revision surgery after anterior cruciate ligament reconstruction [10, 11].
  • 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, despite no significant differences in activity levels based on Tegner scores [12].
  • Cessation of smoking is highly advised for medial meniscus allograft transplantation and meniscus repair performed in the presence of concurrent ligamentous injury [13].
  • 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 [14].
  • Smokeless tobacco use is associated with higher rates of medical- and joint-related complications following primary total hip arthroplasty [15].
  • Orthopaedic surgeons should consider evaluating non-tobacco nicotine dependence within their surgical optimization protocol for total knee arthroplasty [16].

How It Works

  • Tobacco use is a patient factor that influences lesser tuberosity osteotomy healing in stemmed and stemless anatomic shoulder arthroplasty [6].
  • Heated tobacco users have worse clinical outcomes with respect to rotator cuff healing than nonsmokers [7].
  • Current smokers may have poorer functional outcomes after reverse total shoulder arthroplasty compared to former smokers and nonsmokers [9].
  • 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 [12].
  • Cessation of smoking is highly advised for meniscus repair performed in the presence of concurrent ligamentous injury [13].
  • Smoking is a modifiable risk factor that should be addressed to improve outcomes and reduce costs associated with complications in patients undergoing shoulder arthroplasty [14].
  • Cigarette smoking was not associated with impaired radiographic fusion after TLIF with adjunctive posterolateral arthrodesis performed using a standardized technique [17].
  • Former smokers who quit more than 6 months prior to rotator cuff repair are not at a detectably elevated risk of infection or revision surgery compared with those who have never smoked [18].
  • Smoking may primarily affect the early recovery trajectory rather than pain-related outcomes alone following primary total knee arthroplasty [19].
  • Nicotine has a dose-dependent effect on bone healing, bone growth, and implant integration [20].
  • Nicotine use is a modifiable risk factor in rotator cuff surgery [21].
  • Smoking has a negative effect on anatomical total shoulder arthroplasty functional outcomes that may persist even after quitting [22].
  • Nicotine dependence prior to surgical fixation of humeral shaft fractures is associated with a 60-110% increased risk for surgical complications including postoperative infection, wound disruption, nonunion and reoperation [23].
  • Nontobacco nicotine dependence is associated with higher 90-day rates of wound disruptions, infections, sepsis, as well as increased rates of mechanical loosening and prosthetic joint infection at 2 years postoperatively after shoulder arthroplasty [24].
  • Smoking is a significant risk factor for surgical site infection following ankle and calcaneal fracture fixation [26].

What the Evidence Shows

Spine and Arthrodesis

Shoulder and Rotator Cuff

  • Patient factors that influence lesser tuberosity osteotomy healing in anatomic shoulder arthroplasty include a greater BMI and tobacco use [6].
  • The incidence of complications and revision surgery after reverse total shoulder arthroplasty does not differ significantly between current smokers, former smokers, and nonsmokers [9].
  • At 2 and 5 years, nontobacco nicotine dependence showed increased odds of subsequent cuff repair and manipulation under anesthesia or debridement versus controls after arthroscopic rotator cuff repair [30].

Knee and Hip Arthroplasty

  • Smokeless tobacco use is associated with worse outcomes following total knee arthroplasty [8].
  • Differences in follow-up communication suggest that smoking may primarily affect the early recovery trajectory rather than pain-related outcomes alone following primary total knee arthroplasty [19].

Ligament Reconstruction

  • Smokeless tobacco use is associated with perioperative complications and revision surgery after anterior cruciate ligament reconstruction [11].
  • Non-smokers were significantly more likely to achieve superior functional outcomes following ACL reconstruction compared to smokers [28].
  • Anterior cruciate ligament graft failure rates are comparable between smokers and non-smokers [28].

Fractures and Bone Healing

  • Cannabis and nicotine use were independently associated with increased postoperative complications following fixation of upper extremity fractures compared with matched non-user controls [29].
  • Nicotine has a dose-dependent effect on bone healing, bone growth, and implant integration, as demonstrated in various animal and in vitro studies [20].

Cartilage and Meniscus

  • There are no significant differences in activity levels based on Tegner scores between smokers and non-smokers after autologous osteochondral transplantation for osteochondral lesions of the talus [12].

Practical Considerations

Preoperative Screening and Risk Assessment

  • Surgeons should ask all patients with scaphoid fractures about smokeless tobacco or smoking use and add this to the intake history to identify patients at risk for nonunions [4].
  • Specific forms of tobacco use should be considered in preoperative screening for patients undergoing anterior cruciate ligament reconstruction [10, 11].
  • Orthopaedic surgeons should consider evaluating non-tobacco nicotine dependence within their surgical optimization protocol [16].
  • 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 [14].

Cessation Timing and Duration

Impact on Healing and Outcomes

  • Smoking is associated with higher risk for complications than smokeless tobacco use following total knee arthroplasty [8].
  • Current smokers may have poorer functional outcomes after reverse total shoulder arthroplasty compared to former smokers and nonsmokers, despite no significant differences in the incidence of complications and revision surgery [9].
  • Patient factors that influence lesser tuberosity healing in stemmed and stemless anatomic shoulder arthroplasty include a greater body mass index and tobacco use [6].
  • Smoking is an independent risk factor for complications in outpatient total shoulder arthroplasty [27].

Mitigation and Management

  • Cessation of smoking is highly advised for meniscus repair performed in the presence of concurrent ligamentous injury to reduce factors that may contribute to failure [13].
  • Current or recent smokers undergoing total shoulder arthroplasty may benefit from an inpatient setting of minimum 2 nights [27].
  • Nicotine use is a modifiable risk factor, and using research to guide patients on the safest path to recovery is impactful for rotator cuff surgery [21].

Key Evidence

  • [L3] Contemporary techniques and biologic augmentation may mitigate the adverse effects of smoking in this setting. [1] (10.1097/corr.0000000000003999)
  • [L4] This novel study shows that heated tobacco use has a similar deleterious effect on rotator cuff repair healing as cigarette smoking. [2] (10.2106/jbjs.24.00192)
  • [L3] Pack-years and duration of cessation serve as independent predictors of tendon healing. [3] (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. [4] (10.5435/jaaos-d-23-00188)
  • [L1] The literature reveals that active smokers are at an increased risk of both medical and surgical complications. [5] (10.1016/j.arth.2024.10.035)
  • [L3] In addition to the surgical technique, patient factors that influence tuberosity healing include a greater BMI and tobacco use. [6] (10.3390/jcm12030834)
  • [L3] Heated tobacco users, like conventional cigarette smokers, have worse clinical outcomes with respect to rotator cuff healing than nonsmokers. [7] (10.2106/jbjs.23.00804)
  • [L3] However, smoking is associated with higher risk for complications than smokeless tobacco use. [8] (10.1016/j.arth.2023.01.035)
  • [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. [9] (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] (10.1177/2325967125s00229)
  • [L3] These findings highlight the importance of considering specific forms of tobacco use in preoperative screening for patients undergoing ACLR. [11] (10.1177/03635465241303487)
  • [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. [12] (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. [13] (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. [14] (10.1177/17585732251327368)
  • [L3] Smokeless tobacco use is associated with higher rates of medical- and joint-related complications following primary THA. [15] (10.1016/j.arth.2023.05.041)
  • [L3] Orthopaedic surgeons should consider evaluating non-tobacco nicotine dependence within their surgical optimization protocol. [16] (10.5435/jaaos-d-23-01053)
  • [L2] Cigarette smoking was not associated with impaired radiographic fusion after TLIF with adjunctive posterolateral arthrodesis performed using a standardized technique. [17] (10.1097/corr.0000000000003844)
  • [L3] Former smokers who quit >6 months prior to rotator cuff repair are not at a detectably elevated risk of infection or revision surgery compared with those who have never smoked. [18] (10.1016/j.jse.2023.03.007)
  • [L3] Differences in follow-up communication suggest that smoking may primarily affect the early recovery trajectory rather than pain-related outcomes alone. [19] (10.1016/j.arth.2026.04.018)
  • [L2] Nicotine has a dose-dependent effect on bone healing, bone growth, and implant integration, as demonstrated in various animal and in vitro studies. [20] (10.1186/s13018-026-06733-3)
  • [L5] It highlights that nicotine use is a modifiable risk factor and that using research to guide patients on the safest path to recovery is impactful. [21] (10.1002/arj.70199)
  • [L3] Smoking has a negative effect on anatomical total shoulder arthroplasty functional outcomes that may persist even after quitting. [22] (10.1302/0301-620x.106b11.bjj-2024-0202.r1)
  • [L3] Nicotine dependence prior to surgical fixation of humeral shaft fractures is associated with a 60-110% increased risk for surgical complications including postoperative infection, wound disruption, nonunion and reoperation. [23] (10.1016/j.xrrt.2026.100732)
  • [L3] Nontobacco nicotine dependence is associated with higher 90-day rates of wound disruptions, infections, sepsis, as well as increased rates of mechanical loosening and prosthetic joint infection at 2 years postoperatively after shoulder arthroplasty. [24] (10.5435/jaaos-d-24-00706)
  • [L1] Smoking is a significant risk factor for surgical site infection following ankle and calcaneal fracture fixation. [26] (10.1530/EOR-23-0139)
  • [L3] Current or recent smokers may benefit from an inpatient setting of minimum 2 nights. [27] (10.1016/j.jseint.2023.07.009)
  • [L1] Nonetheless, non-smokers were significantly more likely to achieve superior functional outcomes following ACL reconstruction. [28] (10.1002/ksa.70146)
  • [L3] Cannabis and nicotine use were independently associated with increased postoperative complications following fixation of upper extremity fractures compared with matched non-user controls. [29] (10.1186/s13018-025-06635-w)
  • [L3] At 2 and 5 years, NTND showed increased odds of subsequent cuff repair and manipulation under anesthesia or debridement versus controls. [30] (10.1002/arj.70189)

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

[3] 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

[4] 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

[5] 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

[6] 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

[7] 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

[8] 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

[9] 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

[10] 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

[11] 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

[12] 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

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

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

[15] 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

[16] 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

[17] 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

[18] 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

[19] 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

[20] 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

[21] Editorial Commentary : Tobacco or Not—All Nicotine Products Negatively Impact Rotator Cuff Surgery. Arthroscopy. 2026. DOI: 10.1002/arj.70199

[22] The effect of smoking on functional outcomes and implant survival of anatomical total shoulder arthroplasty. The Bone & Joint Journal. 2024. DOI: 10.1302/0301-620x.106b11.bjj-2024-0202.r1

[23] The impact of nicotine dependence on postoperative complications following humeral shaft fracture repair. JSES Reviews, Reports, and Techniques. 2026. DOI: 10.1016/j.xrrt.2026.100732

[24] Nontobacco Nicotine Dependence and Rates of Periprosthetic Joint Infection and Other Postoperative Complications in Shoulder Arthroplasty: A Retrospective Analysis. Journal of the American Academy of Orthopaedic Surgeons. 2024. DOI: 10.5435/jaaos-d-24-00706

[26] Adverse effect of smoking on surgical site infection following ankle and calcaneal fracture fixation: a meta-analysis. EFORT Open Reviews. 2024. DOI: 10.1530/EOR-23-0139

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

[28] 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

[29] Cannabis and nicotine use are independently associated with adverse surgical, medical, and psychosocial outcomes following upper extremity fracture fixation. Journal of Orthopaedic Surgery and Research. 2026. DOI: 10.1186/s13018-025-06635-w

[30] Nontobacco Nicotine Dependence Is Associated With Perioperative Complications and Repeat Surgery After Arthroscopic Rotator Cuff Repair. Arthroscopy. 2026. DOI: 10.1002/arj.70189

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Creative Commons public licenses provide a standard set of terms and conditions that creators and other rights holders may use to share original works of authorship and other material subject to copyright and certain other rights specified in the public license below. The following considerations are for informational purposes only, are not exhaustive, and do not form part of our licenses.

Considerations for licensors: Our public licenses are intended for use by those authorized to give the public permission to use material in ways otherwise restricted by copyright and certain other rights. Our licenses are irrevocable. Licensors should read and understand the terms and conditions of the license they choose before applying it. Licensors should also secure all rights necessary before applying our licenses so that the public can reuse the material as expected. Licensors should clearly mark any material not subject to the license. This includes other CC- licensed material, or material used under an exception or limitation to copyright. More considerations for licensors: wiki.creativecommons.org/Considerations_for_licensors

Considerations for the public: By using one of our public licenses, a licensor grants the public permission to use the licensed material under specified terms and conditions. If the licensor's permission is not necessary for any reason--for example, because of any applicable exception or limitation to copyright--then that use is not regulated by the license. Our licenses grant only permissions under copyright and certain other rights that a licensor has authority to grant. Use of the licensed material may still be restricted for other reasons, including because others have copyright or other rights in the material. A licensor may make special requests, such as asking that all changes be marked or described. Although not required by our licenses, you are encouraged to respect those requests where reasonable. More considerations for the public: wiki.creativecommons.org/Considerations_for_licensees

Creative Commons Attribution-NonCommercial 4.0 International Public License

By exercising the Licensed Rights (defined below), You accept and agree to be bound by the terms and conditions of this Creative Commons Attribution-NonCommercial 4.0 International Public License ("Public License"). To the extent this Public License may be interpreted as a contract, You are granted the Licensed Rights in consideration of Your acceptance of these terms and conditions, and the Licensor grants You such rights in consideration of benefits the Licensor receives from making the Licensed Material available under these terms and conditions.

Section 1 -- Definitions.

a. Adapted Material means material subject to Copyright and Similar Rights that is derived from or based upon the Licensed Material and in which the Licensed Material is translated, altered, arranged, transformed, or otherwise modified in a manner requiring permission under the Copyright and Similar Rights held by the Licensor. For purposes of this Public License, where the Licensed Material is a musical work, performance, or sound recording, Adapted Material is always produced where the Licensed Material is synched in timed relation with a moving image.

b. Adapter's License means the license You apply to Your Copyright and Similar Rights in Your contributions to Adapted Material in accordance with the terms and conditions of this Public License.

c. Copyright and Similar Rights means copyright and/or similar rights closely related to copyright including, without limitation, performance, broadcast, sound recording, and Sui Generis Database Rights, without regard to how the rights are labeled or categorized. For purposes of this Public License, the rights specified in Section 2(b)(1)-(2) are not Copyright and Similar Rights.

d. Effective Technological Measures means those measures that, in the absence of proper authority, may not be circumvented under laws fulfilling obligations under Article 11 of the WIPO Copyright Treaty adopted on December 20, 1996, and/or similar international agreements.

e. Exceptions and Limitations means fair use, fair dealing, and/or any other exception or limitation to Copyright and Similar Rights that applies to Your use of the Licensed Material.

f. Licensed Material means the artistic or literary work, database, or other material to which the Licensor applied this Public License.

g. Licensed Rights means the rights granted to You subject to the terms and conditions of this Public License, which are limited to all Copyright and Similar Rights that apply to Your use of the Licensed Material and that the Licensor has authority to license.

h. Licensor means the individual(s) or entity(ies) granting rights under this Public License.

i. NonCommercial means not primarily intended for or directed towards commercial advantage or monetary compensation. For purposes of this Public License, the exchange of the Licensed Material for other material subject to Copyright and Similar Rights by digital file-sharing or similar means is NonCommercial provided there is no payment of monetary compensation in connection with the exchange.

j. Share means to provide material to the public by any means or process that requires permission under the Licensed Rights, such as reproduction, public display, public performance, distribution, dissemination, communication, or importation, and to make material available to the public including in ways that members of the public may access the material from a place and at a time individually chosen by them.

k. Sui Generis Database Rights means rights other than copyright resulting from Directive 96/9/EC of the European Parliament and of the Council of 11 March 1996 on the legal protection of databases, as amended and/or succeeded, as well as other essentially equivalent rights anywhere in the world.

l. You means the individual or entity exercising the Licensed Rights under this Public License. Your has a corresponding meaning.

Section 2 -- Scope.

a. License grant.

1. Subject to the terms and conditions of this Public License, the Licensor hereby grants You a worldwide, royalty-free, non-sublicensable, non-exclusive, irrevocable license to exercise the Licensed Rights in the Licensed Material to:

a. reproduce and Share the Licensed Material, in whole or in part, for NonCommercial purposes only; and

b. produce, reproduce, and Share Adapted Material for NonCommercial purposes only.

2. Exceptions and Limitations. For the avoidance of doubt, where Exceptions and Limitations apply to Your use, this Public License does not apply, and You do not need to comply with its terms and conditions.

3. Term. The term of this Public License is specified in Section 6(a).

4. Media and formats; technical modifications allowed. The Licensor authorizes You to exercise the Licensed Rights in all media and formats whether now known or hereafter created, and to make technical modifications necessary to do so. The Licensor waives and/or agrees not to assert any right or authority to forbid You from making technical modifications necessary to exercise the Licensed Rights, including technical modifications necessary to circumvent Effective Technological Measures. For purposes of this Public License, simply making modifications authorized by this Section 2(a) (4) never produces Adapted Material.

5. Downstream recipients.

a. Offer from the Licensor -- Licensed Material. Every recipient of the Licensed Material automatically receives an offer from the Licensor to exercise the Licensed Rights under the terms and conditions of this Public License.

b. No downstream restrictions. You may not offer or impose any additional or different terms or conditions on, or apply any Effective Technological Measures to, the Licensed Material if doing so restricts exercise of the Licensed Rights by any recipient of the Licensed Material.

6. No endorsement. Nothing in this Public License constitutes or may be construed as permission to assert or imply that You are, or that Your use of the Licensed Material is, connected with, or sponsored, endorsed, or granted official status by, the Licensor or others designated to receive attribution as provided in Section 3(a)(1)(A)(i).

b. Other rights.

1. Moral rights, such as the right of integrity, are not licensed under this Public License, nor are publicity, privacy, and/or other similar personality rights; however, to the extent possible, the Licensor waives and/or agrees not to assert any such rights held by the Licensor to the limited extent necessary to allow You to exercise the Licensed Rights, but not otherwise.

2. Patent and trademark rights are not licensed under this Public License.

3. To the extent possible, the Licensor waives any right to collect royalties from You for the exercise of the Licensed Rights, whether directly or through a collecting society under any voluntary or waivable statutory or compulsory licensing scheme. In all other cases the Licensor expressly reserves any right to collect such royalties, including when the Licensed Material is used other than for NonCommercial purposes.

Section 3 -- License Conditions.

Your exercise of the Licensed Rights is expressly made subject to the following conditions.

a. Attribution.

1. If You Share the Licensed Material (including in modified form), You must:

a. retain the following if it is supplied by the Licensor with the Licensed Material:

i. identification of the creator(s) of the Licensed Material and any others designated to receive attribution, in any reasonable manner requested by the Licensor (including by pseudonym if designated);

ii. a copyright notice;

iii. a notice that refers to this Public License;

iv. a notice that refers to the disclaimer of warranties;

v. a URI or hyperlink to the Licensed Material to the extent reasonably practicable;

b. indicate if You modified the Licensed Material and retain an indication of any previous modifications; and

c. indicate the Licensed Material is licensed under this Public License, and include the text of, or the URI or hyperlink to, this Public License.

2. You may satisfy the conditions in Section 3(a)(1) in any reasonable manner based on the medium, means, and context in which You Share the Licensed Material. For example, it may be reasonable to satisfy the conditions by providing a URI or hyperlink to a resource that includes the required information.

3. If requested by the Licensor, You must remove any of the information required by Section 3(a)(1)(A) to the extent reasonably practicable.

4. If You Share Adapted Material You produce, the Adapter's License You apply must not prevent recipients of the Adapted Material from complying with this Public License.

Section 4 -- Sui Generis Database Rights.

Where the Licensed Rights include Sui Generis Database Rights that apply to Your use of the Licensed Material:

a. for the avoidance of doubt, Section 2(a)(1) grants You the right to extract, reuse, reproduce, and Share all or a substantial portion of the contents of the database for NonCommercial purposes only;

b. if You include all or a substantial portion of the database contents in a database in which You have Sui Generis Database Rights, then the database in which You have Sui Generis Database Rights (but not its individual contents) is Adapted Material; and

c. You must comply with the conditions in Section 3(a) if You Share all or a substantial portion of the contents of the database.

For the avoidance of doubt, this Section 4 supplements and does not replace Your obligations under this Public License where the Licensed Rights include other Copyright and Similar Rights.

Section 5 -- Disclaimer of Warranties and Limitation of Liability.

a. UNLESS OTHERWISE SEPARATELY UNDERTAKEN BY THE LICENSOR, TO THE EXTENT POSSIBLE, THE LICENSOR OFFERS THE LICENSED MATERIAL AS-IS AND AS-AVAILABLE, AND MAKES NO REPRESENTATIONS OR WARRANTIES OF ANY KIND CONCERNING THE LICENSED MATERIAL, WHETHER EXPRESS, IMPLIED, STATUTORY, OR OTHER. THIS INCLUDES, WITHOUT LIMITATION, WARRANTIES OF TITLE, MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, NON-INFRINGEMENT, ABSENCE OF LATENT OR OTHER DEFECTS, ACCURACY, OR THE PRESENCE OR ABSENCE OF ERRORS, WHETHER OR NOT KNOWN OR DISCOVERABLE. WHERE DISCLAIMERS OF WARRANTIES ARE NOT ALLOWED IN FULL OR IN PART, THIS DISCLAIMER MAY NOT APPLY TO YOU.

b. TO THE EXTENT POSSIBLE, IN NO EVENT WILL THE LICENSOR BE LIABLE TO YOU ON ANY LEGAL THEORY (INCLUDING, WITHOUT LIMITATION, NEGLIGENCE) OR OTHERWISE FOR ANY DIRECT, SPECIAL, INDIRECT, INCIDENTAL, CONSEQUENTIAL, PUNITIVE, EXEMPLARY, OR OTHER LOSSES, COSTS, EXPENSES, OR DAMAGES ARISING OUT OF THIS PUBLIC LICENSE OR USE OF THE LICENSED MATERIAL, EVEN IF THE LICENSOR HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH LOSSES, COSTS, EXPENSES, OR DAMAGES. WHERE A LIMITATION OF LIABILITY IS NOT ALLOWED IN FULL OR IN PART, THIS LIMITATION MAY NOT APPLY TO YOU.

c. The disclaimer of warranties and limitation of liability provided above shall be interpreted in a manner that, to the extent possible, most closely approximates an absolute disclaimer and waiver of all liability.

Section 6 -- Term and Termination.

a. This Public License applies for the term of the Copyright and Similar Rights licensed here. However, if You fail to comply with this Public License, then Your rights under this Public License terminate automatically.

b. Where Your right to use the Licensed Material has terminated under Section 6(a), it reinstates:

1. automatically as of the date the violation is cured, provided it is cured within 30 days of Your discovery of the violation; or

2. upon express reinstatement by the Licensor.

For the avoidance of doubt, this Section 6(b) does not affect any right the Licensor may have to seek remedies for Your violations of this Public License.

c. For the avoidance of doubt, the Licensor may also offer the Licensed Material under separate terms or conditions or stop distributing the Licensed Material at any time; however, doing so will not terminate this Public License.

d. Sections 1, 5, 6, 7, and 8 survive termination of this Public License.

Section 7 -- Other Terms and Conditions.

a. The Licensor shall not be bound by any additional or different terms or conditions communicated by You unless expressly agreed.

b. Any arrangements, understandings, or agreements regarding the Licensed Material not stated herein are separate from and independent of the terms and conditions of this Public License.

Section 8 -- Interpretation.

a. For the avoidance of doubt, this Public License does not, and shall not be interpreted to, reduce, limit, restrict, or impose conditions on any use of the Licensed Material that could lawfully be made without permission under this Public License.

b. To the extent possible, if any provision of this Public License is deemed unenforceable, it shall be automatically reformed to the minimum extent necessary to make it enforceable. If the provision cannot be reformed, it shall be severed from this Public License without affecting the enforceability of the remaining terms and conditions.

c. No term or condition of this Public License will be waived and no failure to comply consented to unless expressly agreed to by the Licensor.

d. Nothing in this Public License constitutes or may be interpreted as a limitation upon, or waiver of, any privileges and immunities that apply to the Licensor or You, including from the legal processes of any jurisdiction or authority.

Creative Commons is not a party to its public licenses. Notwithstanding, Creative Commons may elect to apply one of its public licenses to material it publishes and in those instances will be considered the “Licensor.” The text of the Creative Commons public licenses is dedicated to the public domain under the CC0 Public Domain Dedication. Except for the limited purpose of indicating that material is shared under a Creative Commons public license or as otherwise permitted by the Creative Commons policies published at creativecommons.org/policies, Creative Commons does not authorize the use of the trademark "Creative Commons" or any other trademark or logo of Creative Commons without its prior written consent including, without limitation, in connection with any unauthorized modifications to any of its public licenses or any other arrangements, understandings, or agreements concerning use of licensed material. For the avoidance of doubt, this paragraph does not form part of the public licenses.

Creative Commons may be contacted at creativecommons.org.