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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.

41 citationsUpdated Oct 2026
Illustration: Smoking and Musculoskeletal Healing

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Overview

Tobacco use, including both combustible cigarettes and smokeless products, impairs musculoskeletal healing across a wide spectrum of orthopaedic conditions. In animal models, tobacco extract reduces the mechanical strength of fracture healing in rats, while nicotine alone does not [2]. Smoking also delays chondrogenesis in mouse models of closed tibial fractures, resulting in a larger fracture callus remaining at day 28 post-fracture compared to controls [3]. Clinically, smoking is associated with failure of surgery for scaphoid non-union [4], and active smokers face increased risks of both medical and surgical complications following elective knee or hip arthroplasty [8]. Smokeless tobacco use is similarly linked to higher rates of medical- and joint-related complications after primary total hip arthroplasty [13], though smoking carries a higher risk for complications than smokeless tobacco use following total knee arthroplasty [11].

The adverse effects extend to soft tissue and joint reconstruction. Pack-years and duration of cessation serve as independent predictors of tendon healing after arthroscopic rotator cuff repair [5], and patients who both smoked and had worker's compensation claims experienced poor outcomes after this procedure [6]. Heated tobacco users exhibit worse clinical outcomes regarding rotator cuff healing than nonsmokers, similar to conventional cigarette smokers [10]. Smoking also influences lesser tuberosity osteotomy healing in anatomic shoulder arthroplasty [9] and decreases microcirculatory flow in replanted digits considerably [27]. For meniscus repair performed with concurrent ligamentous injury, cessation of smoking is highly advised [12].

Preoperative screening and cessation counseling are critical components of surgical optimization. Surgeons should consider asking all patients with scaphoid fractures if they use smokeless tobacco or smoke to identify those at risk for nonunions [7]. Specific forms of tobacco use should be evaluated in preoperative screening for anterior cruciate ligament reconstruction [23, 24], and non-tobacco nicotine dependence should be assessed within the surgical optimization protocol for total knee arthroplasty [17]. While contemporary techniques and biologic augmentation may mitigate the adverse effects of smoking on radiographic fusion after combined TLIF and posterolateral lumbar arthrodesis [1], patients are generally advised to avoid smoking pre-operatively and during the healing period for scaphoid non-union [4] and rotator cuff repair, particularly in those with worker's compensation claims [6].

How It Works

Mechanisms and Cellular Effects

Tobacco extract impairs the mechanical strength of fracture healing in rats, while nicotine does not [2]. At day 28, X-ray analysis revealed a larger fracture callus remaining in smoking animals compared to controls [3]. Cigarette smoke exposure decreases cellular density and type I collagen expression in injured ligaments, providing a cellular and molecular basis for delayed or deficient early healing [19]. Disc cell exposure to the constituents of tobacco smoke has negative consequences that have the potential to alter disc matrix homeostasis [29]. Nicotine may not have a direct pharmacological effect on bone density but may have an indirect effect resulting in low bone density in smokers [14]. Nicotine has a dose-dependent effect on bone healing, bone growth, and implant integration [21]. Nicotine modulates tendon matrix degradation specifically through the downregulation of MMP-9 [31]. Cigarette smoking may be involved in the pathogenesis of Dupuytren's disease by producing microvascular occlusion and subsequent fibrosis and contracture [20].

Fracture and Bone Healing

Patient factors that influence lesser tuberosity osteotomy healing include tobacco use [9].

Soft Tissue and Tendon Healing

Heated tobacco users have worse clinical outcomes with respect to rotator cuff healing than nonsmokers [10]. Heated tobacco use has a similar deleterious effect on rotator cuff repair healing as cigarette smoking [18]. Current smoking is associated with delayed wound healing after the open palm technique for Dupuytren’s disease [15]. Patients with preoperative non-tobacco nicotine product use are hypothesized to experience significantly higher rates of wound dehiscence, surgical site infection, and thromboembolic complications compared to patients without nicotine dependence [30].

Arthroplasty and Fusion

Smokeless tobacco use is associated with worse outcomes following total knee arthroplasty [11]. Smoking is associated with a higher risk for complications than smokeless tobacco use [11]. Smoking is a modifiable risk factor that should be addressed to improve outcomes and reduce costs associated with complications in patients undergoing shoulder arthroplasty [16].

What the Evidence Shows

Spine and Arthrodesis

Contemporary surgical techniques and biologic augmentation may mitigate the adverse effects of smoking in combined transforaminal lumbar interbody fusion (TLIF) and posterolateral lumbar arthrodesis [1]. In a standardized technique for TLIF with adjunctive posterolateral arthrodesis, cigarette smoking was not associated with impaired radiographic fusion [26].

Fracture Healing and Bone Biology

In a mouse model of closed tibial fracture healing, X-ray analysis at day 28 revealed a larger fracture callus remaining in smoking animals [3]. Nicotine exerts a dose-dependent effect on bone healing, bone growth, and implant integration, as demonstrated in various animal and in vitro studies [21]. The mechanism by which nicotine influences bone density may be indirect rather than a direct pharmacological effect on bone density [14].

Upper Extremity and Hand

Cigarette smoking is statistically linked to Dupuytren's disease and may contribute to its pathogenesis by producing microvascular occlusion, subsequent fibrosis, and contracture [20]. In men undergoing the open palm technique for Dupuytren’s disease, current smoking is associated with delayed wound healing [15]. However, current smoking is not associated with improvement of joint contracture following this procedure [15]. Regarding upper extremity fracture fixation, cannabis and nicotine use were independently associated with increased postoperative complications compared with matched non-user controls [40].

Shoulder and Rotator Cuff

Smoking status correlates with postoperative shoulder stiffness at 1 week following arthroscopic rotator cuff repair (r = 0.37, P = 0.03) [32]. Additionally, smoking status is associated with reduced restoration of external rotation range of motion between 6 and 12 weeks postoperatively (r = -0.32, P = 0.014) [32]. Current smokers and former smokers who quit within 6 months of repair face an elevated risk of postoperative infection and revision surgery at 90 days, 1 year, and 2 years compared with never smokers [37]. Patients who both smoked and had worker's compensation claims experienced poor results after rotator cuff repair [6]. Consequently, cessation of smoking prior to rotator cuff repair should be recommended to patients with worker's compensation claims as a possible means of improving outcome [6].

In shoulder arthroplasty, smoking has a negative effect on anatomical total shoulder arthroplasty functional outcomes that may persist even after quitting [38]. 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 [22]. 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 [16].

Lower Extremity and Joint Arthroplasty

Following total knee arthroplasty, smoking is associated with a higher risk for complications than smokeless tobacco use [11]. Smoking within 30 days of the procedure was associated with greater postoperative pain and lower odds of achieving an acceptable pain state compared to former and never-smokers [28]. Regarding infection, smoking is not closely related to revision for periprosthetic joint infection after primary total knee and hip arthroplasty [33]. The 4-year arthroplasty survival with periprosthetic joint infection as the endpoint was not significantly different between smoking status groups (p = 0.318) [33].

In hip arthroplasty, there is a strong association between smoking and increased failure of metal-on-metal total hip arthroplasties [42]. For autologous osteochondral transplantation for osteochondral lesions of the talus, 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 [25].

Ligaments and Menisci

Non-smokers were significantly more likely to achieve superior functional outcomes following ACL reconstruction compared to smokers [35]. 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 [12].

Practical Considerations

Preoperative Screening and Risk Assessment

Surgeons should consider asking all patients with scaphoid fractures if they use smokeless tobacco or smoke, adding this information to the patient's intake history to identify those at risk for nonunions [7]. In the context of surgical optimization protocols, orthopaedic surgeons should consider evaluating non-tobacco nicotine dependence [17]. This recognition extends to specific operative treatments; non-tobacco nicotine dependence should be recognized as a distinct risk factor in patient counseling for operative treatment of humeral shaft fractures [36]. Furthermore, specific forms of tobacco use should be considered in preoperative screening for patients undergoing ACL reconstruction [23, 24].

Cessation Timing and Duration

Smokers should be advised to avoid smoking pre-operatively and during the healing period for scaphoid non-union surgery [4].

Impact on Specific Procedures and Outcomes

Shoulder Arthroplasty: Current or recent smokers may benefit from an inpatient setting of minimum 2 nights for outpatient total shoulder arthroplasty [34]. 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 rates [22]. Patient factors that influence lesser tuberosity osteotomy healing in anatomic shoulder arthroplasty include a greater BMI and tobacco use [9].

Knee and Foot/Ankle: Smokeless tobacco use is associated with worse outcomes following total knee arthroplasty, though smoking is associated with a higher risk for complications than smokeless tobacco use [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 [25].

Hand and Spine: Current smoking is associated with delayed wound healing, but not with improvement of joint contracture, after the open palm technique for Dupuytren’s disease in men [15]. Contemporary techniques and biologic augmentation may mitigate the adverse effects of smoking in the setting of combined TLIF and posterolateral lumbar arthrodesis [1].

Mechanisms and Product-Specific Effects

Nicotine use is a modifiable risk factor that negatively impacts rotator cuff surgery outcomes [39]. At the cellular level, cigarette smoking exposure in mice results in decreased cellular density and type I collagen expression in the injured medial collateral ligament, providing a cellular and molecular basis for delayed or deficient early healing [19]. Additionally, smoking delays chondrogenesis in a mouse model of closed tibial fracture healing, resulting in a larger fracture callus remaining at day 28 [3].

Key Evidence

  • [L3] Contemporary techniques and biologic augmentation may mitigate the adverse effects of smoking in this setting. [1] (10.1097/corr.0000000000003999)
  • [Paper] Further studies defining the tobacco extract component(s) responsible, and the influence of exposure period and dose, and evaluated by supportive histological and histomorphological analyses, may be helpful in assessing the risks of various tobacco products with regard to fracture healing. [2] (10.1002/jor.20187)
  • [Paper] At day 28, X-ray analysis revealed a larger fracture callus remaining in the smoking animals. [3] (10.1002/jor.20263)
  • [L3] Smokers should be advised to avoid smoking pre-operatively and during the healing period. [4] (10.1016/j.jhsb.2005.12.010)
  • [L3] Pack-years and duration of cessation serve as independent predictors of tendon healing. [5] (10.1177/03635465261422620)
  • [L4] The results in this study in patients who both smoked and had worker's compensation claims were poor and would suggest that cessation of smoking prior to rotator cuff repair should be recommended to these patients as a possible means of improving outcome. [6] (10.1016/s1058-2746(95)80064-6)
  • [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. [7] (10.5435/jaaos-d-23-00188)
  • [L1] The literature reveals that active smokers are at an increased risk of both medical and surgical complications. [8] (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. [9] (10.3390/jcm12030834)
  • [L3] Heated tobacco users, like conventional cigarette smokers, have worse clinical outcomes with respect to rotator cuff healing than nonsmokers. [10] (10.2106/jbjs.23.00804)
  • [L3] However, smoking is associated with higher risk for complications than smokeless tobacco use. [11] (10.1016/j.arth.2023.01.035)
  • [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. [12] (10.1530/eor-24-0097)
  • [L3] Smokeless tobacco use is associated with higher rates of medical- and joint-related complications following primary THA. [13] (10.1016/j.arth.2023.05.041)
  • [Paper] It is also possible that nicotine may not have a direct pharmacological effect on bone density but may have an indirect effect resulting low bone density in smokers. [14] (10.1016/s0736-0266(02)00107-9)
  • [L3] Current smoking is associated with delayed wound healing, but not with improvement of joint contracture, after the open palm technique for Dupuytren’s disease in men. [15] (10.1142/s2424835519500127)
  • [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. [16] (10.1177/17585732251327368)
  • [L3] Orthopaedic surgeons should consider evaluating non-tobacco nicotine dependence within their surgical optimization protocol. [17] (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. [18] (10.2106/jbjs.24.00192)
  • [Paper] The decreased cellular density and type I collagen expression in the injured ligament of mice exposed to smoke provide a cellular and molecular basis for delayed or deficient early healing. [19] (10.1002/jor.20234)
  • [L4] Cigarette smoking is linked statistically to Dupuytrens's disease and may be involved in its pathogenesis by producing microvascular occlusion and subsequent fibrosis and contracture or by some other mechanism. [20] (10.1016/0363-5023(88)90262-6)
  • [L2] Nicotine has a dose-dependent effect on bone healing, bone growth, and implant integration, as demonstrated in various animal and in vitro studies. [21] (10.1186/s13018-026-06733-3)
  • [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. [22] (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. [23] (10.1177/2325967125s00229)
  • [L3] These findings highlight the importance of considering specific forms of tobacco use in preoperative screening for patients undergoing ACLR. [24] (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. [25] (10.1186/s13018-025-06428-1)
  • [L2] Cigarette smoking was not associated with impaired radiographic fusion after TLIF with adjunctive posterolateral arthrodesis performed using a standardized technique. [26] (10.1097/corr.0000000000003844)
  • [L4] There are clear indications that the smoking of cigarettes decreases the microcirculatory flow in replanted digits considerably. [27] (10.1016/0363-5023(92)90397-8)
  • [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. [28] (10.1016/j.arth.2026.04.018)
  • [L5] Therefore, we have demonstrated that disc cell exposure to the constituents of tobacco smoke has negative consequences which have the potential to alter disc matrix homeostasis. [29] (10.1002/jor.21417)
  • [L3] It hypothesized that patients with preoperative NTNP use would experience significantly higher rates of wound dehiscence, surgical site infection, and thromboembolic complications compared to patients without nicotine dependence. [30] (10.1016/j.jhsg.2026.101136)
  • [Paper] These findings suggest that nicotine may modulate tendon matrix degradation specifically through the downregulation of MMP-9. [31] (10.1002/jor.22259)
  • [L3] Smoking status also correlated with the change in shoulder stiffness experienced by smokers at 1 week (r = 0.37, P = 0.03) and was found to be associated with a reduced restoration of external rotation range of motion between 6 and 12 weeks following arthroscopic intervention (r = -0.32, P = 0.014). [32] (10.1097/bte.0000000000000146)
  • [L3] The 4-year arthroplasty survival with PJI as the endpoint was not significantly different between smoking status groups (p = 0.318). [33] (10.1016/j.otsr.2024.103876)
  • [L3] Current or recent smokers may benefit from an inpatient setting of minimum 2 nights. [34] (10.1016/j.jseint.2023.07.009)
  • [L1] Nonetheless, non-smokers were significantly more likely to achieve superior functional outcomes following ACL reconstruction. [35] (10.1002/ksa.70146)
  • [L3] NTND should be recognized as a distinct risk factor, underscoring the importance of surgeon awareness in patient counseling and the need for future studies evaluating product-specific effects. [36] (10.1016/j.injury.2025.112872)
  • [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. [37] (10.1016/j.jse.2023.03.007)
  • [L3] Smoking has a negative effect on anatomical total shoulder arthroplasty functional outcomes that may persist even after quitting. [38] (10.1302/0301-620x.106b11.bjj-2024-0202.r1)
  • [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. [39] (10.1002/arj.70199)
  • [L3] Cannabis and nicotine use were independently associated with increased postoperative complications following fixation of upper extremity fractures compared with matched non-user controls. [40] (10.1186/s13018-025-06635-w)
  • [L2] We found a strong association between smoking and increased failure of MoM THAs. [42] (10.1002/jor.22603)

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] Tobacco extract but not nicotine impairs the mechanical strength of fracture healing in rats. Journal of Orthopaedic Research. 2006. DOI: 10.1002/jor.20187

[3] Smoking delays chondrogenesis in a mouse model of closed tibial fracture healing. Journal of Orthopaedic Research. 2006. DOI: 10.1002/jor.20263

[4] Failure of Surgery for Scaphoid Non-Union is Associated with Smoking. Journal of Hand Surgery. 2006. DOI: 10.1016/j.jhsb.2005.12.010

[5] 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

[6] Smoking and worker's compensation: Relation to outcome after rotator cuff repair. Journal of Shoulder and Elbow Surgery. 1995. DOI: 10.1016/s1058-2746(95)80064-6

[7] 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

[8] 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

[9] 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

[10] 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

[11] 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

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

[13] 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

[14] Effects of nicotine on bone mass and strength in aged female rats. Journal of Orthopaedic Research. 2003. DOI: 10.1016/s0736-0266(02)00107-9

[15] Current Smoking Is Associated with Delayed Wound Healing But Not with Improvement of Contracture after the Open Palm Technique for Dupuytren’s Disease. The Journal of Hand Surgery (Asian-Pacific Volume). 2019. DOI: 10.1142/s2424835519500127

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

[17] 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

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

[19] Effects of cigarette smoking on early medial collateral ligament healing in a mouse model. Journal of Orthopaedic Research. 2006. DOI: 10.1002/jor.20234

[20] Cigarette smoking and Dupuytren's contracture of the hand. The Journal of Hand Surgery. 1988. DOI: 10.1016/0363-5023(88)90262-6

[21] 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

[22] 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

[23] 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

[24] 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

[25] 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

[26] 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

[27] The acute effect of cigarette smoking on the microcirculation of a replanted digit. The Journal of Hand Surgery. 1992. DOI: 10.1016/0363-5023(92)90397-8

[28] 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

[29] Differential effects of nicotine and tobacco smoke condensate on human annulus fibrosus cell metabolism. Journal of Orthopaedic Research. 2011. DOI: 10.1002/jor.21417

[30] Impact of Non-Tobacco Nicotine Products on Postoperative Outcomes in Soft Tissue Hand Surgery. Journal of Hand Surgery Global Online. 2027. DOI: 10.1016/j.jhsg.2026.101136

[31] Nicotine reduced MMP‐9 expression in the primary porcine tenocytes exposed to cyclic stretch. Journal of Orthopaedic Research. 2012. DOI: 10.1002/jor.22259

[32] The Effects of Smoking on Shoulder Stiffness Following Arthroscopic Rotator Cuff Repair. Techniques in Shoulder & Elbow Surgery. 2018. DOI: 10.1097/bte.0000000000000146

[33] Smoking is not closely related to revision for periprosthetic joint infection after primary total knee and hip arthroplasty. Orthopaedics & Traumatology: Surgery & Research. 2024. DOI: 10.1016/j.otsr.2024.103876

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

[35] 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

[36] Non-tobacco nicotine dependence and postoperative outcomes in operative treatment of humeral shaft fractures. Injury. 2025. DOI: 10.1016/j.injury.2025.112872

[37] 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

[38] 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

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

[40] 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

[42] Strong association between smoking and the risk of revision in a cohort study of patients with metal‐on‐metal total hip arthroplasty. Journal of Orthopaedic Research. 2014. DOI: 10.1002/jor.22603

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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.