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Pagsususok at Pagpapagaling ng Musculoskeletal

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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 Aug 2026
Isang taong nagpupuyat.
Ang pag-ihip ng sigarilyo ay nagpapaliit ng mga ugat ng dugo at nagpapabagal sa paggaling ng buto at sugat, na nagpapataas ng panganib ng mga komplikasyon pagkatapos ng operasyon. Kieran Hirpara 4.0

Ang pahinang ito ay isinalin ng makina at hindi pa nasusuri ng isang doktor. Ang bersyong Ingles ang siyang opisyal.

Ano ang nararamdaman mo

Ang pagsigarilyo at iba pang produkto ng tabako ay nakakaapekto sa paraan ng paggaling ng iyong katawan pagkatapos ng orthopaedic na operasyon. Maaaring mapansin mo na mas matagal ang iyong paggaling kaysa inaasahan. Tanungin ng iyong surgeon ang tungkol sa lahat ng uri ng paggamit ng tabako, kabilang ang smokeless tobacco, upang maunawaan ang iyong mga partikular na panganib. Tumatulong ito sa amin na magplano ng pinakamainam na pag-aalaga para sa iyo.

Kung ikaw ay mayroong operasyon para sa pagpapalit ng tuhod o balikat, ang aktibong pagsigarilyo ay nagpapataas ng iyong panganib ng mga komplikasyon sa medisina at operasyon. Ang smokeless tobacco ay konektado rin sa mas masamang resulta pagkatapos ng total knee replacement. Maaari itong magdulot ng mas maraming problema sa panahon at pagkatapos ng operasyon, kabilang ang mas mataas na tsansang kailanganin ang revision surgery. Maaari kang maranasan ang pagtaas ng sakit o mas mabagal na paggaling sa surgical site.

Para sa shoulder surgery, tulad ng rotator cuff repair, ang bilang ng taon na iyong nagsigarilyo at kung gaano katagal ka nang huminto sa pagsigarilyo ay mahalaga. Ang mga gumagamit ng heated tobacco ay madalas ay may mga resulta ng paggaling na katulad ng mga nagsisigarilyo ng karaniwang sigarilyo. Maaari kang maranasan ang stiffness o kahinaan sa iyong balikat habang ang tendon ay gumagaling. Ang pag-abot sa likod ng iyong likod upang isara ang bra o ang pagtutukoy ng isang damit ay maaaring maging mahirap kung ang paggaling ay maantala.

Kung mayroon kang scaphoid fracture sa iyong pulso, ang paggamit ng smokeless tobacco o pagsigarilyo ay nagpapakita sa iyo ng panganib ng nonunion. Ibig sabihin, maaaring hindi gumaling nang maayos ang buto. Maaari kang maranasan ang patuloy na sakit sa iyong pulso na hindi nawawala kahit pahinga. Ang iyong surgeon ay mag-screens para sa mga galing na ito upang matukoy ang mga panganib nang maaga.

Para sa anterior cruciate ligament reconstruction, ang paggamit ng smokeless tobacco ay nauugnay sa pagtaas ng perioperative complications at revision surgery. Maaari kang harapin ang mas mataas na panganib na mabigo ang graft o kailanganin ang isa pang operasyon. Ang preoperative screening ay isinasaalang-alang ang mga partikular na anyo ng paggamit ng tabako upang i-optimize ang iyong resulta.

Ang mga contemporary na teknika at biologic augmentation ay maaaring tumulong upang bawasan ang mga negatibong epekto ng pagsigarilyo sa spinal fusion pagkatapos ng combined TLIF at posterolateral lumbar arthrodesis. Gayunpaman, ang pag-iwas sa tabako ay nananatiling pinakamainam na paraan upang suportahan ang natural na proseso ng paggaling ng iyong katawan. Ang iyong surgeon ay maaari ring i-evaluate ang non-tobacco nicotine dependence bilang bahagi ng iyong surgical optimization protocol. Ang pag-unawa sa mga salik na ito ay tumutulong sa iyo na maghanda para sa mas maayos na paglalakbay ng paggaling.

Ano ang nangyayari talaga

Kapag nag-iinom ka ng sigarilyo, nahihirapan ang iyong katawan na gumaling ang mga nasugatang tissue. Nakakaapekto ito sa iyong mga buto, tendon, at kasu-kasuan. Kailangan alam ng iyong surgeon kung gumagamit ka ng anumang uri ng tabako. Kasama rito ang mga sigarilyo, smokeless tobacco, o mga produktong tabakong pinainit. Ang lahat ng mga anyong ito ay maaaring magpabagal sa iyong paggaling.

Dala ng iyong dugo ang oxygen at mga sustansya upang matulungan ang pag-aayos ng pinsala. Binabawasan ng pag-iinom ng sigarilyo ang suplay na ito. Halimbawa, pagkatapos ng rotator cuff repair sa balikat, ang bilang ng mga taong iyong naging regular na nag-inom ng sigarilyo at kung gaano katagal kang huminto bago ang operasyon ay nagpapahiwatig kung gaano kagaling ang iyong tendon na gumaling. Ang mga gumagamit ng pinainit na tabako ay nakakaranas ng katulad na hamon sa paggaling kung sa mga nag-iinom ng karaniwang sigarilyo.

Nagdudulot din ng mga problema ang smokeless tobacco. Ito ay nakakonekta sa mas masamang resulta pagkatapos ng knee replacement surgery. Dagdagan nito rin ang risk ng mga komplikasyon at ang pangangailangan para sa revision surgery pagkatapos ng anterior cruciate ligament reconstruction. Ang ligament na ito ay nagpapatatag sa iyong tuhod. Maaaring tanungin ka ng iyong surgeon tungkol sa paggamit ng smokeless tobacco kung mayroon kang scaphoid fracture sa iyong pulso. Tumutulong ito sa pagtukoy sa mga pasyente na nasa risk ng nonunions, kung saan nababigo ang buto na mag-ugnay.

Kahit hindi ka nag-iinom ng sigarilyo, ang nicotine dependence ay maaaring makaapekto sa iyong paggaling. Dapat suriin ng mga orthopaedic surgeon ang nicotine dependence na hindi galing sa tabako habang ikaw ay naghahanda para sa knee replacement. Ang mga aktibong nag-iinom ng sigarilyo ay may mas mataas na risk ng mga medikal at surgical na komplikasyon habang elective hip o knee arthroplasty kumpara sa mga hindi nag-iinom ng sigarilyo. Ang pag-iinom ng sigarilyo ay may kaugnayan sa mas mataas na risk ng mga komplikasyon kumpara sa paggamit ng smokeless tobacco.

Ang mga modernong teknik at biologic aids ay maaaring tumulong upang bawasan ang mga risk na ito. Lalo na ito totoo para sa mga kumplikadong spinal fusion surgeries. Gayunpaman, ang pag-iwas sa tabako ang pinakamainam na paraan upang suportahan ang natural na proseso ng paggaling ng iyong katawan. Gusto ng iyong surgeon na gumaling ka nang maayos at iwasan ang karagdagang mga prosedura.

Ano ang inaasahan

Ang pag-ihip ng sigarilyo ay nakakaapekto sa paraan ng paggaling ng iyong katawan pagkatapos ng orthopaedic na operasyon. Binabawasan nito ang iyong risk para sa mga medikal at surgical na komplikasyon. Tama ito para sa elective knee o hip joint replacement. Kabilang din dito ang mga prosedura tulad ng rotator cuff repair, scaphoid fracture care, at anterior cruciate ligament reconstruction. Posibleng tanungin ka ng iyong surgeon tungkol sa lahat ng uri ng paggamit ng tabako. Kasama rito ang smokeless tobacco at sigarilyo. Maaari rin silang suriin ang nicotine dependence kahit hindi ka umihip ng sigarilyo.

Ang iyong paggaling ay nakadepende sa dami ng iyong pag-ihip at kung gaano katagal kang huminto bago ang operasyon. Para sa mga tendon repair, ang bilang ng pack-years at ang tagal ng paghinto ay nagpapakita ng paggaling. Ang mga gumagamit ng heated tobacco ay nakakaranas ng mas masamang resulta na katulad ng mga regular na umihip ng sigarilyo. Ang paggamit ng smokeless tobacco ay may kaugnayan sa mas mataas na rate ng komplikasyon at revision surgery pagkatapos ng knee replacement at ligament reconstruction. Ang pag-ihip ng sigarilyo ay may mas mataas na risk ng komplikasyon kumpara sa paggamit ng smokeless tobacco.

Sa kabila ng mga risk na ito, ang mga modernong teknik ay maaaring makatulong. Ang mga biologic treatment ay minsan ay nakakabawas ng negative impact ng pag-ihip ng sigarilyo sa bone fusion pagkatapos ng complex back surgery. Gayunpaman, ang smokeless tobacco ay patuloy na nagpapahina ng resulta pagkatapos ng knee replacement. Kung patuloy kang gumagamit ng tabako, ang iyong paggaling ay maaaring mas matagal at mas mahirap. Maaari kang maranasan ang mas maraming sakit o kailangan ng karagdagang mga prosedura. Kung ihhinto mo ang paggamit ng tabako bago ang operasyon, mas magiging malaki ang iyong chance para sa maayos na paggaling. Gusto ng iyong surgeon na tulungan kang gumaling nang maayos. Maging tapat tungkol sa iyong mga gawi upang makapagplano sila ng pinakamainam na pag-aalaga para sa iyo.

Reviewed by Kieran Hirpara · 13 June 2026.

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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 (270°) arthrodesis [1].
  • Pack-years and duration of cessation serve as independent predictors of tendon healing after arthroscopic rotator cuff repair [2].
  • Surgeons should consider asking all patients with scaphoid fractures if they use smokeless tobacco or smoke to identify patients at risk for nonunions [3].
  • Active smokers are at an increased risk of both medical and surgical complications in elective knee or hip arthroplasty [4].
  • 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 a higher risk for complications than smokeless tobacco use [6].
  • Orthopaedic surgeons should consider evaluating non-tobacco nicotine dependence within their surgical optimization protocol for total knee arthroplasty [13].
  • Smokeless tobacco use is associated with increased perioperative complications and revision surgery after anterior cruciate ligament reconstruction [16].
  • Specific forms of tobacco use should be considered in preoperative screening for patients undergoing ACLR [16].

How It Works

  • 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].
  • Pack-years and duration of smoking cessation serve as independent predictors of tendon healing after arthroscopic rotator cuff repair [2].
  • Surgeons should include smokeless tobacco use in patient intake history to identify patients at risk for nonunions following scaphoid fractures [3].
  • Active smokers are at an increased risk of both medical and surgical complications compared to nonsmokers undergoing elective knee or hip arthroplasty [4].
  • Heated tobacco users have worse clinical outcomes regarding rotator cuff healing than nonsmokers, with effects similar to conventional cigarette smokers [5].
  • Smokeless tobacco use is associated with higher rates of medical- and joint-related complications following primary total hip arthroplasty [11].
  • Patient factors influencing lesser tuberosity healing in stemmed and stemless anatomic shoulder arthroplasty include tobacco use and body mass index [7].
  • 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].
  • Cessation of smoking is highly advised for meniscus repair, particularly when performed in the presence of concurrent ligamentous injury [9].
  • 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].
  • Cigarette smoking was not associated with impaired radiographic fusion after TLIF with adjunctive posterolateral arthrodesis performed using a standardized technique [12].
  • All forms of tobacco products, including heated tobacco, adversely affect rotator cuff healing [14].
  • Nicotine has a dose-dependent effect on bone healing, bone growth, and implant integration [18].

What the Evidence Shows

  • Surgeons should ask patients with scaphoid fractures if they use smokeless tobacco or smoke to identify patients at risk for nonunions [3].
  • Active smokers are at an increased risk of both medical and surgical complications following elective knee or hip arthroplasty [4].
  • Heated tobacco users have worse clinical outcomes with respect to rotator cuff healing than nonsmokers [5].
  • Patient factors that influence tuberosity healing after stemmed and stemless anatomic shoulder arthroplasty include greater BMI and tobacco use [7].
  • 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 [9].
  • 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].
  • Heated tobacco use has a similar deleterious effect on rotator cuff repair healing as cigarette smoking [14].
  • Current smokers may have poorer functional outcomes after reverse total shoulder arthroplasty compared to former smokers and nonsmokers [15].
  • 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].
  • Non-smokers were significantly more likely to achieve superior functional outcomes following ACL reconstruction compared to smokers [21].
  • 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 [22].

Practical Considerations

  • Surgeons should ask all patients with scaphoid fractures if they use smokeless tobacco or smoke to identify patients at risk for nonunions [3].
  • Patient factors that influence lesser tuberosity healing in stemmed and stemless anatomic shoulder arthroplasty include greater BMI and tobacco use [7].
  • Cessation of smoking is highly advised for meniscus repair performed in the presence of concurrent ligamentous injury [9].
  • 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].
  • Current or recent smokers may benefit from an inpatient setting of minimum 2 nights for outpatient total shoulder arthroplasty due to being an independent risk factor for complications [19].

Key Evidence

  • [L3] Contemporary techniques and biologic augmentation may mitigate the adverse effects of smoking in this setting. [1] (10.1097/corr.0000000000003999)
  • [L3] Pack-years and duration of cessation serve as independent predictors of tendon healing. [2] (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. [3] (10.5435/jaaos-d-23-00188)
  • [L1] The literature reveals that active smokers are at an increased risk of both medical and surgical complications. [4] (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. [5] (10.2106/jbjs.23.00804)
  • [L3] However, smoking is associated with higher risk for complications than smokeless tobacco use. [6] (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. [7] (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. [8] (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. [9] (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] (10.1177/17585732251327368)
  • [L3] Smokeless tobacco use is associated with higher rates of medical- and joint-related complications following primary THA. [11] (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. [12] (10.1097/corr.0000000000003844)
  • [L3] Orthopaedic surgeons should consider evaluating non-tobacco nicotine dependence within their surgical optimization protocol. [13] (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. [14] (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. [15] (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. [16] (10.1177/03635465241303487)
  • [L3] These findings highlight the importance of considering specific forms of tobacco use in preoperative screening for patients undergoing ACLR. [17] (10.1177/2325967125s00229)
  • [L2] Nicotine has a dose-dependent effect on bone healing, bone growth, and implant integration, as demonstrated in various animal and in vitro studies. [18] (10.1186/s13018-026-06733-3)
  • [L3] Current or recent smokers may benefit from an inpatient setting of minimum 2 nights. [19] (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. [20] (10.1016/j.arth.2026.04.018)
  • [L1] Nonetheless, non-smokers were significantly more likely to achieve superior functional outcomes following ACL reconstruction. [21] (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. [22] (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] 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

[17] 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

[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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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.