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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.

29 citationsUpdated Sep 2026

For patients: a plain-language version of this topic is available. See the patient guide.

Overview

Tobacco use, encompassing cigarette smoking, heated tobacco, and smokeless products, exerts a deleterious effect on musculoskeletal healing across multiple orthopaedic domains. In spinal surgery, contemporary techniques and biologic augmentation may mitigate the adverse effects of smoking on radiographic fusion after combined TLIF and posterolateral lumbar arthrodesis [1]. For rotator cuff repairs, heated tobacco use has a similar deleterious effect on healing as cigarette smoking [2], with pack-years and duration of cessation serving as independent predictors of tendon healing [3]. Heated tobacco users exhibit worse clinical outcomes regarding rotator cuff healing than nonsmokers, a profile similar to conventional cigarette smokers [7]. In shoulder arthroplasty, tobacco use is a patient factor influencing lesser tuberosity osteotomy healing in anatomic procedures [6] and represents a modifiable risk factor that should be addressed to improve outcomes and reduce costs associated with complications [14]. Current smokers may have poorer functional outcomes after reverse total shoulder arthroplasty compared to former smokers and nonsmokers [9], although the incidence of complications and revision surgery does not differ significantly between these groups [9].

The impact of tobacco extends to lower extremity joint replacement and ligamentous reconstruction. Active smokers face an increased risk of both medical and surgical complications following elective knee or hip arthroplasty [5]. Specifically, smoking is associated with a higher risk for complications than smokeless tobacco use following total knee arthroplasty [8], while 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]. For anterior cruciate ligament reconstruction, specific forms of tobacco use should be considered in preoperative screening [10, 11]. In meniscus repair performed in the presence of concurrent ligamentous injury, cessation of smoking is highly advised [13].

Tobacco use also influences fracture healing and cartilage restoration. Surgeons should consider asking all patients with scaphoid fractures if they use smokeless tobacco or smoke to identify patients at risk for nonunions [4]. Following autologous osteochondral transplantation for osteochondral lesions of the talus, smoking is associated with higher residual pain and poorer functional outcomes at midterm follow-up [12], though there are no significant differences in activity levels based on Tegner scores between smokers and nonsmokers [12].

How It Works

Nicotine exerts a dose-dependent effect on bone healing, bone growth, and implant integration, as demonstrated in various animal and in vitro studies [20]. This biological impact translates into clinical risk across multiple orthopaedic procedures. In shoulder arthroplasty, smoking is a modifiable risk factor that should be addressed to improve outcomes and reduce the costs associated with complications [14]. Patient factors that influence lesser tuberosity osteotomy healing in stemmed and stemless anatomic shoulder arthroplasty include a greater BMI and tobacco use [6]. Smoking has a negative effect on anatomical total shoulder arthroplasty functional outcomes that may persist even after quitting [22]. Conversely, 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].

In rotator cuff surgery, nicotine use is a modifiable risk factor [21]. 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]. For humeral shaft fractures, nicotine dependence prior to surgical fixation 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].

In lower extremity and joint replacement contexts, smoking is a significant risk factor for surgical site infection following ankle and calcaneal fracture fixation [26]. Smokeless tobacco use is associated with increased perioperative complications and revision surgery after anterior cruciate ligament reconstruction [10]. 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]. Following primary total knee arthroplasty, smoking may primarily affect the early recovery trajectory rather than pain-related outcomes alone, as suggested by differences in follow-up communication [19]. Cessation of smoking is highly advised for medial meniscus allograft transplantation and meniscus repair performed in the presence of concurrent ligamentous injury to reduce factors that may contribute to failure [13]. Notably, cigarette smoking was not associated with impaired radiographic fusion after TLIF with adjunctive posterolateral arthrodesis performed using a standardized technique [17].

What the Evidence Shows

Spine

Contemporary surgical techniques and biologic augmentation may mitigate the adverse effects of smoking on lumbar fusion [1].

Shoulder

Heated tobacco users experience worse clinical outcomes regarding rotator cuff healing than nonsmokers [7]. Tobacco use is a patient factor that influences lesser tuberosity osteotomy healing in anatomic shoulder arthroplasty [6]. 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]. Nontobacco nicotine dependence is associated with higher 90-day rates of wound disruptions, infections, and sepsis after shoulder arthroplasty [24]. Furthermore, nontobacco nicotine dependence is associated with increased rates of mechanical loosening and prosthetic joint infection at 2 years postoperatively after shoulder arthroplasty [24]. In the context of arthroscopic rotator cuff repair, nontobacco nicotine dependence is associated with increased odds of subsequent cuff repair and manipulation under anesthesia or debridement at 2 and 5 years [30].

Knee

Smokeless tobacco use is associated with worse outcomes following total knee arthroplasty [8]. Differences in follow-up communication following primary total knee arthroplasty suggest that smoking may primarily affect the early recovery trajectory rather than pain-related outcomes alone [19]. Non-smokers were significantly more likely to achieve superior functional outcomes following ACL reconstruction compared to smokers [28].

Foot and Ankle

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].

Upper Extremity Fractures

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 and Bone Healing

Orthopaedic surgeons should consider evaluating non-tobacco nicotine dependence within their surgical optimization protocol [16].

Practical Considerations

Shoulder

Current or recent smokers may benefit from an inpatient setting of minimum 2 nights following outpatient total shoulder arthroplasty [27].

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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