Smoking and Musculoskeletal Healing Info Evidence
Reviewed by Dr Kieran Hirpara, Specialist Orthopaedic Surgeon Last reviewed
What it is
Smoking, vaping, and using smokeless tobacco can slow down how your body heals after orthopaedic surgery. Nicotine affects your bones, tendons, and joints in a direct way. It changes how well your bones fuse together and how securely implants stay in place. It also impacts the healing of soft tissues like tendons and ligaments.
This matters for many types of procedures. If you are having knee or hip replacement, your doctor will note that active smokers face a higher risk of medical and surgical complications. The same risks apply to shoulder surgery, ACL reconstruction, and meniscus repair. Even if you do not smoke cigarettes, using smokeless tobacco or heated tobacco products carries similar risks. Heated tobacco users often see worse healing outcomes than non-smokers. Smokeless tobacco use is linked to higher rates of complications and revision surgery after knee and hip replacements.
Your doctor may ask about all forms of tobacco use during your intake. This includes smokeless tobacco, which is sometimes overlooked. Knowing your habits helps identify risks for nonunion, where a bone fails to heal properly. For example, after a scaphoid fracture in the wrist, smokeless tobacco use increases the chance of nonunion. After rotator cuff repair, the number of years you smoked and how long you have stopped are key predictors of tendon healing.
Nicotine has a dose-dependent effect on your healing. This means the more you use, the greater the impact on bone growth and implant integration. Cessation is highly advised for procedures like meniscus repair to reduce failure factors. While some modern surgical techniques and biologic aids may help mitigate these effects, stopping tobacco use remains one of the most effective ways to support your recovery and improve long-term outcomes.
Does it work?
Smoking and other tobacco products can slow your body’s natural healing process. This affects how well bones fuse and how well tendons reconnect after surgery. The evidence shows that quitting before your operation gives you the best chance for a smooth recovery.
For many procedures, current smoking is linked to higher risks. You may face more medical and surgical complications after joint replacements like hip or knee surgery. Smoking is also associated with higher rates of infection and revision surgery after rotator cuff repair. These risks remain elevated for up to two years if you quit within six months of the operation. You might also experience greater pain and lower function after knee replacement if you smoke in the month before surgery.
The picture is mixed for some specific surgeries. For example, smoking does not always prevent bone fusion after certain complex spine surgeries. However, even when fusion occurs, smokers often report more residual pain and poorer function over time. Smokeless tobacco and heated tobacco products carry similar risks to cigarettes. They are linked to worse outcomes in shoulder and knee replacements.
Your doctor will ask about all forms of tobacco use, including smokeless products and nicotine dependence. This helps identify risks that might affect your healing. Quitting is a modifiable risk factor. Stopping smoking can improve your outcomes and reduce the cost of treating complications. While some studies show no difference in graft failure for ACL reconstruction, non-smokers generally achieve superior functional results.
We advise discussing a cessation plan with your healthcare team before your procedure. This step is crucial for optimizing your healing, regardless of the specific surgery you are having.
Is it right for you?
Smoking and tobacco use can affect how well your body heals after orthopaedic surgery. This applies to joint replacements, tendon repairs, and bone fusion procedures. Your doctor will ask about all forms of tobacco, including cigarettes, smokeless tobacco, and heated tobacco products. These substances increase the risk of medical and surgical complications. They are also linked to poorer functional outcomes and higher rates of revision surgery for procedures like knee replacement, shoulder repair, and ACL reconstruction.
If you are a current smoker, your doctor may recommend stopping before your operation. Cessation is highly advised for certain procedures, such as meniscus repair with ligament injury. For some surgeries, like shoulder arthroplasty, current smokers might need a longer hospital stay to ensure safety. While some techniques may reduce risks for specific spinal fusions, smoking remains a modifiable risk factor that impacts healing. Smokeless tobacco users also face increased risks of complications and nonunion, particularly in scaphoid fractures.
You should discuss your tobacco use openly with your doctor. This is a shared decision to help you achieve the best possible outcome. Stopping smoking can improve healing and reduce costs associated with complications. If you use nicotine for other reasons, your doctor may evaluate this as part of your preparation. Making changes now can support your recovery and long-term joint health.
The bottom line
Smoking and smokeless tobacco increase your risk of complications, pain, and slower healing across many orthopaedic procedures. Your doctor will ask about all tobacco and nicotine use to plan your care safely. Quitting before surgery improves your chances of a smooth recovery. Even recent smokers can benefit from stopping, as healing improves with time away from nicotine.
Evidence & references
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].
- Smokeless tobacco use is associated with increased perioperative complications and revision surgery after anterior cruciate ligament reconstruction [17].
- Specific forms of tobacco use should be considered in preoperative screening for patients undergoing ACLR [16].
- Specific forms of tobacco use should be considered in preoperative screening for patients undergoing ACLR [17].
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
- 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 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].
- 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].
- Patient factors that influence tuberosity healing after stemmed and stemless anatomic shoulder arthroplasty include greater BMI and tobacco use [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 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].
- Smokeless tobacco use is associated with higher rates of medical- and joint-related complications following primary total hip arthroplasty [11].
- Cigarette smoking was not associated with impaired radiographic fusion after TLIF with adjunctive posterolateral arthrodesis performed using a standardized technique [12].
- Orthopaedic surgeons should consider evaluating non-tobacco nicotine dependence within their surgical optimization protocol for total knee arthroplasty [13].
- 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
- 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 ask 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].
- Patient factors that influence lesser tuberosity healing in stemmed and stemless anatomic shoulder arthroplasty include greater BMI and tobacco use [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 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 and joint replacement in patients undergoing shoulder arthroplasty [10].
- Smokeless tobacco use is associated with higher rates of medical- and joint-related complications following primary total hip arthroplasty [11].
- Cigarette smoking was not associated with impaired radiographic fusion after TLIF with adjunctive posterolateral arthrodesis performed using a standardized technique [12].
- Orthopaedic surgeons should consider evaluating non-tobacco nicotine dependence within their surgical optimization protocol for total knee arthroplasty [13].
- 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].
- Smokeless tobacco use is associated with increased perioperative complications and revision surgery after anterior cruciate ligament reconstruction [16].
- Smokeless tobacco use is associated with increased perioperative complications and revision surgery after anterior cruciate ligament reconstruction [17].
- 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
