Smoking and Musculoskeletal Healing Info Evidence
Reviewed by Dr Kieran Hirpara, Specialist Orthopaedic Surgeon Last reviewed
What you're feeling
Smoking and other tobacco products affect how your body heals after orthopaedic surgery. You may notice that your recovery takes longer than expected. Your surgeon will ask about all forms of tobacco use, including smokeless tobacco, to understand your specific risks. This helps us plan the best care for you.
If you are having knee or hip replacement surgery, active smoking increases your risk of medical and surgical complications. Smokeless tobacco is also linked to worse outcomes after total knee replacement. It can lead to more problems during and after the operation, including a higher chance of needing revision surgery. You might experience increased pain or slower healing at the surgical site.
For shoulder surgery, such as rotator cuff repair, the number of years you have smoked and how long you have stopped smoking matter. Heated tobacco users often have healing results similar to those who smoke conventional cigarettes. You may feel stiffness or weakness in your shoulder as the tendon heals. Reaching behind your back to fasten a bra or tucking in a shirt may become difficult if healing is delayed.
If you have a scaphoid fracture in your wrist, using smokeless tobacco or smoking puts you at risk for nonunion. This means the bone may not heal properly. You might feel persistent pain in your wrist that does not go away with rest. Your surgeon will screen for these habits to identify risks early.
For anterior cruciate ligament reconstruction, smokeless tobacco use is associated with increased perioperative complications and revision surgery. You may face a higher risk of the graft failing or needing another operation. Preoperative screening considers these specific forms of tobacco use to optimize your outcome.
Contemporary techniques and biologic augmentation may help reduce the negative effects of smoking on spinal fusion after combined TLIF and posterolateral lumbar arthrodesis. However, avoiding tobacco remains the best way to support your body’s natural healing processes. Your surgeon may also evaluate non-tobacco nicotine dependence as part of your surgical optimization protocol. Understanding these factors helps you prepare for a smoother recovery journey.
What's actually happening
When you smoke, your body struggles to heal injured tissues. This affects your bones, tendons, and joints. Your surgeon needs to know if you use any form of tobacco. This includes cigarettes, smokeless tobacco, or heated tobacco products. All of these forms can slow down your recovery.
Your blood carries oxygen and nutrients to help repair damage. Smoking reduces this supply. For example, after a rotator cuff repair in the shoulder, the number of years you smoked and how long you stopped before surgery predict how well your tendon heals. Heated tobacco users face similar healing challenges as those who smoke conventional cigarettes.
Smokeless tobacco also causes problems. It is linked to worse outcomes after knee replacement surgery. It also increases the risk of complications and the need for revision surgery after anterior cruciate ligament reconstruction. This ligament stabilizes your knee. Your surgeon may ask about smokeless tobacco use if you have a scaphoid fracture in your wrist. This helps identify patients at risk for nonunions, where the bone fails to join together.
Even if you do not smoke, nicotine dependence can affect your healing. Orthopaedic surgeons should evaluate non-tobacco nicotine dependence during your preparation for knee replacement. Active smokers face a higher risk of medical and surgical complications during elective hip or knee arthroplasty than non-smokers. Smoking is associated with a higher risk for complications than smokeless tobacco use.
Modern techniques and biologic aids may help reduce these risks. This is especially true for complex spinal fusion surgeries. However, avoiding tobacco remains the best way to support your body’s natural healing process. Your surgeon wants you to heal well and avoid extra procedures.
What to expect
Smoking affects how your body heals after orthopaedic surgery. It increases your risk of medical and surgical complications. This is true for elective knee or hip joint replacement. It also applies to procedures like rotator cuff repair, scaphoid fracture care, and anterior cruciate ligament reconstruction. Your surgeon will likely ask about all forms of tobacco use. This includes smokeless tobacco and cigarettes. They may also check for nicotine dependence even if you do not smoke.
Your healing depends on how much you smoke and how long you stop before surgery. For tendon repairs, the number of pack-years and the duration of cessation predict healing. Heated tobacco users face worse outcomes similar to conventional cigarette smokers. Smokeless tobacco use is linked to higher rates of complications and revision surgery after knee replacement and ligament reconstruction. Smoking carries a higher risk of complications than smokeless tobacco use.
Despite these risks, modern techniques may help. Biologic treatments can sometimes reduce the negative impact of smoking on bone fusion after complex back surgery. However, smokeless tobacco still worsens outcomes after knee replacement. If you continue to use tobacco, your recovery may be longer and more difficult. You might experience more pain or need additional procedures. If you stop using tobacco before surgery, your chances of a smooth recovery improve. Your surgeon wants to help you heal well. Be honest about your habits so they can plan the best care for you.
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
