Smoking and Musculoskeletal Healing Info Evidence
Reviewed by Dr Kieran Hirpara, Specialist Orthopaedic Surgeon Last reviewed
What it is
Smoking and other tobacco products can slow down how your body heals after orthopaedic surgery. This includes bone fusion, tendon repair, and joint replacement. Nicotine affects your blood vessels, which reduces the oxygen and nutrients reaching your surgical site. This makes healing slower and increases the risk of complications.
This applies to all forms of tobacco. This includes cigarettes, heated tobacco products, and smokeless tobacco. Heated tobacco users face similar risks to conventional cigarette smokers. Smokeless tobacco is linked to higher rates of medical and joint-related complications after knee and hip replacements. It also increases the risk of revision surgery after anterior cruciate ligament reconstruction. Even if you do not smoke, using smokeless tobacco or other nicotine products can impact your outcome.
Your doctor will ask about all tobacco use during your preoperative screening. This helps identify risks for nonunions, such as in scaphoid fractures, or poor tendon healing after rotator cuff repair. The number of pack-years and how long you have smoked are key predictors of healing. Cessation is highly advised, particularly for meniscus repair. While contemporary techniques may mitigate some risks, stopping tobacco use remains the most effective way to support your recovery and reduce complications.
Does it work?
Smoking changes how your body heals. It restricts blood flow and reduces oxygen to your tissues. This makes it harder for bones to fuse and for tendons to repair. The evidence shows that smoking is a significant risk factor for complications across many orthopaedic procedures.
You face a higher risk of medical and surgical complications if you smoke before knee or hip replacement. Smoking within 30 days of knee replacement is linked to greater pain after surgery and lower chances of achieving a comfortable pain level. Smokeless tobacco also worsens outcomes after knee and hip replacements, causing more joint-related problems.
Heating tobacco or using nicotine products still harms healing. Heated tobacco users have worse rotator cuff healing than non-smokers, similar to cigarette smokers. Even former smokers who quit recently (within 6 months of rotator cuff repair) face higher risks of infection and revision surgery compared to those who never smoked.
However, the picture is not always black and white. Some studies show that modern surgical techniques can help overcome the negative effects of smoking on spinal fusion. In these cases, smoking did not significantly impair bone healing when standard methods were used. Other studies find that while smokers may have poorer function after shoulder replacement, their risk of needing revision surgery is similar to non-smokers.
Despite these nuances, quitting remains the best step you can take. Stopping smoking improves your chances of a successful outcome and reduces the likelihood of complications. Your doctor will likely ask about your tobacco use to help plan your care. Addressing this habit is a key part of preparing for surgery.
What are the risks?
Smoking affects how your body heals after orthopaedic surgery. It increases your risk of medical and surgical complications, particularly for elective hip or knee joint replacements. You may experience higher levels of pain after surgery and find it harder to regain full function. For example, smoking within 30 days of a total knee replacement is linked to greater postoperative pain and a lower chance of achieving an acceptable pain state.
Smoking also slows down the healing of bones and tendons. The more you smoke and the longer you continue, the harder it is for tissues like rotator cuff tendons to heal properly. This can lead to poorer functional outcomes. In shoulder surgeries, current smokers often report worse results compared to former smokers or those who never smoked. Even if the surgery itself does not fail, your recovery may feel less successful. Heated tobacco products carry similar risks to conventional cigarettes.
Smokeless tobacco is not a safe alternative. It is associated with higher rates of complications and revision surgeries for procedures like hip replacements and anterior cruciate ligament (ACL) reconstruction. It also increases the risk of nonunion, where a bone fails to heal, such as in scaphoid wrist fractures. Nicotine has a dose-dependent effect on bone growth and implant integration, meaning more nicotine generally means slower healing.
Some studies show that modern surgical techniques and biological aids may help reduce these risks in specific spinal fusion surgeries. However, for most procedures, smoking remains a significant risk factor. If you use any form of tobacco or nicotine, your doctor will discuss this with you to help optimise your outcome. Quitting before surgery is highly advised to reduce the chance of infection and revision surgery.
Is it right for you?
Smoking and tobacco use affect how your body heals after orthopaedic surgery. This includes joint replacements, tendon repairs, and spinal fusion. Your doctor will ask about all forms of tobacco, including smokeless products. This helps identify risks for poor healing or nonunion.
If you are a current smoker, you face higher risks of medical and surgical complications. You may also experience more pain and lower function after procedures like shoulder or knee replacement. Heated tobacco users face similar challenges to conventional smokers. Smokeless tobacco is also linked to worse outcomes in knee and hip surgery, as well as increased revision rates after ligament reconstruction.
Former smokers and non-smokers generally achieve better functional results. For example, former smokers often report better outcomes after shoulder replacement than current smokers, despite similar complication rates. Cessation is highly advised for procedures like meniscus repair, especially if combined with ligament injury. It is also recommended to improve outcomes and reduce costs associated with complications in joint replacement.
While some advanced techniques may mitigate risks in spinal fusion, smoking remains a significant modifiable risk factor. Your doctor will discuss these factors with you. The decision to proceed involves weighing these risks against the benefits of surgery. We encourage you to address tobacco use to optimise your healing potential. Please refer to the Risks section for detailed information on specific complications.
The bottom line
Smoking, including smokeless and heated tobacco, increases your risk of complications, pain, and poor healing across many orthopaedic procedures. Quitting is the most effective step you can take to improve your outcome. Even recent quitters may face higher risks than never-smokers, so stopping well before surgery is ideal. Your doctor will discuss a personalised plan to support you in making this change for your recovery.
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
