Our knowledge of orthopaedics. Your best health.

from the American Academy of Orthopaedic Surgeons

Diseases & Conditions



Staying Healthy

Orthopaedic Surgery and Smoking

Cigarette smoking is recognized as one of the major causes of preventable disease.

Most people know that smoking is linked to heart and lung diseases, as well as to several cancers. However, you may not be aware that smoking also has a serious negative effect on bones, muscles, tendons, and joints, and that smoking often leads to poorer outcomes from orthopaedic surgery.

Studies have shown that:

  • The nicotine in cigarettes and chewing tobacco can cause a decrease in blood flow to areas of bone and tendon that are healing after surgery.
  • Smoking has a negative effect on fracture and wound healing after surgery.
  • Fractures (broken bones) take longer to heal in smokers because of the harmful effects of nicotine on the production of bone-forming cells.

Smokers (including those who vape) also have a higher rate of complications after surgery than nonsmokers — in fact, smoking may be the single most important factor in complications after surgery.

The most common complications caused by smoking include:

  • Poor wound healing
  • Infection
  • Poor final outcomes of surgery

Researchers have noted that patients who quit smoking have improved outcomes for surgical treatments of musculoskeletal conditions and injuries. This means  smoking is a modifiable risk factor (one you can change) that can be addressed before surgery to give you the best possible outcome.

Research on Smoking and Orthopaedic Procedures

For several specific types of surgeries, results were significantly better for people who never smoked and/or for those who stopped smoking than for smokers.

Smoking and Spinal Fusion Surgery

Spinal fusion is often used to treat disk disorders in the neck and the lower back. Two or more of the small bones in the spinal column (vertebrae) are "welded" together with bone grafts and internal devices, such as metal rods.

A successful spinal fusion can reduce pain and improve the patient's ability to perform activities of daily living. However, the success of the surgery depends on how well the bones heal into a solid unit.

In a study on spinal fusions in the lower back:

  • The success rate was 80% to 85% for patients who never smoked or who quit smoking after their surgery. The success rate dropped to under 73% for smokers.
  • More than 70% of nonsmokers and previous smokers were able to return to work after surgery. But only about half of the smokers were able to resume working.

Another study on spinal fusions in the neck showed successful fusion in 81% of nonsmokers, but in only 62% of smokers.

Smoking and Rotator Cuff Surgery

Smoking also has a negative impact on surgeries that focus on tendons healing to bone, such as rotator cuff repair.

One study compared the results of 235 patients treated at two different medical institutions. Results in nonsmokers were significantly better than in smokers.

  • Nonsmokers experienced less pain and a higher degree of function after surgery than smokers.
  • Good or excellent results were seen in 84% of nonsmokers, but in only 35% of smokers.

Evidence like this continues to indicate that smoking is harmful to your bones and tendons.

Smoking and Total Hip and Knee Replacement

A 2019 cohort study reports that smokers have:

  • An increased risk of complications after total hip and total knee replacement
  • Increased opioid use after total hip replacement compared to non-smokers and ex-smokers
  • A higher risk of hospital readmission after total hip replacement than non-smokers
  • A higher 1-year mortality (death) rate after total hip and total knee replacement than nonsmokers

There is also some evidence that quitting or even cutting back on smoking before total hip or knee replacement surgery can reduce post-surgery complications.

Learn more about these procedures, including other factors that can increase the risk of poor outcomes: Total Hip ReplacementTotal Knee Replacement

Quit Smoking Now

You have a better chance for a successful outcome after orthopaedic surgery if you are a nonsmoker or if you have stopped smoking, according to researchers. Even if you vape, the recommendation is to stop to improve your chances of success and minimize risk around the time of surgery.

Before you plan your orthopaedic surgery, be sure to talk to your surgeon about your tobacco use. Find out about support programs to help you quit. There are many low-cost smoking cessation programs available. The American Lung Association is a great place to start: American Lung Association.

Last Reviewed

May 2024

Contributed and/or Updated by

Aaron Chamberlain, MD, FAAOS

Peer-Reviewed by

Thomas Ward Throckmorton, MD, FAAOS

AAOS does not endorse any treatments, procedures, products, or physicians referenced herein. This information is provided as an educational service and is not intended to serve as medical advice. Anyone seeking specific orthopaedic advice or assistance should consult his or her orthopaedic surgeon, or locate one in your area through the AAOS Find an Orthopaedist program on this website.