Smoking Cessation

Smoking is the single most modifiable risk factor for orthopaedic complications, and effective cessation strategies can dramatically improve outcomes in fracture healing, spinal fusion and arthroplasty. Surgeons have a duty to counsel every patient and to document smoking status.

Who smokes. About 20% of adults smoke globally (GBD 2019). Orthopaedic patients typically smoke more than the general population, particularly in trauma cohorts, where rates of 20-30% are quoted. Studies report a prevalence of 20-40% among patients presenting for fracture care or elective procedures [1].

What it costs. The global burden is enormous, trillions of dollars annually worldwide (WHO). In orthopaedics the cost arrives through complications: higher healthcare costs, longer hospital stays with smoking-related complications, and return to work delayed by healing complications.

What is available. Cessation pharmacotherapy (varenicline, NRT, bupropion) is subsidised in most national formularies, and telephone cessation counselling services operate in most countries.

Tobacco smoke is a mixture, and its components damage healing in different ways.

Nicotine is the vasoconstrictor. Carbon monoxide, hydrogen cyanide and tar are combustion products, absent from nicotine replacement, and that distinction is why NRT is safe around surgery (see Intraoperative Considerations).

The osteoblast. Nicotine reduces osteoblast function and impairs vascular supply. Smoking reduces osteoblast proliferation and differentiation, lowers alkaline phosphatase activity and impairs bone matrix production. The cells also respond less to BMP-2 and other growth factors [2,3].

The callus blood supply. VEGF expression falls, fewer capillaries form in the fracture callus, the haematoma organises poorly and revascularisation is delayed [4]. Endothelial dysfunction and microvascular damage add to the impaired angiogenesis.

What that does to union. The callus is weaker and less stiff, and mineralisation is delayed. Radiographic union takes longer, and delayed union and nonunion are more common [5].

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Tissue hypoxia. Nicotine vasoconstricts through alpha-adrenergic stimulation, and carbon monoxide reduces the blood's oxygen-carrying capacity. Tissue PO2 falls by 30-50% and cellular metabolism is impaired [6].

Immune function. Neutrophil chemotaxis and phagocytosis are reduced, complement activation is impaired, antibody production decreases and macrophage function is reduced [7].

Fibroblasts. Fibroblast proliferation and migration are reduced, synthesis of type I and III collagen falls, extracellular matrix deposition is impaired and epithelialisation is delayed [8].

What that does to the wound. Wound dehiscence is more common, healing is delayed and scarring can be hypertrophic. Surgical site infection is increased, but by less than the older literature suggests: small series quote rates 3-6 times higher, whereas the adjusted registry figure after arthroplasty is an odds ratio of about 1.4, and after fracture the increase did not reach significance (see Complications).

Around an implant. In arthroplasty smoking enhances biofilm formation, reduces antibiotic penetration and impairs host defences [9]. Osseointegration is impaired, bone quality around the implant is reduced and wear particle-induced osteolysis is accelerated, with higher revision rates at 10 years [10]. Other problems in smokers are an increased dislocation risk after THA, periprosthetic fracture, delayed mobilisation and a longer hospital stay.

Carbon monoxide. CO binds haemoglobin with roughly 200-250 times the affinity of oxygen (about 240 times), so even small inhaled amounts form substantial carboxyhaemoglobin (COHb), typically up to about 5-10% in smokers against 1-2% in non-smokers.

Two hits to oxygen delivery. COHb reduces oxygen-carrying capacity, because fewer haemoglobin sites are available for oxygen, and it left-shifts the oxyhaemoglobin dissociation curve, so the oxygen that is carried is released less readily to the tissues. Both come on top of nicotine's vasoconstriction.

Why quitting helps within a day. CO has a half-life of only about 4-6 hours breathing room air, shorter with supplemental oxygen, so COHb largely normalises within 12-24 hours of the last cigarette. That is the physiological basis for the immediate improvement in tissue oxygenation, well before any wound or bone effect.

Smoking status. Classify every patient first by status, which sets both the risk and the intervention.

Pack-years. Pack-years = (cigarettes per day ÷ 20) × years smoked, so 20 cigarettes a day for 25 years is 25 pack-years. The bands below grade exposure and the urgency of cessation.

Be careful what you claim about dose. A dose-response relationship between smoking intensity and complications is consistently described, but the published effect sizes are pooled across all smokers, not stratified by pack-year band: nonunion adjusted OR 2.32 overall (Scolaro), SSI adjusted OR 1.41 after arthroplasty (Singh). Neither source reports a graded ladder of numbers, so quoting a specific multiplier for a specific band ("6-8x over 20 pack-years") attaches false precision to a real trend.

Status matters more than dose. In the arthroplasty registry data current smoking carried the clearest excess risk, with prior smokers showing smaller and mostly non-significant increases. Smoking status at the time of surgery is therefore a more useful stratifier than cumulative dose.

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Dependence: the Fagerström test. Pack-years measure exposure; the Fagerström Test for Nicotine Dependence measures dependence. Its questions:

1. How soon after waking do you smoke your first cigarette?
2. Do you find it difficult to refrain from smoking in places where it is forbidden?
3. Which cigarette would you hate most to give up?
4. How many cigarettes per day do you smoke?
5. Do you smoke more frequently in the first hours after waking?
6. Do you smoke if you are so ill that you are in bed most of the day?

The score is read as 0-2 very low, 3-4 low, 5 medium, 6-7 high and 8-10 very high dependence.

History. Record current status (current, former, never), cigarettes per day and pack-years, previous quit attempts and the methods used, and the reasons for any relapse. Ask about readiness to quit (stages of change) and household or social exposure to smoke.

Examination. Look for tobacco staining of the fingers and teeth, chronic cough or sputum production, signs of COPD (barrel chest, prolonged expiration) and signs of peripheral vascular disease. Note the quality of wound healing after any previous surgery.

Readiness to change. The stage the patient is in decides the intervention.

Risk stratification. Intensity and time since quitting combine into a working risk profile, and the profile sets the timing of elective surgery.

When healing fails. In a smoker whose fracture or wound will not heal, smoking is rarely the only contributor. The examiner expects a structured differential, so that smoking is not used as a lazy catch-all and reversible co-factors are not missed.

Self-report. Asking is the standard in clinical practice, and self-report is generally accurate when the patient trusts the provider. It may under-report in settings where there are consequences, which is where biochemical markers come in.

Reading a cotinine. Below 10 ng/mL (serum or urine) indicates a non-smoker, 10-100 ng/mL a light smoker or heavy secondhand exposure, and over 100 ng/mL an active smoker. Passive smoke exposure can elevate levels and renal impairment affects clearance.

Cotinine and NRT. NRT use causes a positive cotinine. Anabasine, a tobacco-specific alkaloid that is not present in NRT, differentiates NRT use from continued smoking, but it is more expensive and less widely available.

Preoperative workup. The smoking history guides what else to request:

• Chest X-ray, if over 20 pack-years or symptoms
• Spirometry, if COPD is suspected
• ECG, if there are cardiac risk factors
• Blood gas or SpO2 at rest, if there are respiratory symptoms

The principle. A minimum of 4 weeks of preoperative cessation reduces complications, and 8+ weeks is optimal. For bone-healing procedures cessation continues for 12+ weeks after surgery. The time available before theatre decides the approach.

Algorithm

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Timing by procedure. The procedure sets how long cessation should run on each side of surgery. Bone-healing procedures need the longest postoperative abstinence.

The first-line approach. For every smoker listed for surgery:

1. Brief counselling (5 A's framework)
2. Pharmacotherapy - offer to ALL motivated smokers
3. Telephone cessation counselling referral
4. Set quit date - ideally 8+ weeks before surgery
5. Follow-up - within 1 week of quit date

Stepped care, level 1: brief intervention for all smokers. Ask, Advise, Refer, in less than 5 minutes, and prescribe pharmacotherapy or refer.

Level 2: standard care for motivated smokers. Full 5 A's counselling, a pharmacotherapy prescription, telephone cessation counselling referral and 2-4 follow-up contacts.

Level 3: intensive support for high dependence or failed previous attempts. Combination pharmacotherapy (varenicline + NRT or bupropion + NRT), smoking cessation clinic referral, multiple behavioural sessions and extended pharmacotherapy (24 weeks). Comorbidities are addressed as well: depression, anxiety, other substance use.

Anaesthesia. Smokers have increased airway reactivity, with a higher risk of bronchospasm, and impaired mucociliary clearance, so secretions need managing. They may need higher oxygen concentrations, and because carbon monoxide displaces oxygen, oxygenation should be optimised. Monitor for bronchospasm during intubation and extubation.

Monitoring. SpO2 may be falsely elevated in recent smokers by carboxyhaemoglobin (see Pathophysiology). Consider an arterial blood gas if there is concern about tissue oxygenation.

Surgical technique. Wound healing is impaired, so haemostasis must be meticulous. Consider tissue-sparing approaches when possible, avoid excessive tension on the wound closure, and place incisions thoughtfully, away from pressure points.

Nicotine replacement through surgery. The patch stays on throughout:

Why it stays on. Continuing NRT brings no increase in wound complications, reduces withdrawal symptoms and agitation, and decreases postoperative relapse risk. Some anaesthetists request stopping NRT preoperatively; this is not evidence-based and increases relapse risk.

Where the risk concentrates. Nonunion risk is roughly doubled in smokers, and pseudarthrosis after lumbar fusion likewise. Smoking is particularly critical in tibial, femoral neck and scaphoid fractures, and wound complications are particularly high-risk after total joint arthroplasty and in open fractures. Older single-site series quote nonunion multipliers of up to 4-8x in tibial and open fractures; the meta-analytic figures above are the ones to quote.

Absolute rates are not in the table. Apart from the fusion rates Glassman actually observed, there are no paired smoker-versus-non-smoker percentages, because the pooled sources report adjusted odds ratios, not absolute rates. Inventing a baseline to sit beside them manufactures precision that no study supports.

Infection after fracture is not significant. Scolaro's meta-analysis found only a non-significant trend. The confident infection multipliers often quoted for fracture surgery come from the arthroplasty literature, where the effect is significant but is closer to 1.4 than to 3-6.

Nonunion in a smoker. Address smoking before any revision surgery, and keep a higher index of suspicion at follow-up. Bone stimulation may help, though the evidence is limited, and biologics (BMP, bone graft) should be considered.

Wound infection in a smoker. Have a lower threshold for deep samples, expect that a longer antibiotic course may be needed, and add wound healing support measures.

The first days (day 0-3). Continue or resume NRT as soon as tolerated; if the patch was removed for surgery, reapply it in PACU. Provide short-acting NRT for breakthrough cravings, and acknowledge how difficult quitting is during recovery.

On the ward. The smoke-free hospital environment supports abstinence. Treat pain adequately, because pain increases relapse risk, offer ongoing behavioural support and consider an inpatient smoking cessation consultation.

How long. Abstinence runs for the procedure-specific duration in the timing table under Management.

When relapse threatens. The first 1-2 weeks carry the highest risk. Hospital discharge returns the patient to their triggers, pain crises bring back smoking as a way of coping, and recovery brings stress and boredom.

Preventing it. Continue pharmacotherapy through the healing period (minimum 12 weeks), and consider extended pharmacotherapy (24 weeks) for high-risk patients. Schedule follow-up contact specifically for cessation support, identify triggers and develop coping strategies, and engage family and social support.

Follow-up.

• Week 1-2: Phone or in-person check on cessation status
• Week 6: Surgical review + reinforce cessation
• Week 12+: Review healing + celebrate sustained cessation
• Ongoing: Continue offering support at all visits

Complications fall. Pooling 6 RCTs, preoperative cessation produced a 41% relative risk reduction in postoperative complications (95% CI 15-59), with a relative risk of 0.76 in the observational data (Mills 2011). Theadom (2006) found a significant reduction in intraoperative complications with any cessation.

The Møller trial. The largest orthopaedic contributor reported the strongest single result: a 6-8 week intervention of cessation plus NRT cut overall complications to 18% from 52% in controls, and wound complications to 5% from 31%.

Fusion depends on postoperative abstinence. Note the direction of Glassman's key finding. Nonunion was not significantly affected by the quantity smoked preoperatively or by the duration of preoperative abatement, whereas patients who quit for more than 6 months after surgery fell to 17.1%, approaching the 14.2% non-smoker rate, and returned to work at 75% versus 53% in continuing smokers. Preoperative cessation is still worth pursuing for wound and pulmonary risk, but for fusion it is the postoperative abstinence that carries the evidence.

Quit rates with intervention, at 1 year:

• Brief advice alone: 3-5%
• Varenicline: 25-30%
• NRT: 15-20%
• Combination (behavioural + pharmacotherapy): 30-40%

Benefit accrues with time. Wound healing starts to benefit at 2-3 weeks, with improved tissue oxygenation.

Beyond the index surgery. Quitting reduces the lifetime orthopaedic complication risk and cardiovascular risk (by 50% at 1 year), and improves pulmonary function. Cancer risk falls, slowly but significantly, and life expectancy rises: quitting at 40 gains about 9 years, at 60 about 3. Sustained cessation is best: permanent cessation eliminates long-term risks.

First-Line Pharmacological Options

The 5 A's Framework

Brief Intervention (Under 5 minutes)

For time-limited clinical encounters, use Ask-Advise-Refer model:

1. Ask: Screen for smoking status
2. Advise: Clear personalized message to quit
3. Refer: Refer to telephone cessation counselling service and/or prescribe pharmacotherapy

Effectiveness: Even brief interventions (under 3 min) increase quit rates by 30-40% when combined with pharmacotherapy. [25]

Motivational Interviewing Techniques

For patients not ready to quit:

Telephone Cessation Counselling

Telephone cessation counselling services - free in many countries:

• Evidence-based behavioral support
• Trained counselors
• Multiple callback sessions
• Free NRT starter packs in some jurisdictions
• Effective: Increases quit rates by 50-100% [26]

Referral process:

• Give patient the local service number
• Encourage active call
• Consider fax/electronic referral (patient consent) - service calls patient

Preoperative Optimization Protocol

Intraoperative and Postoperative Management

Global Epidemiology

The Global Burden of Disease Study 2019 estimated 1.14 billion current smokers worldwide in 2019, consuming 7.41 trillion cigarette-equivalents. Smoking accounted for 7.69 million deaths and 200 million disability-adjusted life-years, and was the leading risk factor for death among males (20.2% of male deaths). Age-standardised prevalence has fallen significantly since 1990 (males 27.5% reduction, females 37.7% reduction), but population growth means the absolute number of smokers has risen from 0.99 billion in 1990. [27]

Side-by-Side Guideline Comparison

Registry and Outcome Data

No dedicated smoking-cessation registry exists for orthopaedics, but national joint replacement registries inform the smoking-outcome link:

• The Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) and the National Joint Registry (NJR, UK) capture revision and infection outcomes against which modifiable risk factors such as smoking are analysed.
• Large cohort and registry-linked studies (e.g. Singh 2011, 33,336 arthroplasties) consistently show higher adjusted surgical site infection and mortality in current smokers, supporting preoperative cessation pathways.

Objective Verification Methods

Self-Report vs Verification

Evidence: Self-report of abstinence is reasonably accurate in most clinical settings. Biochemical verification adds little in routine practice but may be considered for:

• Research protocols
• Programs where cessation is prerequisite for intervention
• Suspected deception

Approach: Trust but verify when stakes are high (e.g., delaying elective surgery contingent on cessation).

Evidence by Procedure Type

Timing of Cessation: Critical Evidence

The Minimum-Timing Controversy: Is Short-Term Cessation Harmful?

• The old concern (Warner): early observational work raised the theoretical worry that stopping in the few weeks immediately before surgery might transiently increase sputum and cough (as mucociliary clearance recovers) and so fail to reduce - or even briefly raise - pulmonary complications. This produced the once-quoted, now largely abandoned idea of an "8-week rule" below which quitting was supposedly not worthwhile.
• The modern position: larger and pooled data have not confirmed any real increase in complications from short-term cessation. The meta-analysis in this topic's evidence base (Mills) shows a clear dose-response - each additional week of preoperative cessation increases the benefit by roughly 19%, with trials of at least 4 weeks showing a significantly larger effect - but no signal of net harm from quitting closer to surgery.
• The practical rule: quitting at any time before surgery is net beneficial and should always be encouraged; longer is better (target 4-8 weeks for elective surgery), but a short lead time or an urgent/trauma presentation is never a reason to advise against quitting. Manage airway-secretion concerns with chest physiotherapy and incentive spirometry rather than by delaying cessation.

1. Nolan J, Jenkins DH, Kurz LT, Horwitz DS. The acute management of the open fracture. J Orthop Trauma. 2009;23(suppl 1):S76-S91.

2. Fang MA, Frost PJ, Iida-Klein A, Hahn TJ. Effects of nicotine on cellular function in UMR 106-01 osteoblast-like cells. Bone. 1991;12(4):283-286.

3. Chen Y, Guo Q, Pan X, Qin L, Zhang P. Smoking and impaired bone healing: will activation of cholinergic anti-inflammatory pathway be the bridge? Int Orthop. 2011;35(10):1555-1561.

4. Silverstein P. Smoking and wound healing. Am J Med. 1992;93(1A):22S-24S.

5. Hernigou J, Schuind F. Tobacco and bone fractures: A review of the facts and issues that every orthopaedic surgeon should know. Bone Joint Res. 2013;2(11):255-265.

6. Jensen JA, Goodson WH, Hopf HW, Hunt TK. Cigarette smoking decreases tissue oxygen. Arch Surg. 1991;126(9):1131-1134.

7. Holt PG. Immune and inflammatory function in cigarette smokers. Thorax. 1987;42(4):241-249.

8. Mosely LH, Finseth F. Cigarette smoking: impairment of digital blood flow and wound healing in the hand. Hand. 1977;9(2):97-101.

9. Singh JA, Houston TK, Ponce BA, et al. Smoking as a risk factor for short-term outcomes following primary total hip and total knee replacement in veterans. Arthritis Care Res (Hoboken). 2011;63(10):1365-1374.

10. Namba RS, Inacio MC, Paxton EW. Risk factors associated with deep surgical site infections after primary total knee arthroplasty: an analysis of 56,216 knees. J Bone Joint Surg Am. 2013;95(9):775-782.

11. Lee SM, Landry J, Jones PM, Buhrmann O, Morley-Forster P. Long-term quit rates after a perioperative smoking cessation randomized controlled trial. Anesth Analg. 2015;120(3):582-587.

12. Glassman SD, Anagnost SC, Parker A, Burke D, Johnson JR, Dimar JR. The effect of cigarette smoking and smoking cessation on spinal fusion. Spine (Phila Pa 1976). 2000;25(20):2608-2615.

13. Andersen T, Christensen FB, Laursen M, Høy K, Hansen ES, Bünger C. Smoking as a predictor of negative outcome in lumbar spinal fusion. Spine (Phila Pa 1976). 2001;26(23):2623-2628.

14. Møller AM, Villebro N, Pedersen T, Tønnesen H. Effect of preoperative smoking intervention on postoperative complications: a randomised clinical trial. Lancet. 2002;359(9301):114-117.

15. Hernigou J, Schuind F. Smoking as a predictor of negative outcome in diaphyseal fracture healing. Int Orthop. 2013;37(5):883-887.

16. Scolaro JA, Schenker ML, Yannascoli S, Baldwin K, Mehta S, Ahn J. Cigarette smoking increases complications following fracture: a systematic review. J Bone Joint Surg Am. 2014;96(8):674-681.

17. Calori GM, Albisetti W, Agus A, Iori S, Tagliabue L. Risk factors contributing to fracture non-unions. Injury. 2007;38 Suppl 2:S11-S18.

18. Singh JA, Houston TK, Ponce BA, Maddox G, Bishop MJ, Richman J, et al. Smoking as a risk factor for short-term outcomes following primary total hip and total knee replacement in veterans. Arthritis Care Res (Hoboken). 2011;63(10):1365-1374.

19. Singh JA. Smoking and outcomes after knee and hip arthroplasty: a systematic review. J Rheumatol. 2011;38(9):1824-1834.

20. Mallon WJ, Misamore G, Snead DS, Denton P. The impact of preoperative smoking habits on the results of rotator cuff repair. J Shoulder Elbow Surg. 2004;13(2):129-132.

21. Warner DO. Perioperative abstinence from cigarettes: physiologic and clinical consequences. Anesthesiology. 2006;104(2):356-367.

22. Cahill K, Lindson-Hawley N, Thomas KH, Fanshawe TR, Lancaster T. Nicotine receptor partial agonists for smoking cessation. Cochrane Database Syst Rev. 2016;(5):CD006103.

23. Anthenelli RM, Benowitz NL, West R, et al. Neuropsychiatric safety and efficacy of varenicline, bupropion, and nicotine patch in smokers with and without psychiatric disorders (EAGLES): a double-blind, randomised, placebo-controlled clinical trial. Lancet. 2016;387(10037):2507-2520.

24. Ramon JM, Nerin I, Comino A, Pinet C, Abella F, Carreras JM, et al. A multicentre randomized trial of combined individual and telephone counselling for smoking cessation. Prev Med. 2013;57(3):183-188.

25. Stead LF, Buitrago D, Preciado N, Sanchez G, Hartmann-Boyce J, Lancaster T. Physician advice for smoking cessation. Cochrane Database Syst Rev. 2013;(5):CD000165.

26. Stead LF, Hartmann-Boyce J, Perera R, Lancaster T. Telephone counselling for smoking cessation. Cochrane Database Syst Rev. 2013;(8):CD002850.

27. GBD 2019 Tobacco Collaborators. Spatial, temporal, and demographic patterns in prevalence of smoking tobacco use and attributable disease burden in 204 countries and territories, 1990-2019: a systematic analysis from the Global Burden of Disease Study 2019. Lancet. 2021;397(10292):2337-2360.

Additional Guideline and Survey Sources

• Royal Australian College of General Practitioners (RACGP). Supporting smoking cessation: A guide for health professionals. Updated 2014.
• Australian Therapeutic Guidelines (eTG). Smoking Cessation. Accessed December 2025.
• Australian Institute of Health and Welfare (AIHW). National Drug Strategy Household Survey 2022.

Suggested Further Reading

• Møller AM, Pedersen T, Villebro N, Nørgaard P. Impact of lifestyle on perioperative smoking cessation and postoperative complication rate. Prev Med. 2003;36(6):704-709.
• Theadom A, Cropley M. Effects of preoperative smoking cessation on the incidence and risk of intraoperative and postoperative complications in adult smokers: a systematic review. Tob Control. 2006;15(5):352-358.
• Mills E, Eyawo O, Lockhart I, Kelly S, Wu P, Ebbert JO. Smoking cessation reduces postoperative complications: a systematic review and meta-analysis. Am J Med. 2011;124(2):144-154.

This comprehensive topic on smoking cessation for orthopaedic surgery is now complete.