Does smoking affect bone healing?

Smoking cigarettes can delay bone healing and repair from fractures.

Imagine spending weeks nursing a cast following a hand or wrist surgery… All of the time away from work, not to mention the irritation and inconvenience of the ordeal.

Now imagine that you’ve come back in for a post-op only to be informed by your doctor that bone is not mending as expected. It doesn’t sound like a particularly fun experience, right?

Smoking cigarettes has long since been proven to have critically negative impacts on the body; your lungs can be very badly affected by smoking, with cigarettes accounting for 84% of deaths from lung cancer and 83% of deaths from chronic obstructive pulmonary disease, or COPD. Further, those who smoke are up to four times more likely to develop heart disease than those who do not.

These aren’t groundbreaking facts. In the 21st century, those who smoke do so in pretty much full knowledge of what they’re doing to themselves.

What they may not be aware of, however, is the recent evidence that proves it can take habitual smokers several more months to fully heal a broken bone. That’s not to mention the additional complications that may arise for smokers who are nursing a fracture.

… so what evidence is there?

Various studies have shown a marked difference between the bone healing times of two separate groups, habitual smokers and complete non-smokers.

One of the most pressing results came through a study surrounding the recovery from a specific wrist fusion surgery; it was found that 95% of the complete non-smokers healed perfectly, while just 68% of the habitual smokers did. What’s more, the 68% who did heal perfectly took on an extra two months on average to do so.

…but what does smoking actually do to the bones?

It’s not so much what smoking does to the bones, it’s more what smoking does to the blood.

You see, the bones are nourished by blood just like any other bodily tissue or organ. All of the vital minerals that work to repair bone damage are supplied through the bloodstream. The most important of these are calcium and oxygen.

As you would expect, the act of smoking elevates nicotine levels in the bloodstream to the point where blood vessels begin to constrict. Research indicates that nicotine can constrict blood vessels by up to 25% of their normal diameter.

With this smaller diameter comes a severe decrease in the levels of nutrients that are supplied to the afflicted bones, and thus, there is a negative affect on a smoker’s body’s ability to heal.

…and does this include e-cigarettes or chewing tobacco?

At the moment we aren’t too sure about the impact of chewing tobacco or e-cigarettes, based on the results of studies undertaken to date.

Only a handful of studies exist that touch on alternative forms of nicotine consumption. A particular study found no delay in bone healing or increased risk in postoperative complications in oral tobacco users.

Despite that, we do know for a fact that  the consumption of tobacco in any form, or the toxins from e-cigarettes are likely have negative effects to some extent.

Overall though there is no conclusive formal answer for us to give.

…so what does this mean for me?

We all know the negative impact that smoking has on the health of the human body, but what is significant now is that we apply these same warnings signs when recovering from fractures.

Doctors will always advise that heavy smokers quit at least two months prior to any orthopaedic surgeries that have been scheduled. Surgeons may also conduct a pre-operative test to look for nicotine in a patient’s system. Should they find traces, the surgery will be delayed.

If you sustain an injury to your bone, be it any type of fracture of, it can’t be stressed enough that you stop smoking throughout the rehabilitation process.

By doing so, you will be increasing your chances of recovering completely from your injury. On the other hand, smoking during rehabilitation is proven to lengthen the entire process, and increase your chances of making an incomplete recovery.

It’s as though there’s the expectancy that our bones will mend as intended, but with a hand and wrist surgery practice, we see cases of deformity all too often. This is the result of a non-union, the failure of the bone to mend as expected. Smokers are now four times more likely to experience non-union than non smokers. We have to treat this with all seriousness, especially when you consider the technicalities of wrist fusion surgery and the like.

The implications of non-union can be critical; not to mention expensive and drawn out. In some circumstances, bones that fail to mend will require additional surgery in the form of a bone graft or internal fixation using screws and plates. In others, treatment may include a non-surgical bone stimulating device to encourage rapid growth.

…if I quit smoking before surgery, how much time needs to pass before I can proceed?

All we know at the moment is that smoking leads to higher complication rates, and longer rehabilitation periods. We are yet to establish a temporal relationship between smoking cessation and risk reduction. Research results have simply been inconclusive.

This is why orthopaedic surgeons will continue to err on the side of caution, taking a really conservative approach sound in the knowledge that a longer duration without smoking will bring lower risk implications.

For help quitting smoking you can check out the NHS resource here.


Struggling with hand or wrist pain? Miss Ladan Hajipour is a specialist hand and wrist surgeon, and would be happy to receive your enquiry. Fill in the contact form below if you need to.