Smoking, nicotine, and your surgical outcome

Prolonged exposure to nicotine is linked to a long list of complications around the time of surgery — what doctors call the perioperative period — and those complications add up to worse outcomes. Across the research, patients who smoke have:

• Longer hospital stays after surgery
• Lower satisfaction with their final result
• A higher likelihood of being readmitted to the hospital

And the relationship is dose-dependent: the more tobacco a patient uses, the poorer the outcomes tend to be. That also means every reduction helps — and quitting entirely helps most. This is the same reason weight and nutrition come up before hip or knee replacement: the best surgical outcomes start before the operating room.

Smoking significantly reduces bone mineral density (BMD) — the measure of how strong and dense your bones are. Weaker bone fractures more easily, and once a fracture happens, smokers face a longer, harder healing process.

Sometimes a fracture fails to heal at all. Orthopedic surgeons call an unhealed fracture a nonunion — and because nicotine interferes with the biology of healing, smokers are considerably more likely to develop one. The same biology that heals a broken hip is the biology that locks a joint replacement implant into place, which is why nicotine matters so much in joint replacement.

Nicotine's documented effects on bone include:

• Slower bone healing after fracture or surgery
• Decreased bone strength
• Reduced revascularization of bone grafts — the regrowth of blood supply that grafted bone needs to survive
• Slowed osteoblast production — osteoblasts are the cells that build new bone
• Loosening of implants inside the body

Nicotine is the main active component of cigarette smoke, but cigarettes are not the only source. Chewing tobacco, nicotine patches, and e-cigarettes all deliver nicotine — and all of them can affect the outcome of your surgery. Switching from cigarettes to vaping does not take nicotine's effects on bone and wound healing off the table.

If you use nicotine in any form, tell Dr. Morton at your consultation. It never changes whether you're treated with respect — it changes how your surgery is planned and how your body is prepared for it.

Multiple studies of smoking's effects on hip and knee replacement surgery point the same direction: smoking is consistently associated with more complications, more infections, and more repeat surgeries. Compared with non-smokers, patients who smoke are more likely to experience:

That last number deserves emphasis. A joint replacement lasts because living bone stays firmly bonded to the implant — and nicotine attacks exactly the cells and blood supply that maintain that bond. A loosened implant usually means revision surgery. These complications don't just burden individual patients; the higher complication rates in smokers place a real added burden on the healthcare system as a whole.

Here is the encouraging part — the damage is not destiny. Quitting smoking improves your chances of a successful joint replacement, and cessation benefits the health of your whole body. For your surgery specifically, quitting:

• Shortens post-operative healing time
• Reduces your chance of a poor outcome
• Improves revascularization — the return of blood supply to the bone around your implant or injury
• Improves bone strength
• Restores osteoblast production, so your body can build new bone again
• Helps keep orthopedic implants well-fixed in position for the long run

Quitting is hard — nobody pretends otherwise. But effective smoking-cessation programs exist, including prescription medications (pharmacotherapy), telephone quitlines, and structured support through your primary care physician. You do not have to do it on willpower alone.

Hawai'i Tobacco Quitline

The Hawai'i Tobacco Quitline offers free online and telephone quit programs to Hawai'i residents. Call 1-800-QUIT-NOW (1-800-784-8669) to get started.

Your primary care physician

Your primary care physician can prescribe medications that meaningfully improve your odds of quitting successfully, and can coordinate a quit plan timed around your surgery.

Dr. Morton's practice

Dr. Morton treats optimization — smoking, weight, nutrition, and overall health — as part of the operation, not a lecture before it. Bring your questions to a consultation at any of the four clinic locations — Honolulu, West O'ahu, Hilo, or Kona — at (808) 439-6201.