Smoking: Impaired Musculoskeletal Healing and Increased Injury Risk
Smoking is a significant risk factor for musculoskeletal injury and delayed recovery. It impairs tissue repair by reducing oxygen delivery, causing vasoconstriction, and disrupting cellular functions essential for healing. Key processes affected include fibroblast migration, collagen synthesis, and mesenchymal stem cell differentiation, which are critical for the repair of bone, tendon, ligament, and muscle [Lee et al., 2013; Tarantino et al., 2021; Aspera-Werz et al., 2019; Hao et al., 2021].
Mechanisms of Smoking-Induced Impairment:
Delayed Bone Healing and Nonunion: Smoking reduces vascular perfusion and oxygen availability, slowing osteoblast activity and bone remodeling. This prolongs fracture healing and increases the risk of nonunion or delayed union [Lee et al., 2013; Scolaro et al., 2014; Mahajan et al., 2021].
Slower Tendon, Ligament, and Muscle Recovery
Nicotine and other toxic compounds interfere with fibroblast function, collagen formation, and mesenchymal stem cell differentiation, slowing tendon, ligament, and muscle repair and reducing tissue strength and resilience [Aspera-Werz et al., 2019; Hao et al., 2021].
Higher Rates of Wound and Soft Tissue Complications
Smoking disrupts inflammatory and reparative cell responses, leading to increased infection risk, delayed wound closure, and incomplete soft tissue recovery. Heavier or long-term smokers experience greater deficits in tissue repair and regenerative capacity [Tarantino et al., 2021; Al-Bashaireh et al., 2018].
Clinical Implications
Individuals who smoke are at higher risk of complications following fractures, surgical interventions, or musculoskeletal injuries. Impaired tissue repair increases the likelihood of chronic deficits, delayed functional recovery, and reinjury. Smoking cessation, particularly immediately after injury, improves healing outcomes and reduces complications [Iwamae et al., 2024].
References:
Al-Bashaireh, A.M., Haddad, L.G., Weaver, M. et al., 2018. The effect of tobacco smoking on musculoskeletal health: a systematic review. Journal of Environmental and Public Health, 2018, p.4184190. https://doi.org/10.1155/2018/4184190
Aspera-Werz, R.H., Chen, T., Ehnert, S. et al., 2019. Cigarette smoke induces the risk of metabolic bone diseases: transforming growth factor beta signaling impairment via dysfunctional primary cilia affects migration, proliferation, and differentiation of human mesenchymal stem cells. International Journal of Molecular Sciences, 20(12), p.E2915. https://doi.org/10.3390/ijms20122915
Hao, Z., Li, J., Li, B. et al., 2021. Smoking alters inflammation and skeletal stem and progenitor cell activity during fracture healing in different murine strains. Journal of Bone and Mineral Research, 36(1), pp.186–198. https://doi.org/10.1002/jbmr.4175
Iwamae, M., Tamai, K., Nishino, K. et al., 2024. Does cessation of combustible cigarette and heated tobacco product smoking immediately following a fracture benefit fracture healing? In vivo and in vitro validation. Biochemical and Biophysical Research Communications, 736, p.150512. https://doi.org/10.1016/j.bbrc.2024.150512
Lee, J.J., Patel, R., Biermann, J.S. & Dougherty, P.J., 2013. The musculoskeletal effects of cigarette smoking. Journal of Bone and Joint Surgery American, 95(9), pp.850–859. https://doi.org/10.2106/JBJS.L.00375
Mahajan, A., Kumar, N. & Gupta, B., 2021. Delayed tibial shaft fracture healing associated with smoking: a systematic review and meta-analysis of observational studies conducted worldwide. International Journal of Environmental Research and Public Health, 18(19), p.10228. https://doi.org/10.3390/ijerph181910228
Scolaro, J.A., Schenker, M.L., Yannascoli, S. et al., 2014. Cigarette smoking increases complications following fracture: a systematic review. Journal of Bone and Joint Surgery American, 96(8), pp.674–681. https://doi.org/10.2106/JBJS.M.00081
Tarantino, U., Cariati, I., Greggi, C. et al., 2021. Skeletal system biology and smoke damage: from basic science to medical clinic. International Journal of Molecular Sciences, 22(12), p.6629. https://doi.org/10.3390/ijms22126629