Many dangers associated with smoking, such as heart, lung and respiratory disease, are well-known. But most people are unaware of the ways smoking can harm the day-to-day function of muscles, tissues and bones, and how that could impact their healing from a musculoskeletal injury.

We asked Dr. Chad Zooker, a sports medicine and arthroscopic specialist in our OrthoMaryland care center, to answer common questions about the impact of smoking on the musculoskeletal system, and what smokers should be aware of if they are recovering from an injury or planning for a surgery.

First, can you explain how smoking affects the muscles and musculoskeletal system?

Unfortunately, smoking has a variety of negative impacts on our healing processes, especially the healing of broken bones or surgical sites. For example, a rotator cuff repair performed on a smoker may fail to heal or may tear again after surgery. Across the board, whether it’s a simple knee scope or a joint replacement, a smoker’s risk of post-surgical infection can be as much as three times the rate of a non-smoker. Here’s the good news: Those risk factors start to improve as soon as you quit smoking, or even dial back the amount of smoking. It won’t help much if you quit the day before surgery, but quitting even a few weeks beforehand can really reduce your risk factor.

Is smoking cessation often an important part of non-surgical treatment?

Absolutely. Smoking primarily affects your healing by restricting your blood flow, the microcirculation, in a given area. When that happens, the tissues in your body can’t keep up with their daily maintenance. So quitting smoking enhances the way your tissues heal naturally. If someone suffers a bone fracture, their bones are less likely to heal completely if they smoke because of this. We encourage patients to quit smoking and give themselves a better chance of successful healing if we’re trying to be conservative and heal a bone fracture without the use of plates and screws and surgical techniques.

Why are smokers more prone to osteoporosis?

Osteoporosis describes a condition where the mineral quality of the bones is less than average. Smoking increases that negative balance to make your bones less mineralized and decrease the blood flow to the bone in general. This decreases the body’s ability to repair the micro cracks that happen from day to day. Smoking also slows down the production of osteoblast cells. These are the cells responsible for making new bone. And finally, it can cause the body to break down estrogen more quickly, which is a hormone that is important – especially in women – for bone strength and health. As a result of these factors, elderly smokers are especially at risk for breaking bones from falling. One research study found that elderly smokers are around 40 percent more likely to break their hip than others at the same age.

Are smokers more likely to experience muscle injuries or pain due to restricted blood flow?

In general, smokers are more likely to experience sprains, suffer overuse injuries like bursitis and tendonitis or break their bones. Due to the decreased blood flow, the tissue itself – as well as the ligaments and muscles – is more prone to strains. And, smokers also tend to be less active. Unfortunately, being inactive is one of the most dangerous things we can do to our bodies, and so this can also cause injury.

Will you still perform surgery on a patient who smokes?

In general, I won’t tell a patient they can’t have surgery, but will always make sure they know there is a direct link between their smoking and any increased risk of complication, especially for things like fractures or non-healing rotator cuff repairs. In some situations, if you have a patient with a fracture that won’t heal – or maybe they already had a surgical procedure or resulting infection that didn’t heal – I put extra emphasis on the need to quit smoking as part of their overall treatment plan.

How do you support patients who are willing to quit smoking?

We have several handouts and resources that we provide to help patients understand their risks and guide them in the smoking cessation process. If they want medication to help with that process, I’ll refer them to their primary care doctor for the right prescription.

Dr. Chad Zooker specializes in sports medicine and arthroscopic surgery at our OrthoMaryland care center in Baltimore, Lutherville and Owings Mills, Maryland. He earned his medical degree from the University of Maryland School of Medicine and completed his residency at Union Memorial Hospital. During his fellowship at the Rothman Institute/Thomas Jefferson Hospital in Philadelphia, Dr. Zooker served as assistant Orthopaedic team physician for the Eagles, Phillies, indoor football Soul, and St. Joseph’s  University Hawks.