Tobacco use and complications after open reduction and internal fixation of distal radius fractures in older adults: A propensity score-matched analysis

Abstract

Background

Distal radius fractures (DRFs) are among the most common fragility-related fractures in older adults. Although open reduction and internal fixation (ORIF) is often selected to restore function and enable early mobilization, preoperative risk factors such as tobacco use may impair bone metabolism and immune function, affecting ORIF outcomes. This study aimed to investigate 90-day and 2-year outcomes after DRF ORIF in geriatric patients with a history of tobacco use or nicotine dependence.

Methods

A retrospective cohort analysis was performed using a nationwide database to identify patients aged ≥60 years who underwent DRF ORIF with at least two-year postoperative follow-up between 2005-2025. Patients were categorized into tobacco users and controls. Propensity score matching (1:1) was applied for demographics and major comorbidities. Primary outcomes included implant removal, malunion/nonunion repair, and infection at two years postoperatively; secondary outcomes encompassed ninety-day medical systemic complications.

Results

After matching, 5,725 patients remained in each cohort. Tobacco users had higher rates of sepsis (0.2% vs 0%, p=0.002), renal failure (RR 2.64, p=0.001), pneumonia (RR 2.64, p<0.0001), wound complications (RR 1.62, p=0.004), and postoperative infection (RR 2.46, p<0.0001). At two years, rates of malunion/nonunion repair (RR 2.08, p=0.001) and malunion (RR 1.54, p=0.042) remained significantly elevated.

Conclusion

A history of tobacco use is associated with increased 90-day and 2-year complications after ORIF for DRF in older adults. These findings highlight the importance of preoperative counselling, smoking cessation, and perioperative optimization to improve surgical outcomes in this population. Further research is needed to identify targeted interventions and strategies to reduce these complications and improve recovery in older adults with a history of tobacco use.

Keywords

ORIF tobacco geriatrics distal radius complications

Introduction

Distal radius fractures account for a substantial proportion of fragility-related injuries in older adults.¹ Population‐based studies have documented that incidence has increased by more than 30% over the past two decades, due to rising life expectancy and the continued prevalence of falls from standing height in individuals with osteoporotic bone.² Although many stable fractures can be managed non-operatively, open reduction and internal fixation (ORIF) is frequently chosen for displaced, intra-articular, or unstable patterns in geriatric patients to expedite mobilization and support an earlier return to daily activities.^3–7 Older adults often have baseline vulnerabilities, including reduced bone density and comorbidities, which can affect fracture healing and recovery.⁸ These age-related vulnerabilities can be further worsened by modifiable risk factors such as tobacco use.⁹

Tobacco use is a recognized risk factor for adverse surgical outcomes. Smoking can impair osteoblast activity, reduce blood supply to bone, and may weaken the immune response, all of which can, in turn, delay fracture healing and increase the risk of infection.^9,10 Clinical studies across the musculoskeletal system support these findings: smokers often experience delayed union of lower-extremity fractures, higher infection rates after foot and ankle reconstruction, and greater need for hardware removal or other secondary procedures.^11,12 When considering the wrist, studies suggest that smokers undergoing ORIF for distal radius fractures experience higher rates of early complications.^13,14 These include postoperative stiffness, short-term wound problems, and a greater likelihood of early revision surgery.¹⁴ However, reported estimates vary, likely due to small sample sizes, limited follow-up, and residual confounding in many institutional series.

Understanding the impact of smoking on distal radius fracture surgical fixation in older adults is critical, as it points to a perioperative risk factor that may be modifiable. There is a need to interrogate and study the long-term skeletal and systemic outcomes in a large, nationally representative cohort of older adults with rigorous control for demographic and medical variables. This study aims to investigate two-year fracture-related outcomes and ninety-day medical complications between propensity-matched cohorts of tobacco users and non-users aged 60 and above who underwent DRF ORIF over a twenty-year period.

Methods

Data were extracted from the US nationwide database TriNetX, an aggregated database of deidentified electronic medical records from 68 health care organizations within the US Collaborative network.¹⁵ Analysis and data extraction were conducted on June 5th, 2025. Patients in the United States who underwent DRF ORIF and had at least two-year postoperative follow-up between January 1, 2005, and January 1, 2025, were included. This index surgery window was selected to ensure that all included patients had the potential for a complete two-year postoperative follow-up period when attempting to ascertain the outcome. Due to its use of deidentified patient records and the absence of individually identifiable data, this study was exempt from Institutional Review Board approval.

Cohort selection

This retrospective cohort study evaluated patients who underwent distal radial fracture ORIF with a minimum of two years of postoperative follow-up. Subjects were identified based on Current Procedural Terminology (CPT) codes (CPT-25607, 25608, 25609, 1014742). These patients were further categorized into two cohorts based on their use of tobacco (ICD10: Z72.0) or nicotine dependence (ICD10: F17) and those without. The inclusion criteria encompassed patients 60 years old and above at the time of ORIF.

Tobacco exposure was therefore defined as using EHR-coded tobacco use or nicotine dependence rather than relying on the smoking status as reported by patients.

1:1 Propensity score matching (PSM)

There was a total of 32,555 patients who underwent DRF ORIF identified, 5,755 patients in the tobacco cohort with a mean age of 62.2 (+/- 7.8), and 26,800 patients in the control cohort with a mean age of 66.4 (+/- 9.1) years prior to matching. Significant differences were observed in both groups across various factors between these two cohorts, including sex, ethnicity/race, and comorbidities. A 1:1 propensity matching was employed for demographics (age, sex, race, ethnicity) and comorbidities (diabetes, hypertension, chronic kidney disease, BMI, heart failure, liver diseases, osteoporosis). The use of propensity score matching in large database studies is well established.^16,17

The TriNetX platform was utilized to conduct 1:1 propensity score matching employing logistic regression, resulting in matched cohorts of 5,725 patients each (Table 1). The platform integrates the nearest-neighbor matching with a tolerance level of 0.01 and ensures that the difference between propensity scores is p≤0.1.

Table 1.

Patients’ characteristics pre-matching and post-matching.

Category	Characteristic	Cohort	Pre-matching				Post-matching
Category	Characteristic	Cohort	Patients	% cohort	p-value	Std diff	Patients	% cohort	p-value	Std diff
Demographics	Age at Index	Tobacco	5,755 (62.2 ± 7.8)	100%	<0.001	0.493	5,725 (62.3 ± 7.8)	100%	0.272	0.021
		Control	26,800 (66.4 ± 9.1)	100%			5,725 (62.1 ± 8.1)	100%
	Male	Tobacco	1,526	26.5%	<0.001	0.270	1,498	26.2%	0.932	0.002
		Control	4,181	15.6%			1,502	26.2%
	Female	Tobacco	3,989	69.3%	<0.001	0.277	3,987	69.6%	0.935	0.002
		Control	21,748	81.1%			3,983	69.6%
	American Indian or AK Native	Tobacco	43	0.7%	0.001	0.044	41	0.7%	0.351	0.017
		Control	111	0.4%			33	0.6%
	Native Hawaiian/Pacific Isl.	Tobacco	18	0.3%	0.189	0.018	18	0.3%	0.273	0.021
		Control	59	0.2%			12	0.2%
	Black or African American	Tobacco	467	8.1%	<0.001	0.186	450	7.9%	0.461	0.014
		Control	1,003	3.7%			429	7.5%
	Hispanic or Latino	Tobacco	345	6.0%	0.002	0.047	345	6.0%	0.075	0.033
		Control	1,919	7.2%			301	5.3%
	Not Hispanic or Latino	Tobacco	4,212	73.2%	0.512	0.010	4,186	73.1%	0.203	0.024
		Control	19,501	72.8%			4,246	74.2%
	White	Tobacco	4,636	80.6%	<0.001	0.058	4,625	80.8%	0.022	0.043
		Control	22,187	82.8%			4,720	82.4%
	Other Race	Tobacco	112	1.9%	0.547	0.009	112	2.0%	0.137	0.028
		Control	490	1.8%			91	1.6%
	Asian	Tobacco	68	1.2%	<0.001	0.160	68	1.2%	0.502	0.013
		Control	973	3.6%			76	1.3%
Diagnosis	Chronic Kidney Disease	Tobacco	262	4.6%	0.130	0.022	258	4.5%	0.039	0.039
		Control	1,102	4.1%			214	3.7%
	Diabetes mellitus	Tobacco	674	11.7%	<0.001	0.069	665	11.6%	0.020	0.044
		Control	2,567	9.6%			587	10.3%
	Heart failure	Tobacco	238	4.1%	<0.001	0.090	229	4.0%	0.169	0.026
		Control	676	2.5%			201	3.5%
	Liver diseases	Tobacco	34	0.6%	<0.001	0.057	30	0.5%	0.266	0.021
		Control	61	0.2%			22	0.4%
	Hypertensive diseases	Tobacco	2,321	40.3%	<0.001	0.153	2,297	40.1%	0.909	0.002
		Control	8,836	33.0%			2,303	40.2%
	Osteoporosis (no fracture)	Tobacco	491	8.5%	0.020	0.034	490	8.6%	1	<0.001
		Control	2,551	9.5%			490	8.6%
	Osteoporosis (with fracture)	Tobacco	55	1.0%	0.683	0.006	55	1.0%	0.185	0.025
		Control	272	1.0%			42	0.7%
Laboratory	Body Mass Index	Tobacco	3,943 (27.6 ± 6.6)	68.5%	<0.001	0.062	3,922 (27.6 ± 6.6)	68.5%	<0.001	0.089
		Control	17,267 (28.0 ± 6.4)	64.4%			3,795 (28.2 ± 6.5)	66.3%

Outcomes

The primary outcomes assessed in this study include implant removal, malunion/nonunion repair, amputation, post-traumatic osteoarthritis, complex regional pain syndrome, nonunion, malunion, implant infection at two years postoperatively.

The secondary outcomes included emergency department visits, sepsis, myocardial infarction, pulmonary embolism, deep vein thrombosis, stroke, renal failure, pneumonia, transfusion, hematoma, readmission, wound complications, postoperative infection, and anemia within 90 days.

Statistics

For all outcomes of interest, risk ratios (RRs) and 95% confidence intervals (CIs) were computed using the TriNetX system, and the proportion of complications was analyzed. Categorical variables were assessed using the chi-squared test, while continuous variables were evaluated with Student's t-tests. Statistical significance was set at p<0.05.

Results

Patients with tobacco use undergoing distal radius fracture ORIF experienced significantly higher rates of several 90-day complications compared to controls, including sepsis (0.2% vs 0%, p=0.002), renal failure (0.7% vs 0.3%, RR 2.640, p = 0.001), pneumonia (1.1% vs 0.4%, RR 2.636, p<0.0001), hematoma (0.2% vs 0%, p=0.002), readmission (2.5% vs 1.3%, RR 1.884, p<0.0001), wound complications (1.7% vs 1.0%, RR 1.619, p=0.004), and postoperative infection (1.2% vs 0.5%, RR 2.461, p<0.0001).

At two years, tobacco users had higher rates of malunion & nonunion repair (1.0% vs 0.5%, RR 2.081, p=0.001) and malunion (1.0% vs 0.7%, RR 1.539, p=0.042) (Table 2).

Table 2.

90 day and 2 year outcomes of distal radial fractures ORIF in tobacco geriatrics vs control (n=5,725 for each group).

Outcome	Risk % for tobacco	Risk % for control	Risk ratio (95% confidence interval)	p-value
90 Day Outcomes
Emergency Department Visits	2.6%	2.4%	1.056 (0.729, 1.531)	0.772
Sepsis	0.2%	0%	-	0.002
Myocardial Infarction	0.2%	0.2%	1.018 (0.442, 2.346)	0.966
Pulmonary Embolism	0.3%	0.2%	1.249 (0.585, 2.665)	0.565
Deep Vein Thrombosis	0.5%	0.3%	1.392 (0.760, 2.549)	0.281
Stroke	0.3%	0.2%	1.627 (0.739, 3.583)	0.222
Renal Failure	0.7%	0.3%	2.640 (1.457, 4.783)	0.001
Pneumonia	1.1%	0.4%	2.636 (1.627, 4.271)	<0.0001
Transfusion	0.8%	0.7%	1.149 (0.713, 1.853)	0.568
Hematoma	0.2%	0%	-	0.002
Readmission	2.5%	1.3%	1.884 (1.374, 2.583)	<0.0001
Wound Complications	1.7%	1.0%	1.619 (1.165, 2.250)	0.004
Postoperative Infection	1.2%	0.5%	2.461 (1.575, 3.845)	<0.0001
Anemia	1.6%	1.4%	1.097 (0.796, 1.513)	0.570
2 Year Outcomes
Implant Removal	10.5%	10.2%	1.030 (0.924, 1.147)	0.598
Malunion/Nonunion Repair	1.0%	0.5%	2.081 (1.317, 3.289)	0.001
Amputation	0.2%	0.2%	1.000 (0.417, 2.401)	1.000
Post-traumatic Osteoarthritis	0.7%	0.5%	1.354 (0.853, 2.151)	0.197
CRPS	0.7%	0.9%	0.723 (0.480, 1.089)	0.119
Nonunion	1.1%	0.9%	1.293 (0.888, 1.881)	0.179
Malunion	1.0%	0.7%	1.539 (1.013, 2.338)	0.042
Implant Infection	0.9%	0.6%	1.409 (0.926, 2.144)	0.108

Discussion

In this retrospective cohort study, tobacco use was associated with significantly increased rates of multiple short- and long-term complications. At 90 days, tobacco users demonstrated higher rates of postoperative infection, pneumonia, renal failure, readmission, and wound complications compared to controls. Over a 2-year period, tobacco users had increased rates of malunion and malunion & nonunion repair. These findings suggest that tobacco use remains a clinically relevant risk factor for both perioperative and long-term complications following distal radius fracture repair in older adults. However, it is important to note that because of the way tobacco exposure was defined using diagnostic codes this may not necessarily serve as evidence of a dose-response relationship or as a definitive causal effect of active smoking.

Several of the complications observed in this study are consistent with the systemic effects of tobacco use. Our findings align somewhat with other studies, which identified smoking and tobacco use as having both increased fracture risk and increased rates of complications during subsequent recovery.^18,19 Prior studies have demonstrated that tobacco use impairs immune function and tissue oxygenation, leading to delayed wound healing and increased risk of infection.^20,21 Similarly, smoking impairs osteoblastic function and encourages the action of osteoclasts, which can further delay the healing process.¹⁰ These biological mechanisms contribute to the increased incidence of surgical site infection, nonunion, and prolonged recovery observed in our cohort, emphasizing the critical need for smoking and tobacco use cessation as a part of bone health optimization in geriatric patients who are already at increased risk for osteoporotic fractures at this age.

An important thing to consider while interpreting the findings of this study is that there was no granular accounting of smoking behavior and its manifestations among patients. Many of the biological effects as it relates to fracture healing, microvascular compromise, impaired tissue oxygenation, immune dysfunction, and altered activity of osteoblast and osteoclast may actually vary depending on the current smoking status of a patient, their cumulative lifelong exposure, the recency of cessation (if applicable), and the type of tobacco product used.

Beyond the 90-day postoperative window, our study identified a statistically significant increased risk of malunion and malunion/nonunion repairs in the 2-year postoperative window. Nicotine has been shown to suppress osteogenesis while increasing the rate of bone turnover, thereby decreasing overall bone mass.²² These effects were noted even in the presence of second-hand smoke, where other studies have showcased that individuals who were never-smokers had elevated risks of fractures if a member in their household smoked.²³Long-term smoking cessation has also been noted to lower this risk, although short-term smoking cessation can often maintain an elevated risk level.^24,25

Our findings carry important implications for patient management. Given the modifiable nature of tobacco use, preoperative cessation should be strongly encouraged in patients. Though the risk of fracture remains elevated in the short term after smoking cessation, those who temporarily stop tobacco use see improved results following surgery.²⁶ Additionally, those who are given smoking interventions for the purposes of minimizing perioperative complications and aiding recovery from surgery may be more likely to quit smoking entirely.²⁷ Therefore, it is prudent for physicians to work with their patients on adhering to standard postoperative smoking cessation interventions (including smoking cessation consultation and free nicotine substitution) with the goal of complete abstinence for at least the first six weeks after surgery, which has been shown to reduce the risk of postoperative complications in acute fracture patients.^28,29

This study is not without limitations. As a retrospective analysis of electronic medical records from the TriNetX database, outcomes are reliant on accurate diagnostic coding. It is important to note that although propensity score matching did help in ensuring there is comparability between the cohorts, there was not a complete balance post-match for every single covariate. For example, BMI remained statistically different between the groups even after matching, with a mean BMI of 27.6 ± 6.6 kg/m² in the tobacco cohort and 28.2 ± 6.5 kg/m² in the control cohort. Though of course the absolute difference between these two was small, BMI can impact wound healing, risk of infection, recovery options, and complications in other ways. As a consequence, the association that was observed between tobacco use and wound complications or postoperative infection should be interpreted bearing in mind this limitation. Furthermore, important variables such as fracture pattern, surgical technique, fixation method, and adherence to postoperative rehabilitation may not have been captured in the dataset. The study does rely on codes that identify documented tobacco use or nicotine dependence, but they do not always necessarily distinguish between current and former use or characterize the specific type of tobacco or nicotine product that was used. There is also little quantification of the dose or duration of exposure. As a consequence, the exposure group in this study may need to be interpreted as being patients with a documented tobacco use or nicotine dependence as per their medical records, rather than a necessarily confirmed cohort of active smokers. Therefore, while our findings are consistent with prior literature linking smoking to postoperative infection, impaired wound healing, and delayed fracture recovery, the present analysis cannot conclusively determine whether risk differs between current smokers, former smokers, light versus heavy smokers, or patients using non-cigarette nicotine products.

Furthermore, the database does not capture many of the specific fracture and surgery related factors such as the morphology of a fracture, potential intra-articular involvement, degree of comminution, open vs closed injury, bone quality, operative approach, fixation construct, use of volar locking plates or other fixation methods, and immobilisation protocols that may be relevant in this case. Many of these factors are drivers of malunion, nonunion, infection, implant-related complications, reoperation, and may not be accounted for despite propensity score matching for demographic variables and major morbidities. There is also a paucity of data on patient-reported outcomes, range of motion, grip strength, pain, or functional recovery, which are often central to evaluating treatment for a distal radius fracture in older adults. However despite these limitations, considering the study’s sample size, matched cohorts, and focus on clinically relevant outcomes, there are strengths that bolster these findings.

Conclusion

In conclusion, a documented use of tobacco in older adults undergoing distal radius fracture fixation is associated with both higher rates of short-term medical complications, as well as increased rates two-years out on malunion and malunion/nonunion repair. These results emphasize the need for preoperative risk stratification and management to ensure the best outcomes for older adults. Future studies should investigate the impact of smoking cessation timing and pharmacological interventions such as bupropion on improving fracture healing, minimizing complications, and possible prevention of fracture entirely. They may alo benefit from looking at more granular breakdowns of tobacco type and duration use.

Footnotes

ORCID iDs

Zina Smadi

Bilal Irfan

Barock Tesfaye

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

References

Nordback

Ragupathi

AndreEJ

. A proposed paradigm shift in the management of distal radius fractures. J Orthop 2024; 49: 117–122. https://doi.org/10.1016/j.jor.2023.11.065

Viberg

Tofte

Rønnegaard

, et al. Changes in the incidence and treatment of distal radius fractures in adults – a 22-year nationwide register study of 276,145 fractures. Injury 2023; 54: 110802. https://doi.org/10.1016/j.injury.2023.05.033

Lampert

Linhart

Holzapfel

, et al. Open Reduction and Internal Fixation Is a Feasible Alternative to Femoral Revision Arthroplasty in Geriatric Patients with Vancouver B2/3 Type Periprosthetic Fractures: A Study Analyzing In-Hospital Outcomes. J Clin Med 2024; 13: 6475. https://doi.org/10.3390/jcm13216475

Toemen

Collocott

Heiss-Dunlop

. Short Term Outcomes Following Open Reduction Internal Fixation Surgery for a Distal Radius Fracture: 2 Week Versus 4 Week Immobilization. A Retrospective Analysis. Geriatr Orthop Surg Rehabil 2021; 12: 21514593211004528. https://doi.org/10.1177/21514593211004528

Jayaram

Wood

Kane

, et al. Association of Open Reduction and Internal Fixation With Volar Locking Plate for Distal Radius Fractures With Patient-Reported Outcomes in Older Adults: A Network Meta-analysis. JAMA Netw Open 2023; 6: e2318715. https://doi.org/10.1001/jamanetworkopen.2023.18715

Lee

Elfar

. External Fixation Versus Open Reduction With Locked Volar Plating for Geriatric Distal Radius Fractures. Geriatr Orthop Surg Rehabil 2014; 5: 141–143. https://doi.org/10.1177/2151458514542337

O’Toole

Hui

Chandra

, et al.

How Often Does Open Reduction and Internal Fixation of Geriatric Acetabular Fractures Lead to Hip Arthroplasty?

J Orthop Trauma 2014; 28: 148–153. https://doi.org/10.1097/BOT.0b013e31829c739a

Foulke

Kendal

Murray

, et al. Fracture healing in the elderly: A review. Maturitas 2016; 92: 49–55. https://doi.org/10.1016/j.maturitas.2016.07.014

Hernigou

Schuind

. Tobacco and bone fractures: A review of the facts and issues that every orthopaedic surgeon should know. Bone Jt Res 2019; 8: 255–265. https://doi.org/10.1302/2046-3758.86.BJR-2018-0344.R1

10.

Xie

Huang

Jiang

, et al. Smoking and osteoimmunology: Understanding the interplay between bone metabolism and immune homeostasis. J Orthop Transl 2024; 46: 33–45. https://doi.org/10.1016/j.jot.2024.04.003

11.

Jerjes

Ramsay

Stevenson

, et al. Effect of chronic heavy tobacco smoking on ankle fracture healing. Foot Ankle Surg 2024; 30: 343–348. https://doi.org/10.1016/j.fas.2024.02.003

12.

Pour

Garibaldi

Seidel

, et al. Smoking-related complications in foot and ankle surgery: a systematic review. Eur Rev Med Pharmacol Sci 2024; 28: 4691–4700. https://doi.org/10.26355/eurrev_202412_37003

13.

Galivanche

FitzPatrick

Dussik

, et al. A Matched Comparison of Postoperative Complications Between Smokers and Nonsmokers Following Open Reduction Internal Fixation of Distal Radius Fractures. J Hand Surg 2021; 46: 1–9.e4. https://doi.org/10.1016/j.jhsa.2020.09.020

14.

Hess

Carstensen

Moore

, et al. Smoking Increases Postoperative Complications After Distal Radius Fracture Fixation: A Review of 417 Patients From a Level 1 Trauma Center. HAND 2020; 15: 686–691. https://doi.org/10.1177/1558944718810882

15.

Smadi

McBee

Irfan

, et al. Testosterone Levels and Risk of Adhesive Capsulitis: A 1:1 Propensity Matched Analysis. J Shoulder Elbow Surg 2026; 35(8): e848–e854. https://doi.org/10.1016/j.jse.2026.01.012

16.

Smadi

Diab

Alsaidi

, et al. Obesity is associated with higher 90-day and 2-year complication rates following surgical fixation of upper extremity fractures: A nationwide analysis. Injury 2025; 56: 112891. https://doi.org/10.1016/j.injury.2025.112891

17.

Smadi

Pereira

Ghali

, et al. Outcomes of open reduction and internal fixation (ORIF) of lower extremity fractures in homeless patients. Injury 2025; 56: 112884. https://doi.org/10.1016/j.injury.2025.112884

18.

Bedard

DeMik

Owens

, et al. Tobacco Use and Risk of Wound Complications and Periprosthetic Joint Infection: A Systematic Review and Meta-Analysis of Primary Total Joint Arthroplasty Procedures. J Arthroplasty 2019; 34: 385–396.e4. https://doi.org/10.1016/j.arth.2018.09.089

19.

Smolle

Leitner

Böhler

, et al. Fracture, nonunion and postoperative infection risk in the smoking orthopaedic patient: a systematic review and meta-analysis. EFORT Open Rev 2021; 6: 1006–1019. https://doi.org/10.1302/2058-5241.6.210058

20.

Fan Chiang

Lee

Lam

, et al. Smoking increases the risk of postoperative wound complications: A propensity score matched cohort study. Int Wound J 2023; 20: 391–402. https://doi.org/10.1111/iwj.13887

21.

Lee

Grigorian

Rutledge

, et al. Increased Associated Risk of Surgical Site Infections in Trauma Patients Who Are Smokers. J Surg Res 2025; 312: 221–226. https://doi.org/10.1016/j.jss.2025.05.024

22.

Al-Bashaireh

Haddad

Weaver

, et al. The Effect of Tobacco Smoking on Bone Mass: An Overview of Pathophysiologic Mechanisms. J Osteoporos 2018; 2018: 1–17. https://doi.org/10.1155/2018/1206235

23.

Ahn

Park

H-S

Cho

, et al. Association of secondhand smoke with fracture risk in community-dwelling nonsmoking adults in Korea. JBMR Plus 2024; 8: ziae010. https://doi.org/10.1093/jbmrpl/ziae010

24.

Park

J-S

Kang

K-C

Park

S-J

, et al. The positive impact of smoking cessation on fracture risk in a nationwide cohort study. Sci Rep 2024; 14: 9892. https://doi.org/10.1038/s41598-024-60301-5

25.

Zarzour

Leslie

. The Effect of Smoking Cessation versus Current Smoking on Fracture Risk: The Manitoba BMD Registry. J Clin Densitom 2024; 27: 101523. https://doi.org/10.1016/j.jocd.2024.101523

26.

Mills

Eyawo

Lockhart

, et al. Smoking Cessation Reduces Postoperative Complications: A Systematic Review and Meta-analysis. Am J Med 2011; 124: 144–154.e8. https://doi.org/10.1016/j.amjmed.2010.09.013

27.

Alsanad

Aljanoubi

Alenezi

, et al. Preoperative smoking cessation interventions: a systematic review and meta-analysis. Perioper Med 2025; 14: 5. https://doi.org/10.1186/s13741-024-00479-4

28.

Nåsell

Adami

Samnegård

, et al. Effect of Smoking Cessation Intervention on Results of Acute Fracture Surgery: A Randomized Controlled Trial. J Bone Jt Surg-Am 2010; 92: 1335–1342. https://doi.org/10.2106/JBJS.I.00627

29.

Rigotti

Munafo

Stead

. Smoking Cessation Interventions for Hospitalized Smokers: A Systematic Review. Arch Intern Med 2008; 168: 1950–1960. https://doi.org/10.1001/archinte.168.18.1950