Comparative Postoperative Outcomes After Rotator Cuff Repair in Tobacco and Nontobacco Nicotine Users
Orthopaedic journal of sports medicine · 2026
Nicotine without tobacco looks less risky than smoking after cuff repair, but 'less bad than cigarettes' is not the same as safe.
The paper
Retrospective cohort study using the PearlDiver claims database; three propensity-matched comparisons after arthroscopic rotator cuff repair (nontobacco nicotine vs nonusers n=4844, tobacco vs nonusers n=19,182, nontobacco nicotine vs tobacco n=4882).
What they found
Nontobacco nicotine users had a small absolute increase in lysis of adhesions versus nonusers (0.7% vs 0.4%, OR 1.95, P=.033) but no other significant differences from nonusers. Compared directly with tobacco users, nontobacco nicotine users had lower rates of pneumonia (0.6% vs 1.2%, OR 0.46), ED visits (8.8% vs 13.6%, OR 0.62) and readmissions (0.8% vs 1.5%, OR 0.54), all P<.01; tobacco users had higher AKI, pneumonia, infection, ED visits, readmissions and revision surgery than nonusers.
Study design
Retrospective, propensity-matched administrative claims cohort study (Level of evidence 3) using PearlDiver, a large US insurance claims database, in patients with at least 2 years follow-up after arthroscopic RCR. Three separate 1:1 matched cohorts were built rather than one multi-group comparison.
Methodology
Claims data relies on ICD/CPT coding to define nicotine, tobacco and nonuser status and to capture complications, which is vulnerable to misclassification (undercoded vaping/nicotine pouch use, coding of 'lysis of adhesions' as a procedure code rather than a clinically confirmed stiffness diagnosis) and to unmeasured confounding (smoking intensity, pack-years, cessation timing, comorbidities, socioeconomic factors) that propensity matching on coded variables cannot fully resolve. There is no surgical detail (repair technique, tear size, surgeon), no patient-reported outcomes, and administrative data cannot verify actual nicotine/tobacco exposure at the time of surgery, so this is hypothesis-generating association data rather than a controlled comparison of biological effect.
The appraisal
The tobacco-vs-nonuser findings are consistent with a well-established literature and are both statistically and plausibly clinically significant given the range of complications affected. The nontobacco nicotine signal is much weaker: the only significant difference from nonusers was a modest absolute bump in lysis of adhesions (0.3 percentage points), and the comparisons against tobacco users show fewer complications, but these are all differences in low-frequency events with database-level confounding, so 'less harmful than tobacco' should not be read as 'safe.'
The gap
There is no way from claims data to know actual nicotine dose, duration, or timing of cessation before surgery, and no functional or patient-reported outcome data, so it is unclear whether nontobacco nicotine affects the things that matter to a rehabbing patient, tendon healing, retear rate, strength, and pain.
Landmark context
This builds on the well-established literature (e.g. Galatz-era and subsequent cohort work) linking smoking to impaired rotator cuff healing and higher retear/complication rates; it extends that question to nontobacco nicotine (vaping, pouches, gum) where prior evidence has been sparse and mostly extrapolated from smoking data.
What to do Monday
Continue counselling patients to stop tobacco before RCR given its consistent link to AKI, pneumonia, infection, ED visits, readmission and revision; do not tell patients that vapes, pouches or nicotine replacement are cleared as safe alternatives, since this study only shows they look less harmful than cigarettes, not that they are harmless.
In practice
This applies to any patient or athlete listed for arthroscopic RCR who uses tobacco, vapes, or nicotine pouches, not just people who smoke. In clinic, the honest message to someone who has switched from cigarettes to pouches or vaping pre-op is reassurance, not a green light: their AKI, infection, ED and readmission risk tracks close to nonusers, but keep your usual early ROM checks sharp in nicotine users given the small bump in lysis-of-adhesions risk, rather than relaxing stiffness-prevention follow-up just because they quit smoking. On the S&C floor, don't treat 'they switched to pouches' as permission to accelerate a throwing or loading progression after cuff repair, since this is complication and healthcare-utilisation data, not tendon-healing or retear data, and nicotine is still vasoconstrictive regardless of delivery method, so tissue-healing timelines stay standard. The one thing that should genuinely change is the conversation: tobacco cessation stays non-negotiable pre-op, but you can stop implying vaping or pouches carry the same surgical risk as cigarettes, because this dataset says they don't.
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