Published 5/19/2020

New study shows majority of patients do not believe e-cigarettes and vapes impact bone fracture healing

ROSEMONT, Ill. (May 19, 2020)—The use of e-cigarettes, vapes and mods have increased as smokers considered these alternatives to be healthier and not having the same side effects of traditional cigarettes. Because e-cigarettes are readily available over the internet, unlike the sale of cigarettes, it perpetuates the notion that these are a safer alternative.[i] A new study, “The New Era of Nicotine: Better for Patients?” released as part of the American Academy of Orthopaedic Surgeons’ (AAOS) Virtual Education Experience found that smokers and non-smokers believe the use of e-cigarettes and other smoking alternatives have less of an impairment on bone fracture healing than smoking traditional cigarettes, when in fact the nicotine found in both cigarettes and e-cigarettes can impede the healing process.

“Many smokers, especially adolescents and young adults, don’t realize that e-cigarettes contain similar chemicals to those found in traditional cigarettes, such as anti-freeze, formaldehyde, nicotine and tobacco—all with varying degrees of concentration,” said Colin T. Ackerman, MD, lead author and orthopaedic resident at Temple University Hospital in Philadelphia. “Unfortunately, e-cigarettes have been positioned as a safer alternative and a solution to help people quit smoking. Much of this narrative has caused misconceptions when it comes to how e-cigarettes can impact a person’s bone health, not to mention their overall health and wellness.”

Because smoking while healing from a bone fracture can cause adverse effects in patients such as wound complications, infections and nonunions (when a broken bone fails to heal), [ii] [iii] Dr. Ackerman and his team wanted to understand patients’ perceptions of traditional cigarette and e-cigarette use on fracture healing and willingness to quit.

According to co-author Christopher L Haydel, MD, FAAOS, the researchers developed a multiple-choice survey (in English and Spanish) that was randomly distributed to 231 patients, 18 years and older, who sustained an extremity fracture. All surveys were administered in an outpatient orthopaedic surgery clinic at a Level 1 urban trauma center. They received 100% participation, and of all the respondents, 55.3% were male and 46.8% African American with a mean age of 46 years old. Use of either cigarettes or e-cigarettes represented 41.1% of respondents with 79.8% being daily smokers. The study found that:

  • A greater percentage of nonsmokers felt that cigarettes “definitely” impaired fracture healing (29.4% of nonsmokers vs. 20% of smokers).
  • Concerning cigarette alternatives (e-cigarettes/vapes), 22.8% of nonsmokers and 14.7% of smokers answered they “definitely” impaired fracture healing.
  • A larger portion of smokers (36.8%) felt that e-cigarettes didn’t impact bone fracture healing compared to 25.3% of smokers who felt that traditional cigarettes did not affect bone fracture healing.
  • Among smokers, 87.6% responded that they would be interested in smoking cessation if told nicotine impaired fracture healing.

The survey also highlighted the gap in patient education regarding this topic in a low income, urban healthcare setting.

“It’s our hope that this information can be used to guide clinicians in acquiring more thorough social health histories and better inform patients about the dangers of not only traditional cigarette smoking, but smoking alternatives,” said Dr. Haydel. As the latest generation of e-cigarettes comes to market, more research is needed to fully understand how the toxins in these products impact the health of the smoker.

For additional information about the impact of smoking on musculoskeletal health, visit

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Disclosure Statement

About the AAOS
With more than 39,000 members, the American Academy of Orthopaedic Surgeons is the world’s largest medical association of musculoskeletal specialists. The AAOS is the trusted leader in advancing musculoskeletal health. It provides the highest quality, most comprehensive education to help orthopaedic surgeons and allied health professionals at every career level to best treat patients in their daily practices. The AAOS is the source for information on bone and joint conditions, treatments and related musculoskeletal health care issues and it leads the health care discussion on advancing quality.

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[i] NIDA. Electronic Cigarettes (E-cigarettes). Accessed June 10, 2018.
[ii] Scolaro JA, Schenker ML, Yannascoli S, Baldwin K, Mehta S, Ahn J. Cigarette Smoking Increases Complications Following Fracture: A Systematic Review. J Bone Jt Surg-Am Vol. 2014;96(8):674-681. doi:10.2106/JBJS.M.00081
[iii] Raikin SM, Landsman JC, Alexander VA, Froimson MI, Plaxton NA. Effect of Nicotine on the Rate and Strength of Long Bone Fracture Healing. Clin Orthop Relat Res. 1998;353:231.

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Lauren Riley