Nicotine Products Consideration in the Perioperative Setting: A Narrative Review


  • Ross Groeschl Resident Physician, Grant Medical Center, Columbus, OH
  • Robert Mendicino Director of Ohiohealth Grant Medical Center Residency, Columbus, OH



Nicotine, tobacco, electronic cigarettes, cigarettes, chewing tobacco, nicotine replacement therapy, nicotine pouch


Nicotine-containing products, including combustible tobacco, smokeless tobacco, electronic cigarettes (e-cigarettes), and nicotine replacement therapies (NRT), are widely used and have significant implications in the perioperative setting for orthopedic surgery. Smoking has been linked to numerous surgical complications such as delayed wound healing, infection, cardiovascular and pulmonary complications and impaired bone healing. This narrative review aims to provide an overview of the different nicotine-containing products, their nicotine content, and the potential effects observed with their use in orthopedic surgery. A comprehensive literature search was conducted to identify studies reporting on dosage, health effects, and perioperative outcomes associated with various forms of tobacco and nicotine products. The findings reveal that combustible tobacco products contain varying levels of nicotine, ranging from 7.2 to 26.3 mg per gram of tobacco. Smokeless tobacco products have nicotine contents ranging from 7.1 to 23.1 mg per gram. Smokeless tobacco users exhibit better surgical outcomes in terms of bone healing compared to smokers. Nicotine content in e-cigarette liquids varies widely, from 0 to 134.7 mg per milliliter. Limited evidence exists regarding the effects of e-cigarettes on surgical outcomes, but animal studies suggest similar soft tissue healing rates compared to combustible cigarettes due to comparable nicotine levels. NRT, available as gum, nasal spray, lozenges, patches, and inhalers, aims to replace tobacco use and gradually reduce nicotine intake. Dosages range from 0.5 mg per spray to 42 mg in high-dose patches. Understanding the nicotine content, absorption, and route of administration of NRT products is crucial for perioperative management. In conclusion, different nicotine-containing products have varying nicotine levels and potential implications for surgical outcomes. Further research is needed to elucidate the specific effects of e-cigarettes and NRT on bone healing and to establish optimal perioperative management strategies for nicotine users undergoing orthopedic surgery.


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How to Cite

Groeschl R, Mendicino R. Nicotine Products Consideration in the Perioperative Setting: A Narrative Review. J Int Foot Ankle [Internet]. 2023 Aug. 1 [cited 2024 Jun. 19];2(8). Available from: