New bone volume was calculated with use of 3D image processing software

Heated Tobacco Products and Impact on Bone Healing   

An extensive body of clinical and basic science research has confirmed that cigarette smoking negatively impacts bone healing. Newer products, such as electronic cigarettes (e-cigarettes) and heated tobacco products (HTPs), are often described as safer alternatives to traditional cigarettes, but what are their effects on health and, more specifically, on the orthopaedic healing process?  

Where e-cigarettes (vaping devices) typically involve heating a liquid solution that may contain nicotine as well as flavorings and other substances, HTP technology heats processed tobacco, at a lower temperature than conventional cigarettes. Sometimes marketed as “heat-not-burn” products, HTPs come in different forms, and the FDA approved the marketing of HTPs in the U.S. in 2019. Given the expected rise in the use of these products, additional data regarding their impact on musculoskeletal health are needed.  

In the current issue of JBJSNishino et al. report the results of their basic science investigation examining the effects of HTPs on cell viability, osteoblastic differentiation in vitro, and bone fracture healing in vivo using a rat femoral fracture model. They further compared their findings with those of conventional combustible cigarettes. The methodology of generating the cigarette smoke extracts (CSEs) from combustible cigarettes and HTPs was described in prior research and, as the authors note, allows investigators to use the same solution for in vitro and in vivo studies, ensuring that the cells and animals are exposed to the same molecules, and making it possible to dilute the CSE to different concentrations.  

What They Found 

From their experiments, the authors concluded that the use of HTPs impairs cell viability, osteoblastic differentiation, and bone fracture healing “at levels comparable with those associated with combustible cigarette use.” Click here to read the full report. 

As to which substance, or substances, of HTP output specifically impact bone healing needs to be elucidated, and I agree with the authors that the research community should direct attention toward further clarifying questions regarding the underlying mechanisms contributing to their observations. For elective procedures necessitating bone healing for success, we may wish to consider counseling patients on the cessation of HTP use for a period of time yet to be determined; 4 weeks may be a reasonable starting point, but any period of time is likely to benefit patient outcomes.  

Additional perspective on this study is provided in the related Author Insights video. Click here to access the video.  

Marc Swiontkowski, MD
JBJS Editor-in-Chief 

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