Nontobacco Nicotine in Orthopaedic Surgery: Current Knowledge and Limitations of Database Investigations

» Non-tobacco nicotine (NTN) products (e.g., e-cigarettes and nicotine pouches) are increasingly used, including among patients who identify as "nonsmokers," but their independent impact on surgical outcomes remains uncertain. » Basic science and animal studies demonstrate biologic plausibility that nicotine may impair healing of soft tissue and osseous structures; however, these models do not define clinical risk associated with modern NTN use patterns. » Retrospective database studies suggesting increased complications among "NTN users" are highly susceptible to exposure misclassification due to reliance on nonspecific nicotine dependence coding, potentially conflating smokers with exclusive NTN users. » The absence of standardized exposure metrics for NTN products limits dose-response assessment; development and adoption of a uniform quantification framework (e.g., nicotine milligrams per week) is essential for future clinical research and risk stratification. » In the absence of prospective human data with validated exposure measurement, perioperative cessation of all nicotine products is a reasonable precaution, but definitive, nicotine-specific surgical risk cannot be established.