All Forms of Tobacco Products Adversely Affect Rotator Cuff Healing

Commentary It is widely known that cigarette smoking has a negative effect on healing after rotator cuff repair. This novel study by Yoon et al. looks to associate the use of heated tobacco products with healing, validated outcome measures, and range of motion. Understanding the preoperative risk profile of each patient allows us to provide a more informative discussion when counseling patients on the risk of failure following rotator cuff repair. This study provides information on the risk of using new heated tobacco products that will greatly add to the literature and will allow practitioners to discuss the benefits of cessation of heated tobacco use in the perioperative period. This retrospective study identified patients who underwent arthroscopic rotator cuff repair for symptomatic rotator cuff tears with a minimum 2-year follow-up and 6-month postoperative magnetic resonance imaging (MRI). Forty-five heated tobacco smokers were identified, and 1:1:1 propensity score matching was used to select comparison patients from the substantially larger cigarette smoker and nonsmoker groups. Propensity scoring predicts the probability of belonging to a specific group by matching patients on the basis of relevant covariates to reduce confounding variables. Yoon et al. used age, fatty infiltration, and tear size to perform matching. Important to note, the inclusion criteria for the heated tobacco smoker group required the exclusive use of heated tobacco for at least 3 months prior to the surgical procedure and throughout the postoperative period. However, if the heated tobacco smokers were previous cigarette smokers, they were not excluded. The propensity score matching diminished the effect of selection bias; however, it failed to eliminate the confounding variable of smoking history in heated tobacco smokers. Recently, Livesey et al.1 demonstrated that even patients who quit smoking up to 6 months prior to a rotator cuff surgical procedure still experienced an elevated risk of repair failure. Heated tobacco has been marketed and used as a smoking alternative; thus, a high number of former smokers transitioning to this will make it difficult to fully elucidate the effect of exclusively heated tobacco products without greatly diminishing the size of the analyzed population. A strength of this study method was the review of 6-month postoperative MRI scans by 2 independent observers to assess retears. A power analysis was used to assess the ability to identify a significant difference in retears among the groups; however, this was not undertaken for clinical outcomes, and likely this population was underpowered to find clinical outcome differences. A weakness of the study is the lack of uniform fixation of the tears; some tears were fixed with a double row, and some were fixed with a single row. The retear rate was significantly lower in the nonsmoker group. The heated tobacco smoker group and the cigarette smoker group mirrored each other's retear rates. No significant differences were found in clinical scores or range of motion, but the study was likely underpowered. Univariate and multivariable analysis revealed smoking status, age, tear size, and fatty infiltration as significant variables, which corresponds to the current literature and helps to further validate the study methods that Yoon et al. used. In summary, this novel study shows that heated tobacco use has a similar deleterious effect on rotator cuff repair healing as cigarette smoking. The clinical importance of this is still to be understood and would require a much larger study to be adequately powered to assess. In addition, the effect of former smoking prior to heated tobacco use cannot be discounted as a confounding variable. To our knowledge, this is the first study to address the impact of heated tobacco use on rotator cuff repair. Further study on heated tobacco use is needed to understand the effect of differing usage (heavy compared with light usage) and of the preoperative timing of cessation. Answers to these will help surgeons to better counsel patients on the likelihood of success and how best to mitigate risk.