Differential Associations of Smoking, Alcohol, and Substance Use Disorders With Morbidity and Mortality After Traumatic Rib Fracture

IntroductionA "smoker's paradox" has been described in rib fractures for which smokers have demonstrated increased complications but decreased mortality. Alcohol has shown increased mortality risk but the effect of substance use has not been well evaluated. Given the paucity of data surrounding these outcomes, we evaluated the impact of alcohol use, smoking, and substance use disorders on outcomes after traumatic rib fracture.MethodsWe performed a five-year retrospective review for all adult patients admitted to our level 1 trauma center with rib fractures. Each outcome was evaluated independently in a stepwise backward regression model for potential confounding factors. We then performed multivariable linear and logistic regression to examine the relationship between alcohol, smoking, and substance use to outcomes.ResultsIn total, 3,327 patients were included for review. Smoking was associated with increased morbidity but a paradoxical decreased risk of respiratory failure and a 56% decreased risk of mortality. Substance use disorder had increased risk of respiratory failure and complications but a paradoxical 66% decreased risk of mortality. Alcohol use disorder was associated with increased morbidity with no change in mortality and no paradoxical beneficial outcomes. Both alcohol and substance use disorders were associated with significantly prolonged hospital length of stay.ConclusionDespite increased morbidity, both smoking and substance use disorder demonstrated significantly decreased mortality. These findings could support the expansion to a "smoker's and substance use paradox" in traumatic rib fracture although further study is warranted.