Nicotine Equivalence Across Modern Delivery Systems: A Clinical Framework for Perioperative Assessment

Background Nicotine use is a well-established risk factor for impaired bone healing, infection, and poor outcomes following orthopedic surgery. Although perioperative assessment traditionally focuses on cigarette smoking, nicotine consumption has shifted toward electronic cigarettes, oral nicotine pouches, and other alternative systems. Many of these products deliver nicotine doses that equal or exceed those of traditional cigarettes, yet no standardized clinical method exists to quantify and compare exposure across products. This review provides an updated framework for nicotine exposure equivalence using cigarette pack equivalents, enabling clinicians to estimate systemic nicotine absorption across delivery systems. Methods A narrative review was conducted of PubMed, Google Scholar, and Scopus for studies related to nicotine delivery systems, orthopedic outcomes, bone healing, and fracture through 2024. Nicotine concentrations from major brands and route-specific bioavailability data were identified from the literature. Cigarette pack equivalents were calculated using published bioavailability estimates and standardized against estimated systemic nicotine delivery from one pack of cigarettes. Results Our model demonstrates many alternative products deliver nicotine comparable to or exceeding traditional cigarettes: a single 5,000-puff disposable vape delivers systemic nicotine equivalent to approximately 25 packs of cigarettes, a can of 6 mg nicotine pouches is exceeds 2 packs, and a single JUUL pod approximates 1 pack. Discussion Despite differences in delivery mechanisms and pharmacokinetics, nicotine’s negative effects on fracture and wound healing remain present. As nicotine usage evolves, surgeons must evaluate usage beyond cigarettes alone. This framework provides a practical method to estimate total and systemic nicotine exposure across delivery systems.