After reconstructive arterial surgery 190 patients with peripheral arterial disease of lower limbs (PAD) were followed up for three years in a prospective manner to assess the effects of smoking habits on the outcome. 173 patients (91%) were smokers at presentation. 48 patients reported to have given up smoking during the study. Exsmokers could not be included in the analysis, however, due to differences in the severity of PAD, age, sex ratio, type of operation and other risk factors. Current moderate (MS) (less than 15 cigarettes/day, N = 45) and heavy smokers (HS) (greater than or equal to 15, N = 80) were comparable groups. The three-year relative cumulative survival rates among male HS and MS were 0.40 and 0.65 (p less than 0.05), respectively. HS died mostly of cardiovascular causes. Major amputation was needed in 21% of HS compared to only 2% in MS (p less than 0.001). The present results show a strong association with heavy smoking, cardiovascular mortality and severe local adverse events. Thus, arterial thrombogenity appears to be enhanced by continued heavy smoking in patients with peripheral atherosclerosis.