Cigarette smoking and its ramifications are coming under increasing scrutiny in the field of orthopedic surgery. Smoking has been implicated in impeding bone metabolism and fracture repair, and increasing the rate of postoperative infection and the incidence of nonunion. This article reviews the current body of knowledge on these topics, as well as the potential adverse effects of smoking on wound healing and microsurgical procedures. An in-depth discussion on the pathophysiologic mechanisms of nicotine is also included.