Despite the known health risks associated with cigarettes, millions of Americans continue to smoke. Much has been reported on the adverse effects of cigarette smoke on wound healing. Recent experimental work and clinical observation have demonstrated the risk of impaired bone healing associated with cigarette smoking. The authors review the biological aspects of bone healing and analyze how the chemical components of cigarette smoke affect the bone healing process. Laboratory and clinical data are also reviewed. Cessation of cigarette smoking before foot and ankle surgery is recommended by the authors.