The impact of tobacco smoking on recovery from orthopaedic trauma surgery is well known, with cigarettes linked to increased risk of post-operative infection, [1–3] wound and flap necrosis, [4] and a decrease in the tensile strength of wounds [5]. Despite this, rates of tobacco smoking among orthopaedic trauma patients remain higher than that in the general population (37% vs. 14.5% in 2014) [6, 7].

When treating tobacco addiction, it is important to identify factors that may undermine quit attempts. Comorbidity, that is, having more than one co-occurring physical or mental health condition at any one time, [8] is known to complicate smoking cessation treatment [9]. Rates of symptoms of anxiety and depression have been found to be higher in orthopaedic trauma patients (39 and 30.5% respectively) [10] when compared to the general population, [7] and rates of symptoms of anxiety and depression continue to remain high up to two years post-hospital discharge (29.4 and 37.6%, respectively) [11]. Previous research also indicates that rates of hazardous alcohol and recent cannabis use are high in the orthopaedic trauma population [12]. In addition, orthopaedic trauma patients who are readmitted to hospital are more likely to use tobacco, alcohol and other drugs, indicating the need to address the comorbidities within the orthopaedic trauma population [13]. As far as the authors are aware, rates of smoking, alcohol and cannabis use, and symptoms of depression and anxiety have yet to be assessed in the one study among orthopaedic trauma patients.

Guidelines recommend provision of smoking cessation care and nicotine replacement therapy (NRT) during the inpatient stay [14, 15]. Research suggests that concurrent treatment of co-occurring tobacco and other substance use is more effective than delayed treatment [16]. Concurrent treatment of alcohol use and depression, [17] and depressive symptoms and smoking [18] have been found to be effective. Further, treating tobacco addiction has a positive impact on rates of use of other drugs, with tobacco cessation related to long term reduction or abstinence from other drugs [19]. Thus, if comorbid smoking, alcohol use, cannabis use, and symptoms of depression and anxiety are found to be high among a cohort of hospitalised orthopaeic trauma patients, then there would be implications for the treatment of tobacco use in this setting.

We hypothesise that addressing comorbid health conditions of tobacco smoking (such as other substance use or mental ill-health) when providing smoking cessation care in this setting may: a) improve the health outcome of patients faster, given the negative health impact substance use and mental ill-health can have on recovery; [1–3] and b) decrease health care costs and lengths of hospital admissions, given continued substance use may result in readmission or longer hospital stays, [20] and that are readmitted to hospital are more likely to use substances [13].

Thus, this study aims to characterise an orthopaedic trauma population, and build on prior research in this population [6, 12]. Specifically, this study aims to:

1. describe the rates of symptoms of anxiety, depression, and substance use (alcohol and cannabis) among patients admitted for an orthopaedic trauma;
2. compare rates of symptoms of anxiety, depression, and alcohol and cannabis use among smokers versus non-smokers; and.
3. examine the relationship between comorbid symptoms of anxiety and depression, alcohol and recent cannabis use with current tobacco use.