The Impact of Cigarette Smoking, Waterpipe Smoking, and E‑Cigarette Vaping on Peri-Implant Clinical Outcomes and Inflammatory Markers: a Systematic Review and Meta-Analysis

Abstract

Objectives: The purpose of this systematic review and meta-analysis was to evaluate and compare the impact of cigarette smoking, waterpipe smoking, and electronic cigarette vaping on peri-implant clinical outcomes and inflammatory biomarkers in comparison with non-smokers.

Material and Methods: The systematic review was conducted following PRISMA guidelines. A comprehensive literature search was performed using the MEDLINE (PubMed) database. Studies published between October 2015 and October 2025 involving adults with dental implants were included. Random-effects models calculated mean differences (MD) for marginal bone loss and cytokines, and standardized mean differences (SMD) for plaque index and bleeding on probing (BOP).

Results: All smoking modalities were associated with significantly worse peri-implant outcomes than non-smokers. Plaque index increased for cigarette (+5.22 units), waterpipe (+6.31), and e-cigarette users (+1.61). Marginal bone loss was greater in cigarette (+2.16 mm), waterpipe (+1.9 mm), and e-cigarette users (+0.83 mm). Cigarette smokers showed the highest IL-1β (MD = 239.63 pg/mL), while e-cigarette users exhibited elevated IL-1β (+170 pg/mL) and TNF-α (+17.6 pg/mL). A paradoxical reduction in BOP was observed. Subgroup analyses confirmed a risk gradient of cigarette > waterpipe > e-cigarette > non-smoker.

Conclusions: Cigarette smoking exerts the greatest detrimental effect on peri-implant outcomes, followed by waterpipe and e-cigarette use. All modalities promote bone loss, plaque accumulation, and inflammation despite reduced bleeding, likely due to nicotine-induced vasoconstriction. Evidence on waterpipe and vaping remains limited, emphasizing the need for standardized long-term studies.