The Prospective, Multicenter Scoli-RISK-1 Study analyzed 270 patients. For a study, the researchers wanted to determine how smoking affected the frequencies of postoperative adverse events (AEs) in patients who had high-risk adult spine deformity surgery. Although smoking is a proven predictor of medical issues following adult deformity surgery, the impact on complications, implant failure, and other adverse effects has yet to be properly documented in prospective research. Out of the 272 patients, 26 participated in the SCOLI-RISK-1 research who underwent difficult adult spinal deformity surgery at 15 locations with a 2-year follow-up and had a history of current smoking. Univariate analysis was used to compare the outcomes and incidence of AEs in these patients to the nonsmoking sample (n=244), with further multivariate regression used to account for the effect of patient demographics, surgical complexity, and other variables. In both cohorts, the number of levels and the complexity of operation were comparable. The rates of implant failure were nearly double (odds ratio 2.28 [0.75–6.18]) in the smoking group (n=7; 26.9%) than in the nonsmoking group (n=34; 13.9%) in the univariate analysis, although this was not statistically significant (P=0.088). Excessive bleeding (>4L) associated with surgery was considerably higher in the smoking group (n=5 vs. n=9; 19.2% vs 3.7%; OR 6.22 [1.48–22.75]; P=0.006). Both groups had equal rates of wound infection and respiratory problems. The smoking group had a greater incidence of any surgery-related AEs over 2 years (n=13 vs n=95; 50.0% vs 38.9%; OR 2.12 [0.88–5.09]) (P=0.094). A history of smoking significantly increased the risk of excessive intraoperative bleeding and non-significantly increased the probability of implant failure or surgery-related AEs over 2 years in the secondary analysis of participants from the SCOLI-RISK-1 research. As a result, the authors recommend that patients undergoing difficult adult spine deformity surgery participate in a smoking cessation programme.