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The detrimental effects of smoking on pedicled and free flap reconstruction are well documented. The purpose of this study was to examine the effect of smoking on flap, donor-site, and other individual and multiple complications in pedicled transverse rectus abdominis myocutaneous (TRAM) flap breast reconstruction.A retrospective review was carried out of 224 pedicled TRAM flaps in 200 patients over a 10-year period. Three subgroups of patients were identified: active smokers, former smokers (defined as patients who stopped smoking at least 4 weeks before reconstruction), and nonsmokers (patients with no history of smoking). Active smokers made up 15.5 percent of the study population, while former smokers and nonsmokers made up 17.5 percent and 67 percent, respectively. There were no statistically significant differences in age, weight, radiation/chemotherapy history, distribution of flap pedicle types, timing of reconstruction, or percentage of delay procedures performed among the smoking subgroups. Logistic regression analysis was used to identify significant risk factors and determine their odds ratios.Compared with nonsmokers, both active and former smokers had a higher incidence of multiple flap complications (p = 0.0023 and 0.0018, respectively; odds ratios, 5.1 and 4.9). Active smokers also had a statistically significant higher rate of TRAM infection compared with nonsmokers (p = 0.0243; odds ratio, 4.7). Finally, former smokers were found to have a higher rate of TRAM delayed wound healing compared with nonsmokers (p = 0.0165; odds ratio, 4.7).Logistic regression identified active smoking as a statistically significant risk factor for developing multiple flap complications and TRAM infection, while former smoking was a risk factor for multiple flap complications and TRAM delayed wound healing. Thus, active and former smoking should similarly be considered contraindications for pedicled TRAM flap breast reconstruction, unless the patient has stopped smoking for more than 4 weeks before surgery.