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Studies investigating the association of cigarette smoking with prostate cancer incidence and outcomes have revealed controversial results.To systematically review and analyze the association of smoking status with biochemical recurrence, metastasis, and cancer-specific mortality among patients with localized prostate cancer undergoing primary radical prostatectomy or radiotherapy.A systematic search of original articles published between January 2000 and March 2017 was performed using PubMed, MEDLINE, Embase, and Cochrane Library databases in March 2017.Observational studies reporting Cox proportional hazards regression or logistic regression analyses were independently screened.This systematic review and meta-analysis was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement and the Cochrane Handbook for Systematic Reviews of Interventions. Available multivariable hazard ratios (HRs) and corresponding 95% CIs were included in quantitative analysis. A risk-of-bias assessment was completed for nonrandomized studies.Prespecified outcomes of interest were biochemical recurrence, metastasis, and cancer-specific mortality.A total of 5157 reports were identified, of which 16 articles were selected for qualitative analysis and 11 articles were selected for quantitative analysis. All included studies were observational and nonrandomized and comprised a total of 22 549 patients. Overall, 4202 patients (18.6%) were current smokers. The overall median follow-up was 72 months. Current smokers had a statistically significantly higher risk of biochemical recurrence (HR, 1.40; 95% CI, 1.18-1.66; P < .001 [10 studies]), as did former smokers (HR, 1.19; 95% CI, 1.09-1.30; P < .001 [7 studies]). Current smokers were also at a higher risk of metastasis (HR, 2.51; 95% CI, 1.80-3.51; P < .001 [3 studies]) and cancer-specific mortality (HR, 1.89; 95% CI, 1.37-2.60; P < .001 [5 studies]), whereas former smokers were not (metastasis: HR, 1.61; 95% CI, 0.65-3.97; P = .31 [2 studies]; cancer-specific mortality: HR, 1.05; 95% CI, 0.81-1.37; P = .70 [4 studies]).Current smokers at the time of primary curative treatment for localized prostate cancer are at higher risk of experiencing biochemical recurrence, metastasis, and cancer-specific mortality.