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Background: Sinonasal inverted papilloma (IP) is a neoplasm in the nasal cavity, characterized by its local aggressiveness and tendency to cause malignancy. Despite the frequent recurrence of IP, few studies have reported the effects of situational parameters including smoking on the recurrence rate of IP. This study was performed to evaluate clinical and environmental factors including smoking that can predict neoplasm recurrence after surgery in patients with IP. Methods: This study was conducted retrospectively on 132 patients who were diagnosed with IP between November 1985 and September 2007. The study focused on the risk factors of recurrence, such as smoking behaviors, diabetes mellitus (DM), hypertension (HTN), allergic rhinitis (AR), the sites of tumor origin and involvement, neoplasm staging, and the surgical method. The age of the patients ranged from 22 to 85 years, and among the 132 patients, 39 patients were smokers (29.5%), 17 (13.3%) with DM, 31 (24.4%) with HTN, and 11 (9.3%) with AR. Results: The recurrence rate showed great disparity between the groups of smokers and nonsmokers: 28.2% of smokers suffered recurrence compared with 10.7% recurrence from the nonsmoker group. The Krouse stage IV group experienced more frequent recurrence than the stage I, II, and III groups. Some patients in Krouse stage III (5/72, 6.9%) and IV (3/3, 100%) groups underwent malignant transformation of IP. Histories of DM, HTN, and AR did not exert a statistically meaningful influence on the recurrence and malignant transformation. Conclusion: The smoking behavior and tumor with extranasal/sinus extension appear to be associated with recurrence of IP after surgical resection. [ABSTRACT FROM AUTHOR]