Preoperative Smoking Cessation: The Role of the Primary Care Provider

doi:10.4065/80.2.252

Mayo Clinic Proceedings

Volume 80, Issue 2, February 2005, Pages 252-258

https://doi.org/10.4065/80.2.252 Get rights and content

Millions of cigarette smokers require surgery each year. Those who quit smoking may reduce their risk of respiratory, cardiovascular, and wound-related complications. Scheduling of surgery may present a unique opportunity to help smokers quit permanently. Primary care providers can play an important role in helping their patients scheduled for surgery quit smoking before their operation and maintain their abstinence after surgery. To do so effectively, physicians need to understand (1) the consequences of smoking in the perioperative period and how quitting can mitigate these problems, (2) how surgery can serve as a “teachable moment” to aid in smoking cessation, and (3) specific techniques that can be used to help their patients quit smoking, including brief counseling and pharmacotherapy.

Section snippets

SMOKING AND PERIOPERATIVE COMPLICATIONS

Although smoking contributes to many perioperative complications, 3 are of greatest clinical importance: pulmonary complications, cardiovascular complications, and complications related to impaired healing of bones and surgical wounds.

Cigarette smokers are at increased risk of postoperative complications such as pneumonia and respiratory failure.¹ Although some of this risk may be explained by smoking-related respiratory pathology such as chronic obstructive pulmonary disease, complications may

EFFECT OF SMOKING ABSTINENCE ON POSTOPERATIVE COMPLICATIONS

Quitting smoking reduces the risk of smoking-related disease in general, and perioperative complications are no exception. What is unknown in most cases is the minimum duration of preoperative abstinence necessary to confer benefit.

Smoking cessation is associated with a reduction in the risk of postoperative pulmonary complications; the frequency of complications in patients who have been abstinent for several months approaches that of patients who have never smoked.1, 10, 11 Observational

ELECTIVE SURGERY AS A “TEACHABLE MOMENT” FOR SMOKING CESSATION

The scheduling of elective surgery presents an excellent opportunity to provide interventions directed toward tobacco use. A “teachable moment” is an event that motivates individuals to change health behaviors that increase risk.¹⁸ There is strong evidence that the concept applies to tobacco dependence because events such as disease diagnosis, pregnancy, and hospitalization may be associated with an increased spontaneous rate of smoking cessation compared with the general population. For

HELPING SURGICAL PATIENTS QUIT SMOKING

Although smoking cessation is extremely difficult, millions of people have done so. Effective interventions are now available to help those who want to quit smoking. Practice recommendations based on expert panel opinion and meta-analysis of available studies provide clear guidance to primary care physicians.²⁶ The elements of brief tobacco interventions have been codified as the “5 A's” (Table 1) according to the Clinical Practice Guideline for Treating Tobacco Use and Dependence (available at

SUMMARY

The perioperative period provides a unique opportunity to intervene in cigarette smokers, which may improve immediate postoperative outcomes. Moreover, by exploiting the potential of surgery as a teachable moment, clinicians can substantially benefit the long-term health of their patients, a benefit that extends far beyond the perioperative period. Effective strategies require coordination between all involved in the surgical process, and such strategies are only beginning to be explored.

Acknowledgments

I thank Dr Richard D. Hurt, Dr Lowell C. Dale, Kenneth P. Offord, and Darrell R. Schroeder (all from the Nicotine Research Center, Mayo Clinic, Rochester, Minn) for their continued support and Kay Eberman (Mayo Clinic Nicotine Dependence Center, Rochester, Minn) for assistance with Figure 1.

Questions About Preoperative Smoking Cessation

1.
Smoking does not increase risk for which one of the following postoperative complications?
- a.
  Pneumonia
- b.
  Myocardial ischemia
- c.
  Nausea and vomiting
- d.
  Wound infection
- e.
  Nonunion of fractured bones
2.
Patients should quit smoking before surgery for at least which one of the following periods to maximally decrease the risk of postoperative pulmonary complications?
- a.
  1 day
- b.
  1 week
- c.
  2 months
- d.
  6 months
- e.
  1 year
3.
Which one of the following is not one of the “5 A's” of brief tobacco interventions?
- a.
  Ask
- b.
  Advise
- c.

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Cited by (56)

Guidelines for Perioperative Care in Cytoreductive Surgery (CRS) with or without hyperthermic IntraPEritoneal chemotherapy (HIPEC): Enhanced recovery after surgery (ERAS®) Society Recommendations — Part I: Preoperative and intraoperative management
2020, European Journal of Surgical Oncology
Enhanced recovery after surgery (ERAS) pathways have been shown to considerably reduce complications, length of stay and costs after most of surgical procedures by standardised application of best evidence-based perioperative care. The aim was to elaborate dedicated recommendations for cytoreductive surgery (CRS) ± hyperthermic intraperitoneal chemotherapy (HIPEC) in a two-part series of guidelines based on expert consensus. The present part I of the guidelines highlights preoperative and intraoperative management.
The core group assembled a multidisciplinary panel of 24 experts involved in peritoneal surface malignancy surgery representing the fields of general surgery (n = 12), gynaecological surgery (n = 6), and anaesthesia (n = 6). Experts systematically reviewed and summarized the available evidence on 72 identified perioperative care items, following the GRADE (grading of recommendations, assessment, development, evaluation) system. Final consensus (defined as ≥50%, or ≥70% of weak/strong recommendations combined) was reached by a standardised 2-round Delphi process, regarding the strength of recommendations.
Response rates were 100% for both Delphi rounds. Quality of evidence was evaluated high, moderate low and very low, for 15 (21%), 26 (36%), 29 (40%) and 2 items, respectively. Consensus was reached for 71/72(98.6%) items. Strong recommendations were defined for 37 items, No consensus could be reached regarding the preemptive use of fresh frozen plasma.
The present ERAS recommendations for CRS±HIPEC are based on a standardised expert consensus process providing clinicians with valuable guidance. There is an urgent need to produce high quality studies for CRS±HIPEC and to prospectively evaluate recommendations in clinical practice.
Opioid cessation: another teachable moment
2020, British Journal of Anaesthesia
Cognitive impairment assessment and interventions to optimize surgical patient outcomes
2020, Best Practice and Research: Clinical Anaesthesiology
Citation Excerpt :
This increases the risk of acquired infections and the need for prolonged mechanical ventilation [149]. Tobacco also inhibits the immune system involved in wound healing and increases the risk for blood clots [150,151]. Remarkably, carbon monoxide levels are significantly reduced within 12 h, while nicotine is reduced after 2 h of smoking cessation [152–158].
For elderly patients undergoing elective surgical procedures, preoperative evaluation of cognition is often overlooked. Patients may experience postoperative delirium (POD) and postoperative cognitive decline (POCD), especially those with certain risk factors, including advanced age. Preoperative cognitive impairment is a leading risk factor for both POD and POCD, and studies have noted that identifying these deficiencies is critical during the preoperative period so that appropriate preventive strategies can be implemented. Comprehensive geriatric assessment is a useful approach which evaluates a patient's medical, psycho-social, and functional domains objectively. Various screening tools are available for preoperatively identifying patients with cognitive impairment. The Enhanced Recovery After Surgery (ERAS) protocols have been discussed in the context of prehabilitation as an effort to optimize a patient's physical status prior to surgery and decrease the risk of POD and POCD. Evidence-based protocols are warranted to standardize care in efforts to effectively meet the needs of these patients.
Feasibility of Nurse-Managed Tobacco Use Interventions in Outpatient Surgical Practice
2020, Journal of Perianesthesia Nursing
The aim of this study was to determine the feasibility of developing and implementing a brief nurse-delivered tobacco intervention in an outpatient surgical practice.
Initial formative work used a survey and focus groups to determine knowledge, attitudes, and practices of perioperative nurses working in three outpatient surgical practices regarding smoking use and cessation. Based on this work, a brief intervention was designed and implemented in one of the three practices. The documentation of tobacco use and intervention elements was assessed both immediately and approximately 9 months after implementation.
Formative work identified not only several barriers to implementation and little current activity but also favorable attitudes toward interventions. Implementation improved self-efficacy for intervention delivery and compliance with documentation of intervention elements that was sustained for at least 9 months.
Our results suggest that it is feasible for perioperative nurses to play an important role in the delivery of perioperative tobacco interventions.
Smoking As a Risk Factor for Postcraniotomy 30-Day Mortality
2019, World Neurosurgery
There is limited information on the impact of smoking on postcraniotomy mortality. In this study we used the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) to examine this issue.
We identified 16,280 postcraniotomy patients in the ACS-NSQIP database. Indications for surgery were categorized by vascular, trauma, epilepsy, malignant tumor, and benign tumor. Univariate and multivariable logistic regression analyses were used to identify risk factors associated with mortality.
In the ACS-NSQIP dataset, postcraniotomy mortality within 30 days of surgery was 5.03%. An area under the curve analysis indicated 30 pack-years as the optimal discriminating threshold for risk stratification in terms of 30-day postcraniotomy mortality. Using this threshold, multivariate analyses revealed 3 variables that were closely associated with 30-day post-craniotomy mortality: male gender (P = 0.002), indication for operation (P < 0.001), and a smoking history of ≥30 pack-years (P < 0.001). In subsequent stratified analyses, smoking-associated mortality risk was observed only in males (odds ratio of 2.33 comparing males with ≥30 and <30 pack-years of smoking history; 97.5% confidence interval 1.36–4.03). When the analysis was further stratified by surgical indications, the mortality association with smoking was found only in male patients who underwent craniotomy as treatment for neurovascular diseases (odds ratio 3.88, 97.5% confidence interval 1.39–11.65). Such an association was not seen in patients who underwent craniotomy for traumatic brain injury, malignant tumors, benign tumors, or epilepsy.
This study identified ≥30 pack-years as a risk factor for male patients undergoing craniotomy as treatment for neurovascular diseases.
The effect of smoking on post-operative complications of selected surgical interventions and on their cost analyses
2018, Kontakt
Citation Excerpt :
Although the study did not prove a higher percentage of complications in smokers, nor any effect of a short-term smoking cessation on the decrease in post-operative complications, each patient should receive a brief smoking intervention that does not take more than 5–10 min. In this respect, unfortunately, we found that many physicians are unwilling to tell patients to quit smoking, despite the fact that an operation may be an impulse to change one's lifestyle [26,27]. Another major issue is a high number of smokers among medical professionals [28–31].
This paper studies the effect of smoking on post-operative complications in certain surgical interventions in Czech hospitals. Patients were divided into three groups – smokers, ex-smokers and non-smokers. The first part was a retrospective study of cholecystectomies performed in Jihlava Hospital. The hospital provided anonymised data concerning 253 patients who were operated on in 2014, including 61 smokers, 15 ex-smokers and 177 non-smokers. Consequently, a prospective observational study of the effect of smoking on complications after planned hip or knee replacement surgeries was carried out. The study included all patients of the orthopaedic departments of the University Hospital Královské Vinohrady and the Regional Hospital Mladá Boleslav; those included were scheduled for planned surgeries in January or February 2017, and signed the informed consent for participation in the study. Data concerning a total of 61 patients, including 27 non-smokers, 25 ex-smokers and 9 smokers were collected. This study, the first of its kind in the Czech environment, found neither a higher percentage of complications after the studied surgical interventions in smokers, nor any positive effect of short-term smoking cessation on post-operative complications. Both the results of a literary review and expert opinions of surgeons vary. Above all, Scandinavian authors have defended the positive effect of a short-term smoking cessation before surgery. However, this position seems to be in a conflict with the results of our study, which found the highest incidence of post-operative complications in ex-smokers. The study indicates a need for a carefully designed and sufficiently large research focusing on ex-smokers and the impact of the pre-operative smoking cessation, which would yield statistically significant results (whether positive or negative).

View all citing articles on Scopus

Supported in part by the Minnesota Partnership for Action Against Tobacco and by the Mayo Foundation.

A question-and-answer section appears at the end of this article.

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Concise Review for CliniciansPreoperative Smoking Cessation: The Role of the Primary Care Provider

Section snippets

SMOKING AND PERIOPERATIVE COMPLICATIONS

EFFECT OF SMOKING ABSTINENCE ON POSTOPERATIVE COMPLICATIONS

ELECTIVE SURGERY AS A “TEACHABLE MOMENT” FOR SMOKING CESSATION

HELPING SURGICAL PATIENTS QUIT SMOKING

SUMMARY

Acknowledgments

Questions About Preoperative Smoking Cessation

Clin Chest Med

Respir Med

Am J Surg

J Am Coll Cardiol

Mayo Clin Proc

Chest

Chest

Lancet

Prev Med

Smoking decreases alveolar macrophage function during anesthesia and surgery

Anesthesiology

Smoking and wound healing

Am J Med

Risk of respiratory complications and wound infection in patients undergoing ambulatory surgery: smokers versus nonsmokers

Anesthesiology

Cigarette smoking and its orthopedic consequences

Am J Orthop

Concise Review for Clinicians
Preoperative Smoking Cessation: The Role of the Primary Care Provider