Updated 09/14/2015 by Susan M. Lee, MD
Smoking and Anesthesia/Surgery
An estimated 42.1 million U.S. adults (almost 18% of the population) currently smoke [Jamal Morb Mortal Wkly Rep 63(47):1108-12, 2014] and up to half of these individuals will die prematurely because of their use of tobacco. Each year, millions of cigarette smokers require surgery and anesthesia. The majority of these smokers want to quit [Warner Anesth Analg 101:481-7, 2005]. It is well known that smoking increases the risk of postoperative complications; smoking has repeatedly been shown to be a univariate and multivariate risk factor for respiratory failure, ICU admission, pneumonia, laryngospasm, and increased use of respiratory therapy services [Warner Anesthesiology 104: 356, 2006]. In a cohort study of 607,558 adult National Surgical Quality Improvement Program patients undergoing major surgery, current smokers had increased odds of myocardial infarction, stroke, respiratory events, and even death [Musallam JAMA 148(8):755-762, 2013].
Perioperative Smoking Cessation
Surgery as a “Teachable Moment”
Surgery may represent a “teachable moment” for promotion of long-term smoking cessation: i.e., smokers may be more receptive to messages urging them to quit [Arch Surg 144(12):1106-7, 2009]. A “teachable moment” is an event that motivates individuals to adopt health behaviors that reduce risk and there is strong evidence that the concept applies to smoking cessation. Surgery is one such encounter with the healthcare system (similar to pregnancy, disease diagnosis, and hospitalization) that is associated with increased spontaneous smoking cessation compared with the rate in the general population, particularly in patients undergoing more invasive procedures [Warner Anesth Analg 101:481-7, 2005].
Behavioral techniques (e.g., brief interventions, telephone quit lines, face-to-face counseling) and pharmacotherapy (e.g., nicotine replacement therapy, varenicline) are effective for perioperative smoking cessation. A Cochrane review [Thomsen Cochrane Database Syst Rev 27;3:CD002294, 2014] showed that when such preoperative interventions were delivered intensively with multisession face-to-face counseling, smokers were more than ten times more likely to quit (RR=10.8; 95% CI 4.6-25.5). Brief interventions were also modestly effective (RR=1.3, 95% CI 1.2-1.5).
Reduction in Complications
Well-timed preoperative smoking cessation can reduce postoperative complications, particularly wound and pulmonary. Several randomized trials have achieved 20%-30% absolute risk reductions in complications with interventions started 4-8 weeks preoperatively [Møller Lancet 12;359(9301):114-7, 2002; Lindström Ann Surg 248(5):739-45, 2008]. A Cochrane review [Thomsen Cochrane Database Syst Rev 27;3:CD002294, 2014] showed that preoperative interventions were effective in reducing postoperative complications, although only in the more intensive subgroup (RR 0.42; 95% CI 0.27- 0.65 for any complication; RR 0.31; 95% CI 0.16-0.62 for wound complications).
Timing of Cessation
The length of time necessary to benefit previous smokers is not exactly clear. Twelve to 24 hours is enough to decrease carboxyhemoglobin levels and shift the dissociation curve rightward (increasing oxygen availability to tissues). One to 2 weeks may be enough to reduce sputum volume [Moore Clin Chest Med 21: 139, 2000]. A systematic review of 25 studies on the optimal timing of smoking cessation [Wong Can J Anaesth 59:268-279, 2012] concluded that at least 4 weeks of abstinence from smoking reduced respiratory complications, and abstinence of at least 3 to 4 weeks reduced wound healing complications. Short-term (<4 weeks) smoking cessation did not appear to increase or reduce the risk of postoperative respiratory complications. While some observational studies have shown that short-term smoking cessation before surgery may increase pulmonary complications [Bluman Chest 113: 883, 1998], other studies have not shown any increase in pulmonary complications with short-term cessation [Barerra Chest 127(6):1977-83, 2005]. Observational studies comparing recent, past and current smokers may be limited by confounding (e.g., smokers going for higher-risk surgeries may be more likely to quit smoking shortly before surgery).
In addition to potentially reducing complications in the short-term, perioperative smoking cessation may lead to long-term cessation and its associated public health benefits. Several trials have demonstrated abstinence 12 months after perioperative smoking cessation interventions. Abstinence was achieved in 25-36% of those individuals randomized to cessation programs [Azodi Anaesthesia 64(3):259-65, 2009; Wong Anesthesiology 117(4):755-64, 2012; Lee Anesth Analg 120(3):582-7, 2015].
The U.S. Preventive Services Task Force recommends that all adults be asked about tobacco use at every health visit and all smokers be provided tobacco cessation interventions [Calonge Ann Intern Med 150(8):551-5, 2009]. The ASA recommends that all patients should abstain from smoking for as long as possible both before and after surgery, and they should obtain help in doing so. Patients can receive help in a variety of ways, including pharmacotherpy and telephone quit lines (e.g. 1-800-QUITNOW in the USA), which are of proven efficacy [ASA HOD Statement of Smoking Cessation, 2008].
Ask the Experts Podcast
Dr. David O. Warner discusses smoking Cessation, anesthesia and Alzheimer’s Disease in our September 2013 podcast.