Stopping Smoking Before Surgery:
Advantages and Issues
Dr. John Oyston
Assistant Professor
University of Toronto
Department of Anesthesia
3rd Ottawa Model Conference
February 4th 2011
How Important is Smoking?
• It is the #1 cause of preventable death
• It consumes 15% of health care budget
• It is more important than Breast Cancer
More women die of lung cancer due to smoking than from breast cancer.
Why do anesthesiologists across Canada
care about smoking?
• We provide anesthesia for patients who would
not have needed surgery if they had never
smoked
Anesthesiologists
–
Obvious examples
see the problems
• Peripheral and cardiac vascular disease
caused
by
smoking
every
day
• Lung and ENT cancers
– Less obvious
• Bladder tumours (3 x risk: Smoking causes 50%)
• Cataracts (20% due to smoking, 50,000 per year)
• Fractures (84% increase hip fractures in smokers)
Chronic smokers have chronic
health problems:
CAD
COPD
Arteriosclerosis
Smokers do less well in the
operating suite
ST Depression v CO level
Anesthesia and Analgesia 1999; 89 856 HJ Woehlck et al
Smokers do less well postoperatively
Short Term
- Worse wound
healing (Mastectomy
flap necrosis 18.9% v
9.0 in NS) (DW Chang Plastic &
Long Term
- Worse outcome
(more pain, poorer
function) one year
after ACL repair (Karim,
Reconstr Surg. 2000 p2374)
JBJS, 2006)
- More infections
(12% in smokers, v
2% NS) (Sorensen, Ann Surg,
2003)
“We found that smoking was
the single most important
risk factor for the
development of postoperative
complications”
(Moller JBJS 2002)
… and smokers are more likely to
come back for repeat surgery
• Failure of original operation
Spinal fusion: Non-union twice as common in
smokers (Glassman Spine 2000)
• Postoperative complications
Abdominal wall necrosis (Smokers 7.9% Ex-smokers 4.3%
NS 1.0 %). (Padubidri Plastic & Recon Surgery: 2001: p342)
• Progression of underlying disease
Fem-pop graft -> Revision/Endarterectomy >Sympathectomy ->Toe amputation ->BKA -> AKA
Smokers are a pain in
the butt for
anesthesiologists.
Can we do anything about that?
120 patients for elective joint replacement
Randomised to control or smoking cessation intervention:
Control
Routine preoperative preparation
4 stopped smoking anyway
Intervention Routine preoperative preparation plus
weekly meetings with nurse, NRT therapy
36 stopped smoking, 14 reduced, 6 continued
Results
Control
Wound problems:
31%
CV Insufficiency
10%
Avg. days in hospital
Total days in ICU
13
32
Intervention
5%
0%
11
2
Stopping smoking reduces risk:
When to stop?
• Ideally 6 – 8 weeks or longer
• Definite advantage of 4 weeks
• For carbon monoxide elimination, 4 -8 hours
– “No smoking after midnight”?
– Risk of stopping shortly before surgery?
• Postoperative quitting aids wound healing
How and when to educate patients
about preoperative smoking cessation:
• In community, healthy
• With a surgical condition, in GPs office
• In surgeon’s office
My recommendation:
• At least one preoperative smoking
cessation counselling session should
be mandatory before elective
surgery .
• Surgery should be scheduled no
sooner than six weeks after
attending that session.
How and when to educate patients
about preoperative smoking cessation:
•
•
•
•
In community, healthy
With a surgical condition, in GPs office
In surgeon’s office
During preadmission process
– Phone/MD/Pharmacy
• In hospital
• Post-surgical follow-up
• Back in community
Three quick issues:
Should anesthesiologists
prescribe anti-smoking drugs
(e.g. Bupropion, Varenicline)?
In my clinical setting, where:
– I see patients only once
– I rely on their self-reported medical and psychiatric history
– It is difficult for patients or their families to get back in touch
with me
– There is no out-of-hours coverage
I do not feel it is appropriate to prescribe medications which
have significant risks.
Some colleagues in academic teaching centres disagree.
Does nicotine impair bone healing?
• Yes, in experimental models
– Vasoconstriction
– Parasympathetic system
– Effect on stem cells
• Is this a reason to avoid NRT in Ortho
patients?
– Probably not
– Some studies showing benefit of quitting used
NRT
Is it worth quitting
before minor surgery?
• There is no evidence that quitting before
minor surgery improves outcome
• BUT … if patients quit when they have an
arthroscopy or D & C, when they need a joint
replacement or hysterectomy, they will have
been smoke free for weeks or months!
Can we use surgery as a tool to
promote smoking cessation?
•
•
It’s a reason to quit at a specific date
Suddenly convert from being healthy to
being a patient
•
It’s a way to regain an element of control
in a stressful situation
•
Less withdrawal symptoms
•
Surgery forces interaction with a variety of
health care workers
Does surgery make smokers quit?
(Crouse & Hagaman, Am J Epidemiology, 991 p 699)
Percentage quit smoking 1 year later
Non-cardiac surgery
Angiography
Angioplasty
CABPG
13%
14%
25%
55%
How important is surgery as a reason
to quit?
• 8% of all quitting is related to surgery
• 100,000 patients/yr in US quit due to surgery
(Yu Shi, Anesthesiology, 2010)
But 42% of pts said they were not informed
about the effects of preop smoking and 43%
of anesthesiologists don’t routinely advise
smokers to quit.
• There are specific health and economic
benefits to perioperative smoking cessation
• 1.3 m operations are performed in Canada
every year (~ 250,000 on smokers)
• We are not leveraging this opportunity to get
smokers to quit
• We need a national strategy!
• An independent not-for-profit organization
• Evidence-based, focussed on patient safety
and organizational excellence
• 600 surveyors ensure proper policies in place
in 1000 health service organizations across
Canada and world wide
• Now becoming interested in smoking policies!
Anesthesiology 2006, 104;356-67
www.stopsmokingforsafersurgery.ca
john7@oyston.com
ADDITIONAL SLIDES