Helping Surgical Patients Quit Smoking: Why, When, and How
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MEDICAL INTELLIGENCE
Helping Surgical Patients Quit Smoking: Why, When,
and How
David O. Warner, MD
Department of Anesthesiology, Mayo Clinic College of Medicine
Millions of cigarette smokers undergo elective surgery than double the chances of success. These include sim-
each year. Efforts to help them quit smoking could im- ple physician advice to quit, brief behavioral interven-
prove immediate perioperative outcomes, such as tions that can be provided by physicians or other clini-
those related to the cardiac and respiratory systems, cians, and pharmacotherapy with drugs such as
and the healing of surgical wounds. Perhaps more im- nicotine. Although specific strategies tailored for the
portantly, the scheduling of elective surgery represents surgical patient remain to be developed, there are steps
an excellent opportunity for smokers to permanently that anesthesiologists can implement into their prac-
quit, with great benefit to their long-term health. Al- tices now that can help their patients quit smoking.
though it is difficult for smokers to quit, there are now
several interventions of proven benefit that can more (Anesth Analg 2005;101:481–7)
A
pproximately 23% of American adults smoke to systematically identify all tobacco users who come
cigarettes, and one-third of these individuals in contact with the health care system, strongly urge
will die prematurely because of their use of them to stop, and aid them in doing so. The Guideline
tobacco (1). Each year, millions of cigarette smokers goes on to say that “. . .all physicians should strongly
require surgery and anesthesia. Two major benefits advise every patient who smokes to quit because ev-
could result from efforts to help them quit smoking. idence shows that physician advice to quit smoking
First, smoking increases the risk of some postoper- increases abstinence rates” (4). The scheduling of pa-
ative complications, including pulmonary complica- tients for surgery is a point of contact that is currently
tions such as atelectasis and pneumonia, cardiovas- not being exploited systematically for this purpose (5).
cular complications such as myocardial ischemia, Evidence demonstrates that even brief clinical inter-
and wound-related complications such as infection ventions can significantly increase abstinence rates in
(2,3). Even temporary abstinence from smoking may a variety of settings (4). More intensive services, initi-
reduce the risk of these complications and improve ated by physicians and fully implemented by other
surgical outcomes. Second, a surgical episode may providers, are even more effective. However, little
represent a “teachable moment” that encourages attention has been paid to the role of anesthesiologists
smokers to permanently quit, with great benefit to and surgeons in addressing tobacco use. Indeed, al-
their long-term health. though many surgical specialists recognize the ad-
Many physicians are not aware that there has verse effects of smoking both on short and long-term
been great progress in recent decades in the treat-
outcomes, few are familiar with methods to help their
ment of tobacco dependence, as summarized in the
patients quit smoking (5). Moreover, some may have
most recent United States Public Health Service
concerns with specific issues related to perioperative
Guideline on Tobacco Use and Dependence (4)
smoking cessation, such as whether it is safe for smok-
(available at http://www.surgeongeneral.gov/
ers to quit immediately before surgery and the safety
tobacco/). A primary recommendation of this report is
of nicotine replacement therapy (NRT) in surgical
patients.
This commentary will briefly explore 1) why
Supported, in part, by the Mayo Foundation. smokers should maintain perioperative abstinence
Accepted for publication January 25, 2005.
Address correspondence and reprint requests to David O. Warner,
from cigarettes for as long as possible, 2) why sur-
MD, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, Phone: gery is an opportune moment for smokers to quit
507–255– 4288, Fax: 507–255–7300, Email: warner.david@mayo.edu permanently, and 3) how anesthesiologists can help
DOI: 10.1213/01.ANE.0000159152.31129.84 them do so.
©2005 by the International Anesthesia Research Society
0003-2999/05 Anesth Analg 2005;101:481–7 481482 MEDICAL INTELLIGENCE WARNER ANESTH ANALG
SMOKING CESSATION IN SURGICAL PATIENTS 2005;101:481–7
How Does Abstinence from Smoking Affect Surgeons have long recognized that the healing of
surgical wounds may be impaired in smokers, espe-
Outcomes After Anesthesia and Surgery? cially after procedures such as face lifts that require
Smoking affects perioperative outcomes in two ways. wide undermining of skin flaps (14). Possible mecha-
First, smoking contributes to chronic illnesses such as nisms include a reduction in tissue oxygenation
coronary artery disease, chronic obstructive lung dis- caused by chronic changes in microvasculature or car-
ease, and many others that may increase the risk of boxyhemoglobinemia or effects on immune function.
perioperative complications. Second, some of the These factors can cause wound dehiscence and infec-
more than 3000 constituents of cigarette smoke, such tion. Also, bone healing may be impaired in smokers
as nicotine and carbon monoxide (CO), have acute undergoing orthopedic procedures (15). Preoperative
physiologic effects that could plausibly contribute to smoking cessation can dramatically decrease the fre-
risk. As a result, status as a current cigarette smoker is quency of wound-related complications (7); the dura-
an independent risk factor for many postoperative tion of abstinence necessary for this benefit is not
complications (6,7); however, status as an ex-smoker is known but it appears to be ⬍4 wk (16).
generally not such a risk factor, suggesting that pre-
operative abstinence from smoking can reduce risk.
Although prolonged abstinence before surgery clearly Is It Harmful for Smokers to Quit
can improve postoperative outcomes, the benefits of Immediately Before Surgery?
more brief periods of abstinence are less clear and, for
most complications, the duration of abstinence needed Both patients and physicians may have concerns that
to derive benefit remains to be defined. The best data brief preoperative abstinence may actually be harmful
exist for perioperative cardiac, respiratory, and (13) for at least two reasons. First, many smokers
wound-related complications, which all occur with report that respiratory symptoms, such as cough and
increased frequency in smokers. sputum production, actually increase over the first
Smokers are at increased risk for perioperative car- few weeks after quitting. This may explain why it
diac complications, in part because cigarette smoking takes several weeks of abstinence before a reduction in
postoperative pulmonary complications is observed
increases the risk of developing cardiovascular disease
(6,12). However, abstinence within a few weeks of
(8). Recent smoking may also contribute to acute vas-
surgery does not significantly increase the rate of com-
cular events by promoting a hypercoagulable state,
plications (6,12). Thus, fear of worsening pulmonary
increasing myocardial work, decreasing oxygen deliv-
outcomes should not discourage physicians from urg-
ery secondary to CO, causing coronary vasoconstric-
ing their patients to quit regardless of the anticipated
tion, and releasing catecholamines (9). Constituents of
duration of preoperative abstinence. Second, many
cigarette smoke that may contribute to these effects smokers view cigarettes as a tool to manage stress, and
include nicotine, CO (which can interfere with pulse they may be reluctant to abstain at a time when they
oximetry), oxidant gases, and polycyclic hydrocar- face the considerable stresses associated with surgery.
bons. As a result, smoking acutely decreases exercise Furthermore, nicotine is highly addictive and nicotine
capacity and relatively brief abstinence improves it withdrawal can manifest several unpleasant symp-
(10). In smokers, expired CO concentration, an indica- toms, including irritability, restlessness, sleep distur-
tor of recent smoking, is correlated with the frequency bances, and depression, all of which could potentially
of significant ST depression during general anesthesia complicate postoperative recovery. However, recent
(11). Thus, although the period of abstinence needed work (17) demonstrates that smokers report no greater
to reduce perioperative risk is not known, even rela- increases in psychological stress over the periopera-
tively brief preoperative abstinence may be beneficial. tive period than do nonsmokers, nor do they consis-
Smoking is also a risk factor for postoperative pul- tently develop symptoms of nicotine withdrawal.
monary complications, in part because smoking Thus, patients (and their physicians) can be reassured
causes chronic pulmonary disease (6). Acute effects of that craving for tobacco will not routinely hamper
smoke on ciliary function, the activity of airway effer- their recovery if they remain abstinent. In addition,
ent nerves, and pulmonary immune function may also NRT can be used to help manage any withdrawal
contribute to complications. Smoking cessation im- symptoms that do occur.
proves pulmonary function, but this benefit may take
several weeks or months to become apparent. Like-
wise, it may take a similar period of abstinence before Is Surgery a Good Opportunity for
a reduction in postoperative pulmonary complications
is observed, with available studies estimating that at Smokers to Quit Permanently?
least 2 mo of abstinence is required before risk dimin- A “teachable moment” is an event that motivates in-
ishes (6,12,13). dividuals to adopt health behaviors that reduce riskANESTH ANALG MEDICAL INTELLIGENCE WARNER 483
2005;101:481–7 SMOKING CESSATION IN SURGICAL PATIENTS
(18). There is strong evidence that the concept ap- as using counseling (i.e., information exchange with
plies to smoking cessation, as events such as preg- patients) or pharmacotherapy.
nancy, disease diagnosis, and hospitalization are Several principles are apparent from the evidence
associated with increased rates of spontaneous regarding the role of counseling in promoting smok-
smoking cessation compared with the rate in the ing cessation (4). Physician advice to stop smoking
general population. In hospitalized patients, it ap- increases quit rates. Although the evidence support-
pears that the chances of quitting increase with the ing the role of nonphysician clinicians (such as
intensity of medical interventions. For example, one nurses) is less available, it appears that advice from
study found that of smokers undergoing cardiac these providers is also effective. Thus, even if clini-
interventions, 55% of those undergoing coronary cians do nothing else, smokers should be advised to
artery bypass grafting, 25% of those undergoing quit at every opportunity. Brief counseling (⬍3 min)
angioplasty, and 14% of those undergoing only an- regarding smoking cessation provided by clinicians
giography were abstinent 1 yr after the intervention, will further increase the rate of abstinence. More
a significant difference that persisted even after ad- intensive interventions are even more effective, and
justment for severity of disease (19). For patients
there is a dose-response relationship between the
scheduled for elective surgery, those undergoing
total time spent in interventions and efficacy. These
more extensive interventions (for example, those
interventions can be delivered by a variety of pro-
undergoing inpatient versus outpatient procedures)
viders with equal effectiveness. Many different for-
have a greater likelihood of spontaneously quitting
after surgery (17). Thus, elective surgery can serve mats of interventions are effective, including tele-
as a teachable moment as defined. In addition, as a phone counseling, group counseling, and individual
result of smoke-free policies in United States (US) counseling. In fact, the use of multiple formats in-
health care facilities, some period of abstinence is creases efficacy. Components of effective interven-
mandatory, such that all smokers must at least tem- tions include assisting the patient in devising a per-
porarily address their tobacco dependence. Effective sonalized quit plan, providing practical problem
tobacco interventions could dramatically impact the solving skills, helping the patient obtain social sup-
long-term health of the millions of smokers who port (e.g., from a spouse), and providing supple-
undergo surgical procedures in the US annually. In mental materials (e.g., brochures, etc.). Therapy is
addition, considering that prevalence rates of smok- effective in both genders and across age groups and
ing are even higher in many other countries, the different racial and ethnic backgrounds.
application of effective interventions worldwide Pharmacotherapy is an important element of strat-
could represent a significant contribution to world egies to help smokers quit (22). The use of these med-
public health. ications approximately doubles the rate of abstinence.
Nicotine derived from tobacco use can be replaced
using several different delivery systems, including
gum, inhalers, nasal spray, patches, and lozenges. All
What Methods to Help Smokers Quit Are systems are effective in promoting cessation and each
Effective? has potential advantages. For example, patches need
only be applied once daily, compared with other for-
Most smokers want to quit but find it very difficult
mulations that need to be administered several times
to do so. Approximately 70% of smokers report
throughout the day. Conversely, some patients prefer
wanting to quit, and more than 50% of them make a
to titrate their nicotine levels more precisely using the
quit attempt each year, but most attempts are not
successful (4). Nonetheless, millions of people have other delivery systems. NRT is generally well toler-
succeeded in quitting, usually after multiple at- ated, with the predominant side effect consisting of
tempts. A meta-analysis sponsored by the United local irritation at the site of delivery. Nicotine gum,
States Public Health Service screened more than patches, and lozenges are available without a pre-
6,000 articles and was used to formulate practice scription in the US. Other medications also are useful
recommendations based on expert panel opinion in promoting cessation. Sustained release bupropion,
(4). The efficacy of several interventions is sup- also used as an antidepressant, is approved by the
ported by multiple randomized clinical trials (Fig. Food and Drug Administration (FDA) for this pur-
1). Most of these trials have involved the general pose. Side effects include insomnia and dry mouth.
ambulatory population, and very few have specifi- Unlike nicotine replacement, patients should begin
cally examined surgical patients (20). However, sev- taking bupropion for 1–2 wk before they quit smok-
eral trials have examined the role of tobacco inter- ing. Clonidine is also effective, although it has not
ventions in hospitalized patients and found similar been FDA approved for this indication and side effects
results (21). These interventions can be categorized may limit its application.484 MEDICAL INTELLIGENCE WARNER ANESTH ANALG
SMOKING CESSATION IN SURGICAL PATIENTS 2005;101:481–7
Figure 1. Methods of proven efficacy to help patients quit smoking, based on the highest level of evidence from expert panel review (multiple
randomized clinical trials that are directly relevant to the topic and show a consistent pattern of results). When possible, patients should
receive both counseling and pharmacotherapy.
Is It Safe to Use NRT in Surgical smokers with coronary artery disease, even if they
continue smoking (9). NRT may even reduce cardio-
Patients? vascular risk if cigarette consumption is reduced but
There are two primary concerns with using NRT in not eliminated. For example, NRT significantly de-
surgical patients: the effects of nicotine on cardiovas- creases the extent of exercise-induced myocardial is-
cular function and its effects on wound and bone chemia assessed by exercise thallium imaging in
healing. smokers with coronary artery disease (23). These re-
Although the effects of NRT on cardiac function sults suggest that the benefits of NRT to help patients
have not been studied specifically in surgical patients, with coronary heart disease stop smoking outweigh
much is known about the safety of NRT in ambulatory the risk of continued smoking and support the concept
patients with coronary artery disease. NRT does not that components of cigarette smoke other than nico-
increase the frequency of cardiac events in cigarette tine, such as CO, contribute to adverse cardiac effects.ANESTH ANALG MEDICAL INTELLIGENCE WARNER 485 2005;101:481–7 SMOKING CESSATION IN SURGICAL PATIENTS Figure 2. An example of brief patient educational material that can be used by anesthesiologists in the periopera- tive period. The materials should be customized by adding the phone num- bers for quit lines available in a specific area (available at www.smokefree.gov) or other resources, such as referral to nicotine dependence centers, that may be available in specific practice settings. Animal experiments support the clinical observa- even when nicotine is continued. Although more stud- tion that cigarette smoking can impair wound and ies need to be performed specific to the surgical set- bone healing. For example, the survival of skin flaps ting, available evidence does not support a detrimen- that require wide undermining is decreased in ani- tal effect of NRT in surgical patients, especially when mals exposed to smoke-filled chambers compared compared with the consequences of continued with smoke-free control animals (24). In these studies, smoking. it is not possible to determine which constituents of cigarette smoke are responsible for these effects. Sev- eral studies have shown that nicotine itself can impair How Can Anesthesiologists Help Smokers wound healing in experimental animals (25). How- ever, most studies use nicotine doses far in excess of Quit? those provided by NRT in humans, doses often suffi- Given factors such as the time pressures associated cient to cause anorexia and weight loss. One important with current practice, often associated with limited study (16) showed that quitting smoking dramatically preoperative patient contact with an anesthesiologist, decreased the incidence of surgical wound infection in implementation of tobacco interventions poses very humans; this benefit was observed whether or not the real challenges. Ideally, the interventions provided by subjects used NRT to promote cessation. Thus, as in anesthesiologists should be just one component of a the case of cardiovascular function, avoidance of the comprehensive approach that includes systemic ap- other constituents of cigarette smoke is beneficial, proaches such as collaborations with other health care
486 MEDICAL INTELLIGENCE WARNER ANESTH ANALG
SMOKING CESSATION IN SURGICAL PATIENTS 2005;101:481–7
providers. Given their role as perioperative physi- Depending on practice settings, there may be other
cians, anesthesiologists should at least be supportive opportunities to intervene. If the patient is seen before
of these efforts if they do not take a leading role. the day of surgery, more intensive interventions can
Although much more research is needed regarding be administered, including more extensive counseling
how best to implement systems to help surgical pa- and the preoperative initiation of pharmacotherapy. If
tients quit smoking, in the meantime there are steps anesthesiologists see patients postoperatively before
that all anesthesiologists can take today to help their discharge from the facility, this provides an excellent
patients quit. For primary care physicians, compo- opportunity to reinforce the stop smoking message,
nents of clinical interventions have been codified as and ensures that referral to appropriate resources is
the “5 A’s”: Ask about tobacco use, Advise to quit, made. If these opportunities for intervention are com-
Assess willingness to make a quit attempt, Assist in bined with other physician contact inherent in the
quit attempt, and Arrange followup. Even with lim- surgical process, including the surgeons’ preoperative
ited preoperative patient contact, anesthesiologists can and postoperative visits and interventions by other
perform these first three intervention elements as part clinicians, multiple reinforcing messages could have a
of their preoperative visit. powerful effect on smoking behavior, both in the im-
Ask. All written or electronic medical records used mediate perioperative period and in the long term.
to document patient history as part of the preoperative Indeed, as perioperative physicians, anesthesiologists
evaluation should have a prominent system for con- may be uniquely qualified to develop and lead mul-
sistently identifying current and past tobacco use. In tidisciplinary tobacco interventions by the surgical
addition, all anesthesiologists should verbally query team.
for tobacco use as a part of the preoperative interview,
including the time of last tobacco use.
Advise. Every smoker should be strongly urged to
quit. This message should be tailored to take advan-
Summary
tage of the unique circumstances of surgery. All pa- Anesthesiologists do not hesitate to insist that patients
tients can be told that continued smoking may hinder change their behavior when they believe that such
their recovery from surgery, so that they should try to changes will be beneficial. For example, we consis-
refrain from cigarettes for as long as possible after tently force our patients to deprive themselves of food
their operation. This should be advised to all patients, for a certain preoperative interval. Growing evidence
even those who do not plan on stopping permanently suggests that smoking in the perioperative period is
or those who do not express receptivity to interven- harmful. Even limited perioperative abstinence may
tions. If seen at least 1 day before surgery, patients be beneficial and should be strongly recommended by
should be advised to “fast” from cigarettes beginning anesthesiologists. Perhaps more importantly, if anes-
the evening before surgery, using nicotine gum or thesiologists can take the next step to help their pa-
lozenges, if desired, the morning of surgery. Then, tients take advantage of the excellent opportunity to
taking advantage of surgery as a teachable moment, quit permanently, they can make a significant differ-
they can be told that this is an excellent time to con- ence in the lives of their patients that extends far
sider permanently quitting and that the forced absti- beyond the relatively brief perioperative encounter.
nence associated with their visit to a health care facil-
ity will be an opportune time to initiate and extend a The author thanks Drs. Richard Hurt, Lowell Dale, William Lanier,
quit attempt. Michael Sarr, and David Danielson, and Mr. Kenneth Offord (all
Assist. During a brief preoperative visit, options from Mayo Clinic, Rochester, MN), for their helpful suggestions,
for personally providing assistance may be limited. and Ms. Kay Eberman (Mayo Clinic Nicotine Dependence Center,
However, there are now numerous sources to which Rochester, MN) for assistance designing Figure 2.
patients who want help in quitting can be referred.
Many health systems have specialized nicotine depen-
dence treatment centers that provide a wide range of
services. Many, but not all, health plans will cover References
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