Stopping Smoking Before Surgery:Advantages and Issues

Dr. John OystonAssistant Professor

University of Toronto Department of Anesthesia

3rd Ottawa Model ConferenceFebruary 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 Why do anesthesiologists across Canada care about smoking?care about smoking?

Anesthesiologists see the problems caused by smoking every day

• We provide anesthesia for patients who would not have needed surgery if they had never smoked– Obvious examples

• Peripheral and cardiac vascular disease• 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:

COPDCOPDCADCAD

Arteriosclerosis

Arteriosclerosis

Smokers do less well in the operating suite

ST Depression v CO levelAnesthesia 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 & Reconstr Surg. 2000 p2374)

- More infections (12% in smokers, v 2% NS) (Sorensen, Ann Surg, 2003)

Long Term- Worse outcome (more pain, poorer function) one year after ACL repair (Karim, JBJS, 2006)

“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 complicationsAbdominal wall necrosis (Smokers 7.9% Ex-smokers 4.3% NS 1.0 %). (Padubidri Plastic & Recon Surgery: 2001: p342)

• Progression of underlying diseaseFem-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 replacementRandomised to control or smoking cessation intervention:

Control Routine preoperative preparation4 stopped smoking anyway

Intervention Routine preoperative preparation plusweekly meetings with nurse, NRT therapy

36 stopped smoking, 14 reduced, 6 continued

Results

Control InterventionWound problems: 31% 5% CV Insufficiency 10% 0%

Avg. days in hospital 13 11Total days in ICU 32 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)

55%

25%

14%

13%

CABPG

Angioplasty

Angiography

Non-cardiac surgery

Percentage quit smoking 1 year later

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!

www.stopsmokingforsafersurgery.cajohn7@oyston.com

THANK YOU FOR LISTENING

Anesthesiology 2006, 104;356-67

ADDITIONAL SLIDES