Effects of preoperative smoking cessation on the incidence and risk of intraoperative and postoperative complications in adult smokers: a systematic review

The impact of smoking on neurosurgical outcomes

Cigarette smoking is a common health risk behavior among the general adult population, and is the leading preventable cause of morbidity and mortality in the US. The surgical literature shows that active tobacco smoking is a major risk factor for perioperative morbidity and complications, and that preoperative smoking cessation is an effective measure to lower these risks associated with active smoking. However, few studies have examined the effects of smoking and perioperative complications following neurosurgical procedures. The goal of this review was to highlight the scientific data that do exist regarding the impact of smoking on neurosurgical outcomes, to promote awareness of the need for further work in the specific neurosurgical context, and to suggest ways that neurosurgeons can promote smoking cessation in their patients and lead efforts nationally to emphasize the importance of preoperative smoking cessation. This review indicates that there is limited but good evidence that smoking is associated with higher rates of perioperative complications following neurosurgical intervention. Specific research is needed to understand the effects of smoking and perioperative complications. Neurosurgeons should encourage preoperative smoking cessation as part of their clinical practice to mitigate perioperative morbidity associated with active smoking.

Translating preoperative smoking cessation interventions into routine clinical care of veterans: provider beliefs

Smoking among veterans undergoing surgery is estimated to be 36%. Smoking has been linked to postoperative surgical complications including ischemia and cardiac arrhythmias, pneumonia, deep venous thrombosis, pulmonary embolism, and surgical site infection. Preoperative smoking cessation interventions, in which smokers quit at least 6 weeks prior to surgery, have been shown to be effective both in smoking cessation and reduction of postoperative complications; however, little is known about physician beliefs regarding the optimal location and the responsible provider for intervention, or whether surgery should be postponed or delayed based on smoking status. Within the routine coordination from medical to surgical care, how should cessation interventions best be implemented? To better inform the translation of preoperative best practices for smoking cessation into clinical care in VA, a survey regarding preoperative smoking cessation beliefs and practices was administered to primary care physicians, surgeons, and anesthesia providers. Chi-square tests were used to examine differences in proportions by provider type. Most providers agreed that the primary care clinic is the best location for intervention, with preoperative and surgical clinics ranked by few as the optimal location (13% and 11%, respectively); most respondents (82%) reported that they would refuse or delay surgery in some cases based on smoking status. There were no differences in either beliefs on location or delay based on provider type. Primary care providers were most likely to advise (86.7%) and assess (80.0%) while anesthesia providers were least likely (59.1% and 22.7%, respectively). Taking time to counsel and the belief that dedicated resources would improve quit rates were associated with advising patients to quit smoking, while being uncomfortable with counseling, the belief that acute health takes precedence and the belief that there is not always time to counsel were identified as barriers to assessing patients for smoking cessation intervention. Primary care providers were more optimistic (100%) that patients would quit if counseled, more often (73.3%) reported having time to counsel, and were less likely to report that acute health takes precedence. Most providers believe that smoking cessation would reduce postoperative complications, with the ideal location for the intervention being the primary care clinic, and that some surgical cases should be delayed for this intervention.

Randomized trial of a presurgical scheduled reduced smoking intervention for patients newly diagnosed with cancer

OBJECTIVE

Cancer patients who smoke are advised to quit smoking to reduce treatment complications and future cancer risk. This study's main objective was to evaluate the efficacy of a novel, presurgical cessation intervention in newly diagnosed cancer patients scheduled for surgical hospitalization.

METHOD

We conducted a parallel-arm, randomized controlled trial comparing the efficacy of our hospital-based, tobacco cessation "best practices" treatment model (BP; cessation counseling and nicotine replacement therapy) with BP enhanced by a behavioral tapering regimen (scheduled reduced smoking; BP + SRS) administered by a handheld computer before hospitalization for surgery. Cessation outcomes were short (hospital admission and 3 months) and longer-term (6 months) biochemically verified smoking abstinence. We hypothesized that BP + SRS would be superior to BP alone. One hundred eighty-five smokers were enrolled.

RESULTS

Overall, 7-day-point prevalence, confirmed abstinence rates at 6 months for BP alone (32%) and BP + SRS (32%) were high; however, no main effect of treatment was observed. Patients who were older and diagnosed with lung cancer were more likely to quit smoking.

CONCLUSION

Compared to best practices for treating tobacco dependence, a presurgical, scheduled reduced smoking intervention did not improve abstinence rates among newly diagnosed cancer patients.reserved).

The effect of cigarette smoking on the severity of pain, swelling and trismus after the surgical extraction of impacted mandibular third molar

Objective: The study objective was to investigate the effect of cigarette smoking on the severity of pain, swelling and trismus on male after the surgical removal of impacted lower third molar. Material and Methods: This prospective comparative study was conducted for 150 male in two groups of patients, smokers and non-smokers. Each group consisted of 75 patients; smoking patient were the ones who smoke more than twenty cigarettes per day for more than one year of continuous smoking. Postoperative pain was evaluated using a visual analog scale (VAS) and the degree of swelling was evaluated through facial reference points’ variation. The presence of trismus was analyzed through measurement of the interincisal distance (IID). Result: Clinical and radiographic examinations were carried out. Data regarding the age, gender, angulations type, depth and width of impactions were evaluated and analyzed The severity of pain, swelling and trismus on the 1st, 2nd , 5th and 7thday postoperatively was estimated. In both groups the pain and trismus were reported to be in peak level during the first post-operative day while post-operative swelling reaches its peak level in the second postoperative day. Conclusion: Cigarettes smoking do not have any significant relationship with the severity of pain, swelling and trismus after surgical removal of lower third molar on male gender.

Key words:Cigarettes smoking, pain, swelling, trismus, impacted lower third molars.

What strategies are helpful in the operative management of third molars?

PURPOSE

The purpose of this review was to investigate and report strategies that might improve patient recovery after third molar (M3) surgery.

MATERIALS AND METHODS

This was a literature review on various topics to identify the methods of improving outcomes after M3 removal. Numerous topics were reviewed, including patient age, flap design, effect of smoking, use of antibacterial rinses, pre-emptive analgesia, and the role of antibiotics and corticosteroids in recovery.

RESULTS

Increased patient age appears to be a factor in a higher complication rate, but the literature is sparse. The results of studies on flap design are contradictory, but there is no difference in long-term periodontal health. Systematic reviews clearly show that longer periods of smoking cessation decrease surgical complications, but few studies have addressed M3 surgery. Likewise, the role of pre-emptive analgesia, although beneficial in a general surgical setting, has not been studied thoroughly with regard to M3 surgery. The use of chlorhexidine rinses to prevent alveolar osteitis and surgical site infection has been studied extensively, but meta-analyses have not convincingly proved this effect. The evidence is convincing that antibiotics decrease alveolar osteitis and surgical site infection. Similarly, it is clear that corticosteroids decrease postoperative trismus and edema; however, the role of steroids in decreasing pain is not proved.

CONCLUSION

This review found various factors associated with improving recovery and minimizing complications in M3 surgery.

Perioperative management of chronic respiratory disease

Respiratory disease contributes significantly to the perioperative challenges of surgery. Preexisting pulmonary co-morbidities and respiratory complications can have profound effects on patient outcomes. Knowledge of these conditions and the potentially deleterious effects of anaesthesia and surgery can enable clinicians to optimise lung function, reduce complications and improve results.

Distinguishing features of cancer patients who smoke: pain, symptom burden, and risk for opioid misuse

Although many cancer patients who have pain are smokers, the extent of their symptom burden and risk for opioid misuse are not well understood. In this study we analyzed records of patients being treated for cancer pain, 94 of whom were smokers and 392 of whom were nonsmokers, to determine smoking status group differences. Smokers had significantly higher pain intensity, fatigue, depression, and anxiety than nonsmokers (independent samples t-tests P < .002). Smokers were at higher risk for opioid misuse based on the short form of the Screener and Opioid Assessment for Patients with Pain (SOAPP). Specifically, smokers had more frequent problems with mood swings, taking medications other than how they are prescribed, a history of illegal drug use, and a history of legal problems (chi-square tests P ≤ .002). Changes in pain and opioid use were examined in a subset of patients (146 nonsmokers and 46 smokers) who were receiving opioid therapy on at least 2 of the 3 data time points (consult, follow-up 1 month after consult, follow-up 6 to 9 months after consult). Results based on multilevel linear modeling showed that over a period of approximately 6 months, smokers continued to report significantly higher pain than nonsmokers. Both smokers and nonsmokers reported a significant decline in pain across the 6-month period; the rate of decline did not differ across smokers and nonsmokers. No significant difference over time was found in opioid use between smokers and nonsmokers. These findings will guide subsequent studies and inform clinical practice, particularly the relevancy of smoking cessation.

PERSPECTIVE

This article describes pain, symptom burden, and risk for opioid misuse among cancer patients with pain across smoking status. Smoking appears to be a potential mechanism for having an increased pain and symptom burden and risk for opioid misuse. This improved understanding of cancer pain will inform clinical practice.

Hospital costs associated with smoking in veterans undergoing general surgery

BACKGROUND

Approximately 30% of patients undergoing elective general surgery smoke cigarettes. The association between smoking status and hospital costs in general surgery patients is unknown. The objectives of this study were to compare total inpatient costs in current smokers, former smokers, and never smokers undergoing general surgical procedures in Veterans Affairs (VA) hospitals; and to determine whether the relationship between smoking and cost is mediated by postoperative complications.

STUDY DESIGN

Patients undergoing general surgery during the period of October 1, 2005 to September 30, 2006 were identified in the VA Surgical Quality Improvement Program (VASQIP) data set. Inpatient costs were extracted from the VA Decision Support System (DSS). Relative surgical costs (incurred during index hospitalization and within 30 days of operation) for current and former smokers relative to never smokers, and possible mediators of the association between smoking status and cost were estimated using generalized linear regression models. Models were adjusted for preoperative and operative variables, accounting for clustering of costs at the hospital level.

RESULTS

Of the 14,853 general surgical patients, 34% were current smokers, 39% were former smokers, and 27% were never smokers. After controlling for patient covariates, current smokers had significantly higher costs compared with never smokers: relative cost was 1.04 (95% Cl 1.00 to 1.07; p = 0.04); relative costs for former smokers did not differ significantly from those of never smokers: 1.02 (95% Cl 0.99 to 1.06; p = 0.14). The relationship between smoking and hospital costs for current smokers was partially mediated by postoperative respiratory complications.

CONCLUSIONS

These findings complement emerging evidence recommending effective smoking cessation programs in general surgical patients and provide an estimate of the potential savings that could be accrued during the preoperative period.

Pulmonary complications after major head and neck surgery: A retrospective cohort study

OBJECTIVES/HYPOTHESIS

Postoperative pulmonary complications (PPCs) following head and neck surgery are common. Patients undergoing tracheostomy, free tissue transfer reconstruction, and postoperative ventilation in an intensive care unit (ICU) have a high incidence of PPCs. We sought to define the incidence of PPCs in this cohort and to determine what factors PPCs correlate with.

STUDY DESIGN

Retrospective cohort study.

METHODS

Following institutional research ethics board approval, a retrospective review of patients undergoing major head and neck surgery at a Canadian tertiary care center was conducted. The development of PPCs was the outcome of interest. Quality assurance parameters including ICU and hospital lengths of stay, and mortality were also recorded.

RESULTS

There were 105 patients enrolled, of which 47 (44.8%) sustained one or more PPCs. The most frequent PPC was respiratory failure, accounting for 39 of 94 PPCs observed. Hypertension was the only comorbidity that correlated with development of a PPC (P = .031). Those who sustained PPCs were older than those who did not (median age, 65.6 vs. 58.7 years; P = .005). Development of PPCs correlated with longer ICU and hospital stays. There was increased mortality among patients with PPCs compared to those without (12.8% vs. 1.7%, P = .04).

CONCLUSIONS

Patients undergoing major head and neck surgery are at high risk of PPCs. Advanced age and hypertension significantly correlated with PPCs. PPCs correlate with prolonged ICU and hospital stays, and increased mortality. Further research is needed to define risk factors, useful investigations, and effective optimization strategies to mitigate PPCs.

Short-term preoperative smoking cessation and postoperative complications: a systematic review and meta-analysis

PURPOSE

The literature was reviewed to determine the risks or benefits of short-term (less than four weeks) smoking cessation on postoperative complications and to derive the minimum duration of preoperative abstinence from smoking required to reduce such complications in adult surgical patients.

SOURCE

We searched MEDLINE, EMBASE, Cochrane, and other relevant databases for cohort studies and randomized controlled trials that reported postoperative complications (i.e., respiratory, cardiovascular, wound-healing) and mortality in patients who quit smoking within six months of surgery. Using a random effects model, meta-analyses were conducted to compare the relative risks of complications in ex-smokers with varying intervals of smoking cessation vs the risks in current smokers.

PRINCIPAL FINDINGS

We included 25 studies. Compared with current smokers, the risk of respiratory complications was similar in smokers who quit less than two or two to four weeks before surgery (risk ratio [RR] 1.20; 95% confidence interval [CI] 0.96 to 1.50 vs RR 1.14; CI 0.90 to 1.45, respectively). Smokers who quit more than four and more than eight weeks before surgery had lower risks of respiratory complications than current smokers (RR 0.77; 95% CI 0.61 to 0.96 and RR 0.53; 95% CI 0.37 to 0.76, respectively). For wound-healing complications, the risk was less in smokers who quit more than three to four weeks before surgery than in current smokers (RR 0.69; 95% CI 0.56 to 0.84). Few studies reported cardiovascular complications and there were few deaths.

CONCLUSION

At least four weeks of abstinence from smoking reduces respiratory complications, and abstinence of at least three to four weeks reduces wound-healing complications. Short-term (less than four weeks) smoking cessation does not appear to increase or reduce the risk of postoperative respiratory complications.

Impact of smoking on disease phenotype and postoperative outcomes for Crohn's disease patients undergoing surgery

AIM

Whether smoking affects disease distribution, phenotype, and perioperative outcomes for Crohn's disease (CD) patients undergoing surgery is not well characterized. The aim of this study is to evaluate the impact of smoking on disease phenotype and postoperative outcomes for CD patients undergoing surgery

METHODS

Prospectively collected data of CD patients undergoing colorectal resection were evaluated. CD patients who were current smokers (CS) were compared to nonsmokers (NS) and ex-smokers (ES) for disease phenotype, anatomic site involved, procedures performed, postoperative outcomes, and quality of life using the Cleveland Global Quality of Life instrument (CGQL).

RESULTS

Of 691 patients with a diagnosis of CD requiring surgery 314 were classified as CS, 330 as NS, and 47 as ES. CS and ES in comparison to NS were significantly older at diagnosis of Crohn's disease (mean, 29.3 vs. 29.2 vs. 26.3 years) (P = 0.001) and older at the time of primary surgery (mean, 42.9 vs. 48.4 vs. 39 years) (P = 0.001) with a greater frequency of diabetes. In all groups requiring surgery, there was a significant change in disease phenotype from the time of diagnosis to surgical intervention. The predominant phenotype at diagnosis was inflammatory which changed to stricturing and penetrating as the dominant phenotypes at time of surgery. All groups had a significant improvement in CGQL scores post-surgery with the greatest benefit observed in NS. Postoperative complications and 30-day readmission rates were similar between all groups.

CONCLUSIONS

The findings of this study show that in patients with CD, disease phenotype changes over time. This occurs independent of smoking. Smoking does not appear to predispose to complications for CD patients undergoing surgery. CS and ES have a persistently reduced quality of life in comparison to NS post-surgery.

Perioperative surgical care bundle reduces pancreaticoduodenectomy wound infections

BACKGROUND

Pancreaticoduodenectomy (PD) is a complex surgical procedure with a historically high morbidity rate. The goal of this study was to determine if the implementation of a 12-measure perioperative surgical care bundle (SCB) was successful in reducing infectious and other complications in patients undergoing PD compared with a routine preoperative preparation group (RPP).

METHODS

In this retrospective cohort study utilizing the HPB surgery database at the Thomas Jefferson University, we analyzed clinical data from 233 consecutive PDs from October 2005 to May 2008 on patients who underwent RPP, and compared them with 233 consecutive PDs from May 2008 to May 2010 following the implementation of the SCB. The SCB was the product of multidisciplinary discussion and extensive literature review.

RESULTS

The RPP group and the SCB group had similar demographic characteristics. The overall rate of postoperative morbidity was similar between groups (42.1% versus 37.8%). However, wound infections were significantly lower in the SCB group (15.0% versus 7.7%, P = 0.01).The rates of other common complications, as well as postoperative hospital length of stay, readmissions, and 30-d postoperative mortality were similar between groups.

CONCLUSIONS

The implementation of a SCB was followed by a significant decline in wound infection in patients undergoing PD.

The Gap between Tobacco Treatment Guidelines, Health Service Organization, and Clinical Practice in Comprehensive Cancer Centres

Smoking cessation is necessary to reach a higher quality of life, and, for a cancer patient, it represents an important step in improving the outcome of both prognosis and therapy. Being a cancer patient addicted to nicotine may be a critical situation. We conducted a survey to monitor how many comprehensive cancer centres in Italy have an outpatient smoker clinic and which kinds of resources are available. We also inquired about inpatient services offering psychological and pharmacological support for smoking cessation, reduction, or care of acute nicotine withdrawal symptoms. What we have witnessed is a significant gap between guidelines and services. Oncologists and cancer nurses are overscheduled, with insufficient time to engage in discussion on a problem that they do not consider directly related to cancer treatment. Furthermore, smoking habits and limited training in tobacco dependence and treatment act as an important barrier and lead to the undervaluation of smokers' needs.

A smoking cessation program as a resource for bladder cancer patients

BACKGROUND

Continued tobacco use following a bladder cancer (CaB) diagnosis puts patients at risk for other tobacco-associated diseases and has also been associated with heightened risks of treatment-related complications, tumour recurrence, morbidity and mortality. Our aim was to determine if patients with CaB who continue to smoke warrant a smoking cessation program as a resource for improving their prognosis and long-term health.

METHODS

A cross-sectional quantitative questionnaire-based study was performed between January and April 2009. We surveyed patients with a pathologically confirmed diagnosis of CaB during their cystoscopy appointments at a single cancer centre.

RESULTS

One hundred patients completed the survey with 72% of them admitting to smoking in their lifetime. A third of respondents smoked at the time of their diagnosis; 76% of patients who had been active smokers at the time of their diagnosis (n = 33) reported smoking at some point thereafter and 58% continued to smoke. Among continued smokers, they were classified in the following categories: 26% were in "precontemplation," 5% in "contemplation," 16% in "preparation," and 53% in "action;" 37% of patients who continued to smoke were interested in a hospital-based smoking cessation program. Overall, 70% reported smoking as a risk factor for a poor CaB prognosis. The two most common barriers to quitting were "trouble managing stress and mood" and "fear of gaining weight."

CONCLUSION

Based on the data from our centre, patients with CaB who continue to smoke after their diagnosis warrant a smoking cessation program as a resource for improving prognosis and long-term health. Further research should focus on establishing an efficacious and cost-effective program that provides these patients with the resources they need to quit smoking.

Smoking cessation reduces postoperative complications: a systematic review and meta-analysis

OBJECTIVE

We aimed to review randomized trials and observational evidence to establish the effect of preoperative smoking cessation on postoperative complications and to determine if there is an optimal cessation period before surgery.

METHODS

We conducted a systematic review of all randomized trials evaluating the effect of smoking cessation on postoperative complications and all observational studies evaluating the risk of complications among past smokers compared with current smokers. We searched independently, in duplicate, 10 electronic databases and the bibliographies of relevant reviews. We conducted a meta-analysis of randomized trials using a random effects model and performed a meta-regression to examine the impact of time, in weeks, on the magnitude of effect. For observational studies, we pooled proportions of past smokers in comparison with current smokers.

RESULTS

We included 6 randomized trials and 15 observational studies. We pooled the 6 randomized trials and demonstrated a relative risk reduction of 41% (95% confidence interval [CI], 15-59, P = .01) for prevention of postoperative complications. We found that each week of cessation increases the magnitude of effect by 19%. Trials of at least 4 weeks' smoking cessation had a significantly larger treatment effect than shorter trials (P = .04). Observational studies demonstrated important effects of smoking cessation on decreasing total complications (relative risk [RR] 0.76, 95% CI, 0.69-0.84, P < .0001, I(2) = 15%). This also was observed for reduced wound healing complications (RR 0.73, 95% CI, 0.61-0.87, P = .0006, I(2) = 0%) and pulmonary complications (RR 0.81, 95% CI, 0.70-0.93, P = .003, I(2) = 7%). Observational studies examining duration of cessation demonstrated that longer periods of cessation, compared with shorter periods, had an average reduction in total complications of 20% (RR 0.80, 95% CI, 3-33, P = .02, I(2) = 68%).

CONCLUSION

Longer periods of smoking cessation decrease the incidence of postoperative complications.

Implementation of an integrated peri-operative quality management program at the Ottawa Hospital

The 2004 Canadian Adverse Events Study estimated up to 23,750 potentially preventable in-hospital deaths occur annually; 51.4% of adverse events occurred with surgical care delivery. An integrated peri-operative quality management program has been implemented at The Ottawa Hospital using the American College of Surgeons National Surgical Quality Improvement Program (NSQIP). Using root cause analysis within a Plan-Do-Study-Act process improvement cycle, NSQIP will lead to improved peri-operative outcomes at the largest Canadian academic healthcare organization.

Oroantral communication as an osteotome sinus elevation complication

The sinus elevation procedure is a predictable technique to allow for placement of dental implants in the posterior maxilla when the height of the alveolar ridge is limited. The sinus elevation can be performed by various techniques. In the crestal approach, bone graft is utilized to hydraulically elevate the sinus membrane through an osteotomy prepared in the alveolar crest. The implant can be placed either immediately or at a later surgery. This is a case report of an oroantral communication that developed as a complication to a sinus elevation surgery performed with the crestal approach. A 54-year-old female patient presented for dental implant treatment. The patient reported sleep apnea and smoking. Full-thickness flap was reflected in the posterior maxilla and using trephines, an osteotomy was prepared, 1 mm short of the sinus. The trephined core of bone was pushed into the sinus using osteotomes. Particulate bone graft was introduced through the osteotomy to elevate the sinus membrane, and a collagen membrane was used over the bone graft. Six days after surgery, the patient returned to the clinic with an oroantral communication. The patient reported that she was using a positive-pressure breathing mask at night because of sleep apnea. A flap was extended to the tuberosity area and was rotated palatally to achieve closure. The use of the pressure breathing mask was discontinued. The oroantral communication was successfully closed. Relatively few complications have been reported using the osteotome sinus elevation technique. The use of a positive pressure mask may have complicated a sinus elevation surgery. Other factors that may have contributed to this complication include smoking and delayed healing of the area.

Donor factors are associated with bronchiolitis obliterans syndrome after lung transplantation

BACKGROUND

Bronchiolitis obliterans syndrome (BOS) is the major hurdle preventing long-term success in lung transplantation, and is the primary reason for the 50% 5-year survival. Recipient and perioperative risk factors have been investigated in BOS, but less is known about donor factors. Therefore, we investigated what donor factors are important in the development of BOS.

METHODS

We performed a retrospective review of the United Network for Organ Sharing lung transplant database from 1987 to 2008. Lung transplant recipients had yearly follow-up. Donor factors were evaluated for their influence on BOS development. Kaplan-Meier plots of BOS-free survival were compared for each donor factor and a multivariate Cox proportional hazard model for BOS was created with donor factors.

RESULTS

A total of 17,222 lung transplant recipients were identified; 6,991 recipients had sufficient follow-up BOS data. Of these recipients 57% (n = 3,984) developed BOS within 5 years. Recipients who received lungs from donors who were younger, without an active pulmonary infection, or those without current tobacco use had longer BOS-free survival. Recipients who received lungs with higher partial pressures of oxygen in arterial blood (Pao(2)) developed more BOS (p < 0.0001). Donor high Pao(2), older age, and current tobacco use were independent predictors of BOS in lung transplant recipients.

CONCLUSIONS

Donor factors and donor management strategies are important contributors to development of recipient BOS. Identification of these factors may help limit BOS and may identify recipients at high risk. Surprisingly, high Pao(2) in the donor is an independent predictor of BOS development.

Impact of smoking cessation before resection of lung cancer: a Society of Thoracic Surgeons General Thoracic Surgery Database study

BACKGROUND

Smoking cessation is presumed to be beneficial before resection of lung cancer. The effect of smoking cessation on outcome was investigated.

METHODS

From January 1999 to July 2007, in-hospital outcomes for 7990 primary resections for lung cancer in adults were reported to the Society of Thoracic Surgeons General Thoracic Surgery Database. Risk of hospital death and respiratory complications was assessed according to timing of smoking cessation, adjusted for clinical confounders.

RESULTS

Hospital mortality was 1.4% (n = 109), but 1.5% in patients who had smoked (105 of 6965) vs 0.39% in those who had not (4 of 1025). Compared with the latter, risk-adjusted odds ratios were 3.5 (p = 0.03), 4.6 (p = 0.03), 2.6 (p = 0.7), and 2.5 (p = 0.11) for those whose timing of smoking cessation was categorized as current smoker, quit from 14 days to 1 month, 1 to 12 months, or more than 12 months preoperatively, respectively. Prevalence of major pulmonary complications was 5.7% (456 of 7965) overall, but 6.2% in patients who had smoked (429 of 6941) vs 2.5%% in those who had not (27 of 1024). Compared with the latter, risk-adjusted odds ratios were 1.80 (p = 0.03), 1.62 (p = 0.14), 1.51 (p = 0.20), and 1.29 (p = 0.3) for those whose timing of smoking cessation was categorized as above.

CONCLUSIONS

Risks of hospital death and pulmonary complications after lung cancer resection were increased by smoking and mitigated slowly by preoperative cessation. No optimal interval of smoking cessation was identifiable. Patients should be counseled to stop smoking irrespective of surgical timing.

The effect of pre-operative counselling on smoking patterns in patients undergoing forefoot surgery

BACKGROUND

Smoking contributes to higher surgical complication rates. Previous studies assessing smoking cessation interventions examined the provision of comprehensive packages. The use of surgery as an incentive to complement brief advice has not been fully evaluated.

METHODS

Smokers were counselled and referred to their general practitioners for specific cessation strategies. Smoking status was recorded prior to surgery, on admission and in post-operative clinics. A telephone survey at a mean of 12 months post-operation ascertained long-term behavioural changes.

RESULTS

Ninety-seven patients underwent surgery with twenty-five recorded as smokers. Sixteen stopped smoking pre-operatively; a further four reduced their intake, as a direct consequence of counselling. No patients were previously aware of the detrimental effects of smoking associated with foot surgery.

CONCLUSIONS

Surgery provides an incentive for smoking cessation, maintained post-operatively. Although forefoot fusions and arthrodeses were used in our study, the results are transferable to other branches of orthopaedic surgery.

Providing comprehensive smoking cessation care to surgical patients: the case for computers

INTRODUCTION AND AIMS

The provision of smoking cessation care to surgical patients before admission can reduce post-operative complications and encourage long-term smoking cessation. Our aim was to show how a comprehensive computer-based smoking cessation intervention, developed to enhance smoking cessation care to surgical patients, addresses barriers to care provision.

DESIGN AND METHODS

Consultations with preoperative clinic staff and reviews of the scientific literature were conducted and identified the following barriers to the provision of effective smoking cessation care: a lack of organisational support, perceived patient objection, a lack of systems to identify smokers, a lack of staff time and skill, perceived inability to change care practices, a perceived lack of efficacy of cessation care and the cost of providing care. Based on positive findings of a pilot trial, a comprehensive computer-based smoking cessation intervention was implemented in a preoperative clinic. Data from previous evaluations of the intervention were used to assess the extent to which the intervention addressed clinician barriers to care.

RESULTS

The computer-based intervention was found to provide a means to accurately and systematically identify smokers; it required little clinical staff time or skill; it was considered an acceptable form of care by staff and patients; it was effective in encouraging patient cessation and it was inexpensive to deliver relative to other surgical costs. Furthermore, the computer-based intervention continues to operate in the preoperative clinic in the absence of ongoing research support.

DISCUSSION AND CONCLUSIONS

The implementation of such a model of care should be considered by clinical services interested in reducing the smoking related morbidity and mortality of patients.

Cost-effectiveness of a smoking cessation program implemented at the time of surgery for lung cancer

BACKGROUND

Many patients are active smokers at the time of a diagnosis of surgically resectable lung cancer. Perioperative smoking cessation is associated with improved survival, but the cost-effectiveness of a smoking cessation program initiated immediately before surgery is unknown.

METHODS

We developed a decision analytic Markov model to evaluate the incremental cost-effectiveness of a formal smoking cessation program. The parameter estimates were taken from the available literature. The model included the cost and effectiveness of the smoking cessation program, cost and incidence of perioperative complications, postoperative mortality, and utility measured in quality adjusted life years (QALY). Dollars per QALY and life year were calculated and one-way sensitivity analyses were performed.

RESULTS

The cost/QALY and cost/life year were $16,415 and $45,629 at 1 year after surgery and $2609 and $2703 at 5 years, respectively. Most sensitivity analyses showed the 1 year postsurgery cost/QALY estimates were less than $50,000, and all were less than $12,000 at 5 years. Cost-effectiveness estimates were most sensitive to the frequency of perioperative complications and the estimated short-term utility estimates.

CONCLUSION

A smoking cessation program initiated before surgical lung resection is cost-effective at both 1 and 5 years postsurgery. Providers should encourage patients who are still smoking to engage in formal smoking cessation programs.

Effects of a perioperative smoking cessation intervention on postoperative complications: a randomized trial

OBJECTIVE

To determine whether an intervention with smoking cessation starting 4 weeks before general and orthopedic surgery would reduce the frequency of postoperative complications.

SUMMARY BACKGROUND DATA

Complications are a major concern after elective surgery and smokers have an increased risk. There is insufficient evidence concerning how the duration of preoperative smoking intervention affects postoperative complications.

METHODS

A randomized controlled trial, conducted between February 2004 and December 2006 at 4 university-affiliated hospitals in the Stockholm region, Sweden. The outcome assessment was blinded. The follow-up period for the primary outcome was 30 days. Eligibility criteria were active daily smokers, aged 18 to 79 years. Of the 238 patients assessed, 76 refused participating, and 117 men and women undergoing surgery for primary hernia repair, laparoscopic cholecystectomy, or a hip or knee prosthesis were enrolled.

INTERVENTION

Smoking cessation therapy with individual counseling and nicotine substitution started 4 weeks before surgery and continued 4 weeks postoperatively. The control group received standard care. The main outcome measure was frequency of any postoperative complication.

RESULTS

An intention-to-treat analysis showed that the overall complication rate in the control group was 41%, and in the intervention group, it was 21% (P = 0.03). Relative risk reduction for the primary outcome of any postoperative complication was 49% and number needed to treat was 5 (95% CI, 3-40). An analysis per protocol showed that abstainers had fewer complications (15%) than those who continued to smoke or only reduced smoking (35%), although this difference was not statistically significant.

CONCLUSION

Perioperative smoking cessation seems to be an effective tool to reduce postoperative complications even if it is introduced as late as 4 weeks before surgery.

The Physiological Effects of Short-term Smoking Cessation in Claudicants

Introduction

Smoking contributes to atherosclerosis and causes significant postoperative morbidity. New antismoking law forces short-term pre-operative abstinence. Demonstrable clinical benefit might motivate complete cessation. Our aim was to determine the effects of 24-hr smoking cessation on cardiorespiratory function and claudication distance.

Methods

Smoking claudicants were randomized to 24hr smoking or abstinence. Following these separate periods, cardiopulmonary exercise testing was performed. Pre- and post-exercise, serum lactate and ankle brachial pressure index (ABPI) were measured. During exercise, cardiorespiratory function, initial and absolute claudication (IC, AC) distances and visual analogue scores (VAS) of pain were recorded.

Results

16 patients completed both tests. IC, AC and VAS were unchanged with abstinence ( P = .43, .66, .96, .83). ABPI drop post-exercise was unchanged with abstinence ( P = .08, .09). Cardiorespiratory function was not affected by smoking cessation.

Conclusion

Cardiorespiratory function and claudication symptoms are unchanged following 24-hr smoking cessation., No deterioration in respiratory function is important when considering anaesthetic administration. However, lack of symptomatic improvement may discourage patients from abstaining. Further investigation should determine correlation between short-term abstinence and postoperative morbidity.

Postoperative pulmonary infections

INTRODUCTION

Postoperative pulmonary infections are associated with cough, phlegm, shortness of breath, chest pain, temperature above 38 degrees C, and pulse rate above 100 a minute. Up to half of people may have asymptomatic chest signs after surgery, and up to a quarter develop symptomatic disease. The main risk factor is the type of surgery, with higher risks associated with surgery to the chest, abdomen, and head and neck compared with other operations. Other risk factors include age over 50 years, chronic obstructive pulmonary disease (COPD), smoking, hypoalbuminemia, and being functionally dependent.

METHODS AND OUTCOMES

We conducted a systematic review and aimed to answer the following clinical question: What are the effects of interventions to prevent postoperative pulmonary infections? We searched: Medline, Embase, The Cochrane Library, and other important databases up to May 2007 (BMJ Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).

RESULTS

We found 17 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.

CONCLUSIONS

In this systematic review we present information relating to the effectiveness and safety of the following interventions: advice to stop smoking preoperatively, anaesthesia, lung expansion techniques, and postoperative nasogastric decompression.

Tobacco dependence in surgical patients

PURPOSE OF REVIEW

Many patients who smoke cigarettes require anesthesia and surgery. Their smoking can have profound consequences for perioperative management. Efforts to help them quit will be rewarded by both improved immediate postoperative outcomes and the long-term health benefits after surgery. This review will introduce basic concepts important to perioperative tobacco control and cover recent advances in the field.

RECENT FINDINGS

Evidence continues to accumulate regarding how smoking increases perioperative risk, especially of wound-related complications. There is also new information regarding how abstinence from smoking reduces risk, including how the timing of preoperative abstinence affects outcome. Methods to help surgical patients continue to be developed, taking advantage of surgery as a teachable moment for intervention. There is a need to develop methods practical in the surgical setting. Several pharmacological tools to help surgical patients quit smoking are available, including a new partial acetylcholine receptor agonist.

SUMMARY

The fact that the perioperative period represents an excellent opportunity to help surgical patients quit smoking is becoming increasingly apparent. Although these efforts, and the evidence base to support them, are still at an early stage of development, seizing this opportunity will benefit both the short and long-term health of our patients who smoke.

Should smokers be refused surgery?

Last year a primary care trust announced it would take smokers off waiting lists for surgery in an attempt to contain costs. Matthew Peters argues that denying operations is justified for specific conditions but Leonard Glantz believes it is unacceptable discrimination