January 29, 2020

How long should patients stop smoking before surgery? (Maybe longer than you think.)

Daily Briefing

    Patients who quit smoking at least four weeks before they undergo an operation have fewer post-surgical infections and a reduced chance of hospital readmissions, according to a joint report from the World Health Organization (WHO), the World Federation of Societies of Anaesthesiologists (WFSA), and the University of Newcastle.

    Why smoking cessation programs don't have to kill your bottom line

    The report, which was released last week, is based on a review of more than 100 studies on interventions to reduce smoking before an operation and the impact of tobacco and second-hand smoke exposure on postsurgical outcomes.

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    Background

    There are about one billion smokers worldwide, and 4% undergo a major surgery each year, according to the report. But for smokers, surgery presents some unique risks in part because smoking affects cardiovascular function and tissues ability to heal because the carbon monoxide in cigarette smoke reduces the oxygen levels needed for typical cell function. In addition, nicotine is believed to affect blood platelets' clumping that's involved in healing.

    The result, according to research, is that smokers who undergo surgery have more than twice the rate of complications compared with nonsmokers, resulting in a significant burden on hospitals around the world, the New York Times reports.

    Kerstin Schotte, a WHO medical officer who works on tobacco control and was involved with the report, said, "Surgery itself is an assault on the body and your recovery is going to be that much harder if you smoke."

    Edouard Tursan D'Espaignet, a tobacco researcher at the University of Newcastle in Australia who was involved with the report, said, "Not only is [smoking] bad for the patient, but it's bad for the distribution of health services because smokers are likely to be readmitted to the hospital, which potentially denies treatment to someone else."

    Smokers who quit a month before their surgeries experience better outcomes

    However, the report authors found patients who quit smoking a month before their surgeries experienced fewer complications at their six week follow up, and for every additional tobacco-free week after those four weeks, patients' health outcomes improved by 19%. The report authors said the findings provide evidence to support physicians delaying elective surgeries to give smokers more time to quit—and hospitals can help.

    According to the Times, several hospitals in developed countries have in-house tobacco cessation programs, but these are less common in developing countries. For example, at Massachusetts General Hospital, more than 50% of all smokers admitted to the hospital are given nicotine replacement therapy—up from only 5% two decades ago, according to Nancy Rigotti, who directs Massachusetts General Hospital's Tobacco Research and Treatment Center. The hospital helps patients who want to quit by sending them home with nicotine patches when they're discharged and offering them encouragement through follow up calls and texts.

    However, many physicians note that quitting smoking is not easy, and an impending surgery might provide patients with a stronger incentive to kick the habit.

    Amy Anne Lassig, a head and neck cancer surgeon at Hennepin Healthcare in Minnesota, said about 50% of her patients continue smoking after their cancer diagnosis, despite being told that quitting improves their chances for recovery.

    However, Rigotti said, "When you're facing the idea of having general anesthesia and having your chest cracked open, most people will do whatever they can to have a good outcome. What we've found is that illness is a teachable moment for unhealthy behaviors" (Jacobs, New York Times, 1/22; WHO release, 1/20; WHO et al. report, 1/20).

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