Peri‐operative cessation of smoking: time for anaesthetists to act

As the traditional practice of anaesthesia changes and the scope of anaesthetic practice expands beyond the operating theatre to include peri-operative medicine, it is time for anaesthetists to participate actively in interventions of peri-operative smoking cessation as part of a ‘pre-habilitation’ programme. ‘Pre-habilitation’ is increasingly recognised as being important for optimal outcomes after surgery 1. Anaesthetists have an opportunity to play a potential role in general health promotion, improve surgical outcomes and the long-term health of our patients. The first study showing that smokers have increased pulmonary complications after abdominal surgery compared with non-smokers was published over 70 years ago 2. Many trials 3 and several recent large cohort studies 4-6 have shown that smokers have increased risks of respiratory, cardiovascular and wound-related complications, and even death within 30 days of surgery 7. With the solid evidence of peri-operative complications due to smoking, why have anaesthetists not incorporated peri-operative smoking cessation interventions into their clinical practice? Clinical practice guidelines recommend that every physician address tobacco use at each patient visit 8. National professional societies/associations of anaesthestists in the USA, Canada, Australia, the UK and elsewhere in Europe also recommend that anaesthetists promote patient abstinence from smoking before surgery. However, anaesthetists have not consistently applied this approach 9. Some of the barriers to providing smoking cessation interventions may include a lack of knowledge about such interventions, inadequate training to provide counselling, a lack of time, a lack of ability to provide follow-up and inadequate support or funding 10. Anaesthetists may be reluctant to advise patients to quit smoking owing to misconceptions that stopping smoking shortly before surgery has no benefits, or may increase the risk of respiratory complications. This misconception is largely based on a previous study that reported a higher rate of pulmonary complications in the patients who stopped smoking less than eight weeks before surgery 11. Even though the difference in pulmonary complications between those who stopped smoking more or less than eight weeks was not statistically significant, this study was widely cited in anaesthetic and surgical textbooks. We have shown that smokers who quit less than four weeks before elective surgery do not have increased risks for respiratory or cardiovascular adverse events 12. Smokers who quit more than four weeks before surgery have lower risks for respiratory complications compared with those who continue to smoke, and there is a greater benefit with a longer (more than eight weeks) period of abstinence 12. Smokers who quit more than 3-4 weeks before surgery also have lower risks of wound complications than smokers who continue to smoke. Importantly, there is no increased risk of adverse events even if smokers quit less than 3-4 weeks before surgery 12. An intensive pre-operative smoking cessation programme, instituted 6-8 weeks before elective knee and hip replacement surgery, effectively reduced overall postoperative complications in the intervention group (10/56) compared with the control group (27/52), p = 0.0003 13. Since anaesthetists often see patients in the pre-operative clinic within 1-3 weeks of surgery, or even on the day of surgery, is it worthwhile to advise patients to quit? A multicentre randomised controlled trial of an intervention of smoking cessation instituted during the first six weeks after acute fracture surgery found that the risk of postoperative complications was significantly higher in the control compared with the intervention group 14. This study provides strong evidence that patients can benefit from interventions of smoking cessation even if they are started after surgery. It has been estimated that 5-10 per 100 of the population undergoes surgery annually. Although the prevalence of smoking has declined as a result of public health campaigns and other measures, a significant proportion of the population still smokes. The prevalence of smoking in Canada 15, the USA 16 and Great Britain 17 is 16 per 100, 18 per 100, and 19 per 100 individuals, respectively. If all surgical patients who smoked were offered a peri-operative smoking cessation intervention, this could greatly reduce the risks of postoperative complications, resulting in significant savings in healthcare costs. Besides short-term benefits in the peri-operative period, there is a huge opportunity for anaesthetists to have a major long-term public health impact, since tobacco use is a leading cause of preventable disease and death. This would certainly fit into an expanded role of anaesthetists as peri-operative physicians, worldwide. The effects of smoking on increasing the risks of long-term health conditions such as cardiopulmonary disease and cancer are undisputed. In the USA, it is estimated that smoking is responsible for almost half a million deaths and $200bn (£131bn; €183bn) in extra healthcare costs and lost productivity each year 8. Our systematic review of peri-operative smoking cessation interventions showed that these interventions could increase abstinence in seven per 100 patients at 3-6 month follow-up 18. Smokers who were randomly assigned to an intensive peri-operative intervention with nicotine replacement therapy had increased long-term (12 months) abstinence after surgery 19. We found that smokers randomly assigned to an intensive peri-operative intervention with varenicline and counseling, started as little as 1-3 weeks before surgery, increased both short- and long-term (12 months) abstinence from smoking 20. At 12 months, 55/151 smokers in the intervention group were abstinent from smoking, against 34/135 in the placebo group, p = 0.04. For those who continued to smoke, the number of cigarettes smoked per day was reduced from 17.8 to 7.2 in the intervention group, p < 0.05, at 12 months after surgery 20. With a decrease in nicotine dependence, future cessation attempts in these patients may be more successful. Even less intensive interventions such as brief advice, provision of nicotine replacement therapy and referral to a tobacco ‘quit line’, started within 1-3 weeks of surgery, can increase long-term abstinence from smoking at 12 months 21. It has been suggested that the pre-operative visit and peri-operative period are an opportunity for a ‘teachable moment’ for smoking cessation interventions 22. Many smokers are not aware that smoking increases their risks of anaesthetic and surgical complications 23. When smokers were educated about the increased risks of postoperative complications, they were more likely to attempt to quit (Raveendran R, Islam S, Chung F, Wong J. Evaluation & efficacy of a preoperative computer-based educational module of smoking cessation in surgical patients – a pilot study. American Society of Anesthesiologists Annual Meeting 2013; A1127). The immediate risks of surgical complications such as impaired wound healing or wound infection, and the desire for a good surgical outcome, may be real motivators for a patient who may be contemplating quitting actually to attempt to do so. Indeed, undergoing major surgery has been shown to double cessation rates 22. Empowering patients with the knowledge of the increased risks for adverse surgical outcomes, and referring them to resources to assist their attempts to quit, are extremely valuable services that anaesthetists can provide to surgical patients. Advice from physicians to quit smoking has been shown to increase cessation rates in general practice 24. Although increased intensity (frequency or duration) of such advice increases abstinence, even brief advice increases abstinence 24. Brief advice about the risks of smoking and adverse peri-operative outcomes, and the benefits of quitting, can be given in less than three minutes. During the pre-operative period, patients may see multiple healthcare providers including their general practitioners, surgeons, anaesthetists, nurses, and pharmacists. Consistent advice from all of these may increase the likelihood that a smoker will attempt to quit. In addition, smoke-free policies within healthcare facilities require all smokers undergoing surgery to be abstinent from tobacco during their hospitalisation. In fact, abstinence rates are three times higher in hospitalised patients than for those in primary care 25. Educating our trainees to provide smoking cessation interventions, and establishing a smoking cessation programme in the pre-operative clinics and for hospitalised patients, are essential. Pre-operative optimisation of medical conditions that increase a patient's risk for adverse outcomes, such as poorly controlled hypertension or coronary artery disease, are accepted reasons for having an informed discussion with the patient about delaying or cancelling his/her surgery until the condition is optimised. There is compelling evidence that smoking also increases the risks of peri-operative complications, yet anaesthetists may not recognise that smoking is a modifiable risk factor that should be included in pre-habilitation programmes. A lack of training about the peri-operative risks of smoking, and how best to advise and assist patients to quit, may be a barrier. Surveys of medical students in Canada 26 and the UK 27, and anaesthesia residents in the USA 28, have identified that these trainees were inadequately trained to provide smoking cessation interventions. This gap in training needs to be addressed in the curriculum of medical schools and training programmes. Smoking cessation interventions should be incorporated into the routine pre-operative and postoperative care of surgical patients at all hospitals. All healthcare staff caring for surgical patients, including physicians, nurses and pharmacists, should perform brief counseling to educate smokers about the increased risks of surgical and anaesthetic complications. Utilising existing resources, such as the patients’ family physician, telephone ‘quit lines’ and pharmacists, to provide continued follow-up may increase cessation rates after surgery. Free telephone ‘quit lines’, providing counseling from specialists in tobacco cessation, are now widely available in many countries, and surgical patients can be referred before surgery and/or for postoperative follow-up. In many provinces in Canada, pharmacists are able to counsel and prescribe pharmacotherapy, offering another resource for surgical patients. If it is not possible to see a patient in a pre-operative clinic, using a hospital-based smoking cessation programme such as the Ottawa Model may be effective 29. This programme has embedded smoking cessation interventions into routine clinical practice. Smokers are systematically identified and offered pharmacotherapy and brief advice to quit while they are hospitalised. Automated follow-up is provided for 1-6 months after hospitalisation. At our institution, patients contemplating bariatric surgery must quit before they are scheduled for their surgery, as smoking has been shown to increase the risk for developing marginal ulcers and wound dehiscence 30. Whether all smokers should quit before being allowed to undergo elective surgery is controversial. Active interventions for procedures with a high risk of adverse peri-operative events due to smoking would certainly reduce the risks of complications. Greater support is needed for the implementation of peri-operative smoking cessation interventions in a systemic fashion. Provision of free pharmaceutical agents to assist cessation should be considered. The cost savings realised by avoiding surgical complications and development of long-term consequences of smoking should offset the costs related to increased support of smoking cessation interventions. A major shift in the culture of anaesthetists needs to occur, since providing interventions for smoking cessation is an opportunity to expand our role as peri-operative physicians with an impact on patients’ long-term health and safety beyond the operating theatre. The time to act is now. JW has received honoraria from Pfizer, Canada for speaking engagements. FC has received research grants from Pfizer, Canada.

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