Myths in Medicine

SEPTEMBER 16, 2008
Myths Regarding Smoking and Surgery

Surgical Rounds Live addresses 2 common misconceptions physicians and patients have about smoking prior to surgery. If you would like to prove or disprove a medical myth, review our Author Guidelines and submit your myth to cmelton@clinicalcomm.com.
 
#1: It’s okay to smoke prior to surgery provided you limit yourself to 1 cigarette.
 
#2: Recent smoking cessation (1- 8 weeks) prior to an operation increases pulmonary complications.
 

Multiple studies document a host of increased risks for persistent smokers who undergo a range of surgical procedures, from plastic surgery1 to knee replacements2,3 to coronary artery bypass graft.4 In a report on patients who underwent elective orthopaedic surgery, Møller, et al branded smoking as “the single most important risk factor for the development of postoperative complications.”5 Smoking delays wound dehiscence2,3 and increases the likelihood of cardiopulmonary complications.6 It also ups the patient’s chance of landing in intensive care.5 Demars, et al recently found that smokers who underwent uvulopalatopharyngoplasty had double the risk of postoperative bleeding compared with nonsmokers and smokers who underwent combined uvulopalatopharyngoplasty/tonsillectomy had triple the risk.7
 
Chemicals produced by smoking remain in tissues and the bloodstream long after the cigarette has been extinguished.6 One of cigarettes’ primary chemical components is nicotine. In addition to increasing blood pressure and heart rate, nicotine ultimately increases the heart’s demand for oxygen. The half life of nicotine after a single cigarette is 1 to 2 hours; therefore, refraining from smoking for 3 to 4 hours is often sufficient to mitigate nicotine’s effects.6
 
The effects of carbon monoxide, a smoking byproduct, last longer. Carbon monoxide unites with hemoglobin to create carboxyhemoglobin. Excessive amounts of carboxyhemoglobin lead to tissue hypoxia and higher levels of plasma viscosity. Carbon monoxide also influences cardiac rhythm. Several factors impact the rate at which carboxyhemoglobin clears from the system (activity level, patient’s sex, type of cigarette), but generally 12 hours of cessation is considered adequate.6
 
Woehlck has studied the effects of smoking on surgical patients extensively. He found that smoking just 1 cigarette in the 24 hours prior to an operation puts patients at risk.8 In one of Woehlck’s studies, individuals who indulged in 1 cigarette within the 24 hours prior to an operation were 20 times more likely to experience “brief episodes of myocardial ischemia” during an operation than nonsmokers and smokers who refrained for 24 hours prior to their procedure.8
 
A 12-week Denmark study observed that smokers who continued to smoke the day of their operation had a 12% rate of wound infection compared with 2% for never-smokers.3 Smokers who abstained for ≥4 weeks prior to their operation had a wound infection rate comparable to the rate for nonsmokers.3 In 2002 Moller, et al recommended patients refrain from smoking for ≥6 weeks before undergoing a surgical procedure.9 They found that smokers who attempted to quit or who reduced cigarette consumption in the 6 weeks prior to hip or knee arthroplasty were 6 times less likely to experience perioperative complications with wound healing. These patients also had hospital stays 2 days shorter on average than persistent smokers.9
 
The adverse effects of smoking on the pulmonary system are significant and take months to resolve. Habitual cigarette smoking damages ciliary function and stimulates mucus secretions. It impairs tracheobronchial clearance and increases laryngeal and bronchial reactivity.6 Even smokers without diagnosed lung disease are more likely to suffer postoperative pneumonia or respiratory failure than nonsmokers. Research indicates it takes nearly 6 months of cessation for smokers’ perioperative pulmonary risks to decline to the same level as nonsmokers, though a minimum of 8 weeks diminishes these risks significantly.6
 
This brings us to Myth #2. Some earlier studies have suggested that short-term cessation of smoking prior to an operation places smokers at greater risk for surgery-related pulmonary events. The American Society of Anesthesiologists (ASA) wants physicians to know this is untrue (Sidebar). Barrerra, et al found that patients who quit smoking for 1 week to 2 months prior to thoracotomy were at no greater risk for perioperative pulmonary complications than ongoing smokers.10 Warner, et al concluded that cough and sputum production do not “transiently increase over the first few weeks after smoking cessation” and should not prevent physicians from counseling smoking abstinence.11,12
 
While clinicians who treat smokers should always encourage them to quit, it is even more important for patients about to have an operation. Inform your patients who smoke that it is essential they refrain from smoking for a minimum of 24 to 72 hours before and after most surgical procedures. Apprise them of the fact that the longer they go without a cigarette, the better their chances are for a positive surgical outcome. Keep a list handy of smoking cessation hotlines and be ready to offer advice on how they can go about quitting smoking for good. Studies indicate that patients who substitute nicotine patches for cigarettes do not increase their risk for adverse effects during surgery, and this may be one alternative for patients who can’t seem to give up the habit.4

 

 

Get Paid to Help Medicare Patients Quit!

     The chance of anesthetic gas impairing macrophage function—possible even in patients with healthy lungs—is far greater for smokers. This has spurred the ASA to action. In an effort to publicize smokers’ significantly greater risk of perioperative complications, the ASA has implemented a program to educate physicians and patients on the importance of smoking cessation prior to an operation. According to the ASA, a survey of smokers who underwent operative treatment found that 30% believed their surgeons did not offer advice beforehand regarding smoking cessation prior to their procedure. Did you know that you can get reimbursed for counseling qualified Medicare patients on smoking cessation?

 

 

NCPCS codes:


G0375—Smoking and tobacco use cessation counseling visit: intermediate, 3-10 minutes.

G0376—Smoking and tobacco use cessation visit: intensive, >10 minutes.
CMS allows 2 attempts of up to 4 sessions every 12 months.

For more on the ASA program to help physicians help their patients stop smoking, click here.


References
1.    Krueger JK, Rohrich RJ. Clearing the smoke: the scientific rationale for tobacco abstention with plastic surgery [review]. Plast Reconstr Surg. 2001;108(4):1063-1073; discussion 1074-1077.
2.    Abudu A, Sivardeen KA, Grimer RJ, et al. The outcome of perioperative wound infection after total hip and knee arthroplasty. Int Orthop. 2002;26(1):40-43.
3.    Sorensen LT, Karlsmark T, Gottrup F. Abstinence from smoking reduces incisional wound infection: a randomized controlled trial. Ann Surg. 2003;238(1):1-5.
4.    Theadom A, Cropley M. Effects of preoperative smoking cessation on the incidence and risk of intraoperative and postoperative complications in adult smokers: a systematic review. Tob Control. 2006;15(5):352-358.
5.    Moller AM, Pedersen T, Villebro N, et al. Effect of smoking on early complications after elective orthopaedic surgery. J Bone Joint Surg Br. 2003;85(2):178-181.
6.    Rodrigo C. The effects of cigarette smoking on anesthesia [review]. Anesth Prog. 2000 Winter;47(4):143-150.
7.    Demars SM, Harsha WJ, Crawford JV. The effects of smoking on the rate of postoperative hemorrhage after tonsillectomy and uvulopalatopharyngoplasty. Arch Otolaryngol Head Neck Surg. 2008;134(8):811-814.
8.    Woehlck HJ, Connolly LA, Cinquegrani MP, et al. Acute smoking increases ST depression in humans during general anesthesia. Anesth Analg. 1999;89(4):856-860.
9.    Moller AM, Villebro N, Pedersen T, et al. Effect of preoperative smoking intervention on postoperative complications: a randomised clinical trial. Lancet. 2002;359(9301):114-117.
10.  Barrera R, Shi W, Amar D, et al. Smoking and timing of cessation: impact on pulmonary complications after thoracotomy. Chest. 2005 Jun;127(6):1977-83.
11.  Warner DO, Patten CA, Ames SC, et al. Smoking behavior and perceived stress in cigarette smokers undergoing elective surgery. Anesthesiology. 2004;100(5):1125-1137.
12.  Warner DO, Colligan RC, Hurt RD, et al. Cough following initiation of smoking abstinence. Nicotine Tob Res. 2007;9(11):1207-1212.


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