Smoking Cessation for Preoperative Optimization

Abstract

Cigarette smoking is associated with pulmonary and cardiovascular disease and confers increased postoperative morbidity and mortality. Smoking cessation in the weeks before surgery can mitigate these risks, and surgeons should screen patients for smoking before a scheduled operation so that appropriate smoking cessation education and resources can be given. Interventions that combine nicotine replacement therapy, pharmacotherapy, and counseling are effective to achieve durable smoking cessation. When trying to stop smoking in the preoperative period, surgical patients experience much higher than average cessation rates compared with the general population, indicating that the time around surgery is ripe for motivating and sustaining behavior change. This chapter summarizes the impact of smoking on postoperative outcomes in abdominal and colorectal surgery, the benefits of smoking cessation, and the impact of interventions aimed to reduce smoking before surgery.

Historically, quality improvement in colorectal surgery has largely focused on improving perioperative processes and postoperative outcomes. Efforts to implement enhanced recovery pathways, minimally invasive techniques, and surgical site infection prevention bundles have led to decreased hospital length of stay, lower rates of surgical site infection, and reduction of moderate and severe postoperative complications. ^{1 2 3 4 5 6 7 8 9}

In addition to these successes, there is increasing understanding of how a patient's preoperative fitness for surgery impacts their postoperative recovery. “Prehabilitation,” or preoperative rehabilitation, aims to optimize a patient's health before surgery by improving domains including functional capacity, cardiopulmonary reserve, psychological state, and any modifiable risk factor such as malnutrition or smoking. ¹⁰ This strategy utilizes the time between scheduling an operation and the actual surgery date that would otherwise be spent waiting. Prehabilitation interventions include physical therapy, walking programs, pulmonary therapy, dietitian evaluation and counseling, or nutritional supplementation. ^{11 12 13 14 15}

Cigarette smoking is a modifiable risk factor where prehabilitation efforts may lead to considerable benefits. Smoking is associated with pulmonary and cardiovascular disease and confers increased postoperative morbidity and mortality. It is incredibly difficult to stop smoking; 80% of people who try to stop smoking on their own restart within a month, and only 3 to 5% have stopped smoking at 6 months. ¹⁶ Behavioral interventions in combination with pharmacotherapy can assist with smoking cessation, especially in the context of an upcoming operation. ^{17 18}

When considering targeting smoking cessation with prehabilitation interventions, two questions should be asked: (1) Does preoperative smoking cessation positively impact postoperative outcomes? (2) Can preoperative interventions effectively encourage smoking cessation? This article summarizes the impact of smoking on postoperative outcomes in abdominal and colorectal surgery, the benefits of smoking cessation, and the impact of interventions aimed to reduce smoking before surgery.

Fully Leveraging the Preoperative Period for Health Interventions

The preoperative period may be a time where patients are especially positioned to make positive behavior changes. First, undergoing major surgery can be a pivotal life event for many patients, and patients may be motivated to adopt health behaviors they had not previously considered. ^{19 20 21} Second, the preoperative period is a time where patients have defined and scheduled access points to the health care system. Unlike primary care, where engagement may not be readily accessible from both the systems and patient side, access to specialty and procedural care continues to expand, and clinicians can use these visits as an opportunity to work with patients while they will remain engaged in the system. ^{22 23}

This approach is embodied by the “Make Every Contact Count” program in the United Kingdom. This program takes advantage of any time a patient engages with the National Health Service to screen patients for a variety of health behaviors and provide them with necessary resources for improving their health. ²⁴ Historically in the United States, surgical encounters have not systematically been used to address population health measures such as housing or food insecurity, smoking, or obesity unless clinicians decide to on a case-by-case basis. Recent initiatives include the Preoperative Anesthesia and Surgical Screening Clinic at Duke Health and the Michigan Surgical and Health Optimization Program at the University of Michigan—both systematic preoperative pathways that work to intervene on chronic health conditions before surgery on a large scale. These programs screen patients for conditions including obesity, diabetes, stress, and smoking, and connect them to appropriate interventions. ^{15 25}

With respect to smoking, the preoperative period represents an opportunity to educate patients and capitalize on momentum from an upcoming operation. ^{26 27} Surgical patients do not routinely receive education on smoking risks and benefits of cessation from a surgical standpoint, but they are more likely to abstain before surgery when counseled to do so. ^{28 29 30} Surgeons who were surveyed about their preoperative practice reported that they rarely referred patients to smoking cessation services and underestimated the likelihood that these interventions could help patients stop smoking. ³¹ Hopefully, all clinicians involved in preoperative care, whether surgeons, anesthesiologists, nurses, or advanced practice providers, can take advantage of the preoperative period to positively impact patients' health for the surgical period and beyond. ³²

Risks of Smoking in the Perioperative Period

An estimated 30.8 million U.S. citizens smoked cigarettes in 2020, representing 12.5% of the population. ³³ Another 16.3 million people (6.5% of U.S. citizens) used other commercial tobacco products, including electronic cigarettes (3.7%), cigars (3.5%), smokeless tobacco (2.3%), and pipes (1.1%). ³³ The prevalence of cigarette smoking in the United States has declined in the past decades, but this number still represents a considerable proportion of the population.

Smoking causes tissue hypoxia and pulmonary dysfunction through effects of inhaled compounds including carbon monoxide, nicotine, and tar. ^{22 34 35 36} Chronic cigarette smoking may lead to chronic obstructive pulmonary disease (COPD), with harmful compounds in smoke causing alveolar dysfunction, structural abnormalities in pulmonary epithelium, and reduced immune ability to clear respiratory infections. Finally, smoking contributes to atherosclerosis of both coronary and peripheral arteries, with smoke compounds causing oxidant injury to vascular endothelium and enhancing thrombosis. ^{36 37}

Taken together, the harmful effects of smoking lead to an increased risk of postoperative complications including adverse pulmonary events, adverse cardiovascular events, or problems with wound healing, including surgical site infection, hernia, or anastomotic leak ( Table 1 ). A meta-analysis of 107 case control and cohort studies found that patients who smoked preoperatively were more likely to experience general postoperative morbidity compared with nonsmokers after abdominal, thoracic, breast, head and neck, orthopaedic, plastic, general, and transplantation operations (risk ratio [RR]: 1.52; 95% confidence interval [CI]: 1.33–1.74). ³⁸ Higher overall postoperative complications associated with current smoking have also been seen in patients undergoing total hip and knee arthroplasty, hepatic resection, gastrectomy, and cystectomy. ^{39 40 41 42} Current smoking is associated with higher rates of intensive care admission, hospital stay, and readmission. ^{38 41 43 44} Finally, multiple studies have shown an association between current smoking and postoperative mortality. ^{44 45 46} One large study using American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) data propensity matched over 80,000 current and nonsmokers. Patients who currently smoked had a 1.38 times increased odds of 30-day mortality compared with nonsmokers (95% CI: 1.11–1.72). ⁴⁷ Based on an extensive literature review, the French Society of Anesthesia and Intensive Care (SFAR) estimated that current smoking was associated with an increased relative risk of 20% for postoperative mortality and 40% for major postoperative complications. ⁴⁸

Table 1. Impact of smoking and smoking cessation on surgical outcomes.

Adverse surgical outcomes associated with cigarette smoking	General postoperative morbidity Intensive care admission Length of hospital stay Readmission Postoperative mortality Laryngospasm, bronchospasm, and aspiration on induction Reintubation Pneumonia Cardiac events, cardiac arrest, and myocardial infarction Surgical site infection and wound-healing complications Anastomotic leak Incisional hernia
Benefits of smoking cessation on surgical outcomes	Overall postoperative complications Respiratory complications Wound complications

Postoperative Complications Associated with Cigarette Smoking

Patients smoking at the time of surgery are at increased risk of intra- and postoperative pulmonary complications. The risk of laryngospasm, bronchospasm, and aspiration at induction, as well as unplanned reintubation is increased. ^{38 49 50} Risk of pneumonia is also increased, with one study finding that smoking was associated with over twice the odds of developing pneumonia (odds ratio [OR]: 2.09; 95% CI: 1.80–2.43). ^{44 47 51} The risk of adverse cardiac events is also increased in patients smoking at the time of surgery. The propensity-matched study of ACS-NSQIP data found a significantly higher odds of cardiac arrest (OR: 1.57; 95% CI: 1.10–2.25) as well as myocardial infarction (OR: 1.80; 95% CI: 1.11–2.92). ⁴⁷ The association between smoking and myocardial infarction is demonstrated in multiple studies of major operations. ^{44 52 53}

Given the effects of tissue hypoxia, dampened immunity, and impaired collagen production, cigarette smoking confers an increase in infectious and wound healing complications after surgery. ^{54 55} Both superficial and deep/organ space infections are associated with smoking. ^{38 45 47 56 57 58} Smoking is also associated with increased risk of skin flap necrosis in mastectomy, recurrence after groin hernia repair, wound disruption in plastic surgery and head and neck surgery, and incisional hernia formation. ^{59 60 61 62} Wound healing in orthopaedic surgery is impaired, with smokers experiencing higher rates of bone nonunion, delayed union, and delayed healing with prosthetic implants. ^{63 64}

Complications Specific to Colorectal Surgery

In addition to the risks mentioned earlier, patients undergoing colorectal surgery are also at specific risk of anastomotic leak and ostomy-related complications. The association between smoking and anastomotic leak has been demonstrated in patients undergoing various types of colorectal procedures. One study using ACS-NSQIP data examined 497 patients with acute complicated diverticulitis who underwent resection and primary anastomosis, with and without diverting loop ileostomy. ⁶⁵ Current smoking, defined as cigarette use within the last year, was associated with 4.02 times the likelihood of anastomotic leak (95% CI: 1.44–11.26) compared with nonsmokers. Another study of over 9,000 patients undergoing a range of colorectal operations at 64 Michigan hospitals found that current tobacco use conferred a 1.59 increased odds of anastomotic leak (95% CI: 1.2–2.1). ⁶⁶ This finding has been replicated in cohort studies of patients undergoing laparoscopic and open colectomy, left colectomy, low anterior resection, and in patients older than 64 years undergoing colectomy. ^{67 68 69 70 71 72 73}

Our understanding of how smoking physiologically promotes anastomotic leak is not complete, as the process of anastomotic healing and leak is multifactorial and complex. ⁷⁴ However, smoking contributes to atherosclerosis, and atherosclerotic disease of large visceral arteries as well as visceral microvasculature may lead to tissue ischemia at the site of the anastomosis. One 1996 study of 147 patients undergoing colectomy found that smoking was associated with both anastomotic leak and demonstration of colonic microvascular disease at the anastomotic margins on histologic review. ⁷⁵ However, a similar study performed in 81 patients undergoing low anterior resection with double-stapled colorectal anastomosis did not demonstrate a link between leak and microvascular disease. ⁷⁶ There is also emerging evidence that cigarette smoking leads to alterations in the gut microbiome, mucus production, inflammatory cytokine profile, and rectal blood flow. ^{77 78 79 80 81 82} While this research aims mainly to understand the link between smoking and inflammatory bowel disease, the fact remains that cigarette smoking affects multiple aspects of the gastrointestinal tract that likely play a role in anastomotic healing.

Other postoperative complications specific to colorectal surgery include parastomal hernia formation. Smoking is associated with higher risk of incisional hernia, but smoking at the time of surgery has not been implicated as a key risk factor for parastomal hernia in multiple studies, including a systematic review. ^{83 84} However, chronic smoking may lead to COPD, which is a known risk factor for parastomal hernia formation. ⁸⁴

Benefit to Smoking Cessation Before Surgery

There are clear demonstrated benefits of preoperative smoking cessation ( Table 1 ). ^{85 86 87} A 2014 Cochrane review included 13 randomized controlled trials of preoperative smoking cessation interventions before a variety of surgical procedures, including abdominal, cardiac, thoracic, urologic, breast, orthopaedic, head and neck, and ophthalmic operations. ¹⁸ Two trials used intensive interventions (multiple face-to-face counseling sessions at least 4 weeks before surgery), seven trials used brief interventions, and two trials compared pharmacologic interventions (nicotine lozenges or varenicline) to placebo. ^{88 89 90 91 92 93 94 95 96 97 98 99 100} Pooling the results of trials that collected postoperative complication data, the authors found that intensive interventions led to a reduced risk of overall postoperative complications in 210 patients (RR: 0.42; 95% CI: 0.27–0.65), but brief interventions did not have an effect. In a 2011 systematic review, analyses of 15 observational studies revealed similar results: former smokers experienced reduced risk of overall complications after surgery, 22% compared with 32% of current smokers (RR: 0.76; 95% CI: 0.69–0.84). ⁸⁵

Multiple studies have shown the benefit of smoking cessation with respect to airway and pulmonary complications including bronchospasm, pneumothorax, atelectasis requiring bronchoscopy, pneumonia, respiratory insufficiency requiring rescue medications, or need for reintubation. ^{87 101 102 103 104} One observational study of patients undergoing lung cancer resection found that current smokers were at highest risk of postoperative pulmonary complications, and the risk decreased in a stepwise fashion for patients who had stopped smoking between 2 and 4 weeks before surgery, between 1 and 12 months before surgery, and over a year before surgery. ¹⁰⁵

Smoking cessation has also been shown to reduce wound complications after surgery. In a 2002 randomized controlled trial of 108 patients undergoing total joint arthroplasty, patients who completed an intensive preoperative smoking cessation intervention had an 88% relative risk reduction for wound complication compared with control patients. ⁸⁸ Patients undergoing transverse rectus abdominis muscle flap reconstruction of mastectomy who stopped smoking at least 4 weeks before surgery experienced fewer flap and donor site complications compared with smoking patients, and complication rates in patients who stopped smoking were similar to that in nonsmokers. ¹⁰⁶ Another study of patients undergoing breast reconstruction similarly found that patients who stopped smoking at least 3 weeks before surgery had lower complication rates than smoking patients and were comparable to nonsmokers. ¹⁰⁷ For patients undergoing reconstructive head and neck surgery, smoking cessation of at least 3 weeks before surgery was associated with decreased risk of requiring postoperative debridement or flap revision before discharge. ¹⁰⁸

There are few studies examining the relationship between preoperative smoking cessation and complications in colorectal surgery. One randomized trial in 2003 tested a brief intervention for smoking cessation in colorectal surgery patients, but failed to see an effect on overall postoperative complications or wound infection. ⁹⁰ However, a 2020 observational study of 191 patients undergoing operations for gastric cancer and 364 patients undergoing operations for colon cancer compared nonsmokers to patients who stopped smoking at various time intervals (<4 weeks, between 4 and 8 weeks, and >8 weeks before surgery). This study found that compared with nonsmokers, patients who stopped smoking within 4 weeks of surgery had an increased likelihood of anastomotic leak (OR: 8.83; 95% CI: 1.55–50.3), but patients who stopped smoking more than 4 weeks before surgery did not have increased risk of anastomotic leak compared with nonsmokers. ¹⁰⁹

Timing of Preoperative Smoking Cessation Interventions

It is currently unclear exactly how long before surgery a patient should stop smoking to see maximum benefit. Historically, there have been concerns that short-term smoking cessation may increase the risk of pulmonary complications. One 1989 study found that pulmonary complication rate was higher for patients who had stopped smoking within 8 weeks of surgery compared with current smokers. ¹¹⁰ The authors postulated that mucus production and airway sensitivity would increase immediately after smoking, while mucociliary function would improve more slowly (over a period of weeks), leading to an initial buildup of airway secretions. ^{111 112} However, this study did not include a statistical analysis of the results, but rather presentation of unadjusted complication rates within groups. Another study of lung cancer resection patients failed to find a difference in pulmonary complication rates between current smokers, patients who had recently stopped smoking, and patients who were remote smokers. ¹¹³ However, the concern persists that patients should not be counseled to stop smoking before surgery unless there is adequate time in the preoperative period to avoid an anecdotal time frame where complication risk may increase.

One systematic review attempted to answer this question by specifically examining studies of postoperative complications that included patients that stopped smoking within 8 weeks before surgery as well as patients who currently smoked. ¹¹⁴ Out of the nine studies included, only one found a significant result for patients who stopped smoking within 8 weeks—these patients experienced a relative risk of 0.21 (95% CI: 0.08–0.56) for pulmonary complications compared with patients who continued to smoke. ⁸⁸ Analyzing all nine studies together, there was no difference in postoperative complication rate between patients who smoked and who had recently stopped smoking. Multiple systematic reviews and guidelines recommend that patients should be encouraged to stop smoking for at least 4 weeks before surgery to see benefit with respect to postoperative complications, including surgical site infection. ^{18 48 85 86 87 115 116} However, currently there is no conclusive evidence that stopping smoking within 4 weeks of surgery will confer a higher risk of postoperative complications.

Previous Preoperative Interventions to Encourage Smoking Cessation

A Cochrane review of preoperative smoking cessation interventions included 13 randomized trials and designated interventions as intensive or brief. Intensive interventions for preoperative smoking cessation (multisession, weekly face-to-face or telephone counseling, as well as nicotine replacement therapy) were effective in helping patients stop smoking (RR: 10.76; 95% CI: 4.55–25.46). ^{18 88 89} Møller et al found that 36 of 60 patients (60%) stopped smoking by the time of surgery after undergoing weekly counseling for 6 weeks, compared with 4 patients out of 60 controls (7%). ⁸⁸ At 12 months after surgery, 23% of patients in the intervention group remained abstinent, compared with 4% of control patients. Lindström et al used a similar intervention for 8 weeks (4 weeks before and after surgery), finding that 19 of 48 patients in the intervention group (40%) stopped smoking by the time of surgery compared with 1 of 54 patients in the control group (2%). By 12 months after surgery, the quit rates in the intervention and control groups were 37 and 17%. ⁸⁹

Brief interventions employed by randomized controlled trials include single telephone calls, single counseling sessions, or the provision of a telephone number to call for more assistance. ^{90 92 94 98} One study sent patients a letter detailing the postoperative benefits conferred by smoking cessation and included the contact information for a smoking cessation service. ⁹¹ Pooling these studies, the Cochrane meta-analysis concluded that these brief interventions promoted smoking cessation more effectively than usual care, but less so than intensive interventions (RR: 1.3; 95% CI: 1.16–1.46). ¹⁸ A more recent meta-analysis included 19 studies, both randomized controlled trials and quasi-experimental studies, and found that 46.2% of patients in the intervention group stopped or reduced smoking at the time of surgery, compared with 24.5% of patients in the control group (Hedge's g  = 0.56; 95% CI: 0.32–0.80). ¹¹⁷ The authors also performed an analysis of the behavioral change techniques employed by the various interventions. They found that more successful interventions tended to use specific behavior change techniques (such as facilitating goal setting, reviewing goals promptly, or giving information on results of smoking cessation), included more sessions, or used face-to-face sessions.

These studies highlight the fact that a smoking cessation intervention, when implemented before an upcoming surgery, may be more successful in promoting positive behavior change than in a nonsurgical context. ^{22 118} With preoperative interventions, patients can achieve cessation rates exceeding 50% after undergoing surgery for smoking-related diseases, which is much higher than average cessation rates of 5 to 7.5% of the general population. ^{16 118 119 120} This pattern holds true even for operations not related to smoking, such as joint arthroplasty. ^{121 122} Surgeons should be encouraged that approaching patients about smoking cessation may pay dividends with respect to the effectiveness and durability of their efforts. ^{123 124 125}

Electronic Cigarettes (Vaping) as Nicotine Replacement Therapy

There is growing interest in the use of electronic cigarettes, or e-cigarettes, for smoking cessation. E-cigarettes deliver vaporized nicotine for inhalation without the release of combustion products that cause much of the harm of cigarette smoking. ¹²⁶ The use of e-cigarettes, also known as vaping, more closely approximates smoking than other forms of nicotine replacement therapy and may satisfy some of the behavioral or ritualistic aspects of smoking addiction. ^{127 128} However, there are concerns that e-cigarettes release harmful inhaled compounds of their own. For example, formaldehyde, acetaldehyde, and acrolein have been detected in e-cigarette vapor, thought to result from heating of propylene glycol and glycerin (the solvents in nicotine cartridges). However, multiple studies have investigated the components of e-cigarette vapor, finding that the levels of these compounds are much lower than those in cigarette smoke. ^{126 129} E-cigarettes do expose users to higher levels of inhaled propylene glycol and glycerin than when smoking cigarettes, but there are currently no known toxic effects of these compounds. Prevailing evidence thus indicates that e-cigarettes do not pose serious health risks and can be considered much less harmful than cigarette smoking. Although not yet widely recommended in smoking cessation guidelines, if evidence continues to confirm its relative safety, vaping may be offered to patients as a viable form of nicotine replacement therapy for smoking cessation.

Challenges to Incorporating Smoking Cessation Interventions in the Preoperative Period

Despite the benefits, implementing any new intervention in a systematic way is challenging. The logistics of implementation must be considered, as well as the resources and personnel required. For timing, waiting until the patient is seen in the preoperative anesthesia clinic may be too late, as institutional workflows often schedule these visits within 30 days of the scheduled operation. Instead, surgeons should screen patients for smoking at the first encounter where an operation is discussed, and can discuss smoking cessation with patients as well as refer them to smoking cessation services if those are in place at the institution. ¹³⁰ In qualitative studies, surgeons report that they rarely counsel patients in depth on the importance of smoking cessation, citing time constraints, lack of knowledge or educational resources, or an underestimation in the effectiveness of this discussion. ^{131 132} Connecting proceduralists such as surgeons or anesthesiologists to the resources used by primary care providers to help patients stop smoking may address the cited lack of knowledge. For example, the Strong for Surgery program is a free online resource available through the American College of Surgeons Web site (facs.org/strongforsurgery) that provides smoking cessation information for patients and providers. Patients can also be instructed to visit SmokeFree.gov or call 1–800-QUIT-NOW, each of which have programs and counselors trained specifically to help smokers quit.

Finally, these health care initiatives must be reinforced by payment models that value clinician time to improve a patient's longitudinal health. Currently, a hospital earns less than $30 for every 15 minutes spent on smoking cessation counseling. ^{133 134} Reducing postoperative complications is a downstream benefit that can lead to improved reimbursement, and value-based reimbursement strategies may also be used to reward clinician efforts in these domains. ^{32 135}

Conclusions

Smoking places patients at increased risk of complications after surgery and is a modifiable behavior that can be durably changed with the help of behavioral and pharmacologic interventions. Achieving smoking cessation preoperatively can significantly reduce a patient's risk profile. Surgeons, anesthesiologists, nurses, and all clinicians involved in preoperative care pathways should capitalize on a pivotal time in a patient's life to motivate smoking cessation.