“We’re on the Same Team”: A Qualitative Study on Communication and Care Coordination Surrounding the Requirement to Quit Smoking Prior to Elective Orthopedic Surgery

Abstract

Introduction

Many surgeons require patients to quit smoking prior to elective surgeries to reduce the risk of postoperative complications. Our aim was to qualitatively evaluate the communication and care experiences of patients and clinicians involved in conversations about quitting smoking prior to elective orthopedic surgery.

Aims and Methods

A qualitative interview study of rural-residing Veterans, primary care providers (PCP), and Veterans Administration (VA) orthopedic surgery staff and pharmacists, who care for rural Veterans. We performed a combination of deductive and inductive approaches to support conventional content analysis using a Patient-centered care (PCC) framework.

Results

Patients appreciated a shared approach with their PCP on the plan and reasons for cessation. Despite not knowing if the motivation for elective surgeries served as a teachable moment to facilitate long-term abstinence, almost all clinicians believed it typically helped in the short term. There was a lack of standardized workflow between primary care and surgery, especially when patients used care delivered outside of the VA.

Conclusions

While clinician-provided information about the reasons behind the requirement to quit smoking preoperatively was beneficial, patients appreciated the opportunity to collaborate with their care teams on developing a plan for cessation and abstinence. Other aspects of PCC need to be leveraged, such as the therapeutic alliance or patient-as-person, to build trust and improve communication surrounding tobacco use treatment. System-level changes may need to be made to improve coordination and connection of clinicians within and across disciplines.

Implications

This study included perspectives from patients, primary care teams, and surgical teams and found that, in addition to providing information, clinicians need to address other aspects of PCC such as the therapeutic alliance and patient-as-person domains to promote patient engagement in tobacco use treatment. This, in turn, could enhance the potential of surgery as a teachable moment and patient success in quitting smoking.

Introduction

Patients who smoke can optimize their surgical outcomes by quitting smoking in the preoperative period because continuation of smoking can cause post-surgical complications such as impaired wound healing, infections, and cardiovascular complications.¹ Given the increased risk of adverse events, certain surgeons, hospitals, and insurers require that patients quit smoking prior to elective orthopedic surgeries. We previously found that clinicians and patients involved in preoperative smoking cessation discussions thought the offer of an elective surgery provided strong motivation for short-term abstinence, but there was a lack of explanation to patients about specific benefits.² It is unknown how smoking cessation requirements are communicated between clinicians and patients, or how the delivery of preoperative tobacco use treatment is coordinated across primary care, surgical teams, and patients.

Previous qualitative studies among patients seeking surgery have found that preoperative smoking cessation interventions are helpful in assisting with quitting, although the risk of relapse is often high after surgery. Furthermore, patients felt that the time prior to surgery could be an opportune time to quit.^3,4 These studies, however, were primarily conducted among patients with cancer, which may require a more immediate surgery compared to elective surgeries. Among clinicians, those involved in surgeries were unsure of their role in providing cessation assistance.^5,6 While general surgeons and anesthesiologists did not routinely ask patients about their smoking status, they did feel that providing cessation assistance to patients was within their purview.⁷ Though these findings provide insights into the frequency and perceptions of specific aspects of communication and cessation, knowledge of communication practices within clinician-patient discussions from both perspectives is lacking.

Patient-centered care (PCC) is an integral part of high-quality health care that can be manifested through patient-clinician communication.⁸ PCC can be conceptualized as having six main components: Sharing power and responsibility (eg, shared decision-making and patient empowerment); Therapeutic alliance (ie, being on the same page, perception of the clinician as caring); Patient-as-person (eg, attending to the meaning of health for the patients’ life); Biopsychosocial (includes non-medical aspects of problems); Doctor-as-person (eg, clinicians’ self-awareness); and Coordinated care (ie, integration of the care plan).^2,9 Through improved communication, PCC can decrease psychological distress^10,11 and hospital length of stays,¹² and improve adherence to recommendations¹³ and smoking abstinence rates.¹⁴

In this first study known to the authors to include perspectives from patients, primary care teams, and surgical teams, we used this conceptualization of PCC to qualitatively evaluate the care experiences and communication between rural-residing Veterans and clinicians related to quitting smoking prior to elective orthopedic surgery.

Materials and Methods

Setting and Study Sample

The Veterans Health Administration (Veterans Administration (VA)) is the largest integrated health care system in the United States. In 2018, Congress passed the Maintaining Internal Systems and Strengthening Integrated Outside Networks Act to improve access to timely health care¹⁵ and to provide more choices for Veterans on where they can receive care, either within a VA health care facility or through authorized VA-paid health care received in non-VA community settings (ie, “community care”). Each VA medical center is required to provide a Smoking and Tobacco Use Cessation program for all patients who use tobacco as part of primary care and other clinical care settings, but implementation varies across medical centers.^16,17

We focused on rural-residing Veterans as persons in rural areas have higher rates of smoking than those living in urban and suburban areas.¹⁸ We included rural Veterans, VA pharmacists, and orthopedic surgery staff (including surgeons, advanced practice practitioners, and nurse coordinators on the surgical team), and both VA and non-VA primary care providers (PCPs) who serve rural Veterans, as rural-residing patients often engage in non-VA community care through the Maintaining Internal Systems and Strengthening Integrated Outside Networks Act.

Participant Selection

We extracted data from the VA Corporate Data Warehouse, a national repository of clinical and administrative Veteran data, to identify adult patients residing in rural Oregon who were smoking cigarettes prior to, or at the time, a consult was placed for elective orthopedic surgery at the VA Portland Health Care System (VAPORHCS) from January 2021 to July 2022. We mailed 342 letters with an opt-out option to potentially eligible patients, with 162 who declined or were found to not have a current or past history of smoking at the time of the surgery consult and 153 who could not be reached. Twenty-seven patients accepted the invitation; one did not attend the interview and could not be reached to reschedule. The interviewer assessed the patients’ smoking status at the time of the interview and their status at the time the surgery consult was placed.

We sent emails to 85 VA clinicians from two veterans’ integrated service networks, which represent regionalized, integrated care systems. We used a combination of key informant and snowball sampling, and collected names and email addresses from the VA intranet. We recruited non-VA PCPs by email via partners at the Oregon Rural Practice-based Research Network (ORPRN), a practice-based research network that conducts research and quality improvement projects with clinics across the state. Non-VA PCPs were also recruited by advertising in the ORPRN newsletter (641 recipients) for 6 months and through existing ORPRN contacts (recipients unknown). Of clinicians, 38 consented to participate, one VA clinician responded via email that they did not want to participate and the remainder did not respond. Eligible PCPs and pharmacists had to serve rural-residing Veterans (defined by Rural–Urban Commuting Area codes).¹⁹ The only inclusion criterion for surgery staff was they had to work in a VA orthopedic department. Non-VA clinicians were reimbursed $100 (VA clinicians could not be paid for their time via institutional policies) and Veterans were reimbursed $50 for completion of the single interview. All participants completed informed consent. This study was approved by our Institutional Review Board (VAPORHCS/Oregon Health & Science University IRB#22100).

Data Collection and Analysis

We performed interviews by phone or online video platform (Microsoft Teams) between February 2021 and July 2022. Interviews ranged from 15 to 39 minutes for patients and 22 to 42 minutes for clinicians. We took field notes to track patterns and capture additional questions to ask participants in subsequent interviews. The interviews were digitally recorded, professionally transcribed, and verified for accuracy. All participants self-reported demographic and smoking characteristics after the interview. The interviewers did not provide personal goals but did provide participants with justification for this research as part of the consent process.

Interview guides focused on how smoking behaviors were addressed and discussed in the context of elective surgery, (clinician-perceived) patient understanding, and coordination of resources (Appendix S1). The clinician interview guide specifically asked about rural-residing patients, but did not limit the discussion to Veterans living in rural areas. The guides were pilot-tested with two clinicians and one patient. The pilot interviews are included in the analysis as pilot participants met the inclusion–exclusion criteria and were recruited in the same way as the rest of the participants. Only slight changes were made to the interview guide. We used probing questions with participants as needed. One experienced female social science investigator (lead author; PhD degree, female sex, White, non-Hispanic, and non-Veteran) conducted most interviews; a trained female research assistant (BS degree, female sex, South Asian, non-Hispanic, and non-Veteran) performed two. Both researchers conducting interviews introduced themselves by name and VA affiliation at the start of the interview. They included in their introduction the interview’s purpose in understanding Veteran and clinician experience of the requirement that Veterans stop smoking before elective surgeries. One clinician participant was known to the interviewer as a research collaborator; the remainder were not. We achieved saturation of the main themes upon completion of the interviews. Participants herein are given anonymous identifiers: “IDP” for Patients, “IDPC-non-VA/VA” for Primary Care, “IDPh” for pharmacists, and “IDS” for Surgical team members (all pharmacists and surgical teams were VA).

We used ATLAS.ti 22 (ATLAS.ti GmbH, Berlin, Germany) to organize and support conventional content analysis²⁰ of the qualitative data using a combination of deductive and inductive approaches. SRB (psychologist/principal investigator) and SEG read the first three interviews, created preliminary codebooks based on these and the interview guide, and iteratively refined the codebook and coding throughout. The codebook was considered final for clinicians after a review of 10 transcripts and for patients after review of six. We continued to code every other interview together, evaluating any overlapping coding or un-coded text to verify appropriateness. Following initial review of the data, we found that the emerging themes shared several commonalities with the PCC model, which helped to facilitate subsequent data analysis. Using the conceptual model, we developed initial and integrative memos throughout to capture thoughts or analytic ideas related to PCC, which aided in the final interpretation of the data in matrix form by identifying patterns and variations in the transcripts to assist in identifying cross-group differences. We also utilized an audit trail for tracking modifications and decisions related to the codebook and qualitative analysis. We used a team-based reflexivity model involving group reflections during regular meetings, orienting questions on relations in the team and ensuring rigor of research, and constructing a shared understanding of how the team influences research output.²¹

Results

We interviewed 26 rural-residing Veterans, 10 VA orthopedic surgery staff (from two veterans integrated service networks), 24 rural PCPs (14 VA; 10 non-VA), and 4 VA pharmacists. At the time of our interviews, 42% of patients reported current smoking at the time of the interview and 58% reported having quit smoking within the past 30 days (Table 1). Three patients were actively trying to quit in preparation for an upcoming elective surgery; not all patients reported being required to quit, but all were at least advised. Thirty-eight percent of patients reported having had an orthopedic surgery. Of the remaining patients who had not had surgery at the time of the interview, there were various reasons, including other surgical requirements.

Table 1.

Self-Reported Participant Characteristics

Patient characteristic, N = 26	N (%)* or mean (SD)
Age in years	61 (8.8)
Gender
Male	24 (92%)
Female	2 (8%)
Race
White/Caucasian	24 (92%)
More than one race	2 (8%)
Ethnicity
Hispanic or Latino	1 (4%)
Not Hispanic or Latino	25 (96%)
Highest education completed
High school	8 (31%)
Some college	12 (46%)
College	4 (15%)
Graduate school	2 (8%)
Employment
Full-time	2 (8%)
Part-time	1 (4%)
Self-employed	1 (4%)
Retired	16 (62%)
Disabled	6 (23%)
Annual income	$44 000 (27 000)
Marital status
Married	11 (42%)
Divorced	12 (46%)
Never married	3 (12%)
Smoking status
Current	11 (42%)
Cigarettes per day for current smokers	11 (7.3)
Former (no cigarettes within the past 30 days)	15 (58%)
History of e-cigarette use
Yes	4 (15%)
No	22 (85%)
Pack years	35 (21)
Surgery
Yes	10 (38%)
No	16 (62%)
Clinician characteristic, N = 38	N (%)* or Mean (SD)
Age in years	46 (12)
Gender
Male	20 (53%)
Female	18 (47%)
Race
White/Caucasian	27 (71%)
Asian	5 (13%)
More than one race	3 (8%)
Other	1 (3%)
Missing response	2 (5%)
Ethnicity
Hispanic or Latino	0 (0%)
Not Hispanic or Latino	36 (95%)
Missing response	2 (5%)

Clinician characteristic, N =38	N (%)* or mean (SD)
Smoking status
Former	6 (16%)
Never	30 (79%)
Missing response	2 (5%)
Specialty
Surgery	10 (26%)
Primary care	23 (61%)
Pharmacy	4 (11%)
Other	1 (3%)
Role
Attending physician	20 (53%)
Resident physician	1 (3%)
Advanced practice provider	13 (34%)
Nurse (RN)	1 (3%)
Other clinic staff	2 (5%)
Student	1 (3%)
Years in practice	14 (10)
VA/non-VA
VA	28 (74%)
Non-VA	10 (26%)
Years at site	6.9 (6.3)

^*Percents may not add up to 100 based on rounding.

We found themes related to five of the six PCC components (Figure 1), with doctor-as-person being the only dimension not represented in the interviews. We list the themes below with the PCC components underlined. Thematic differences by role are noted below. Additional exemplary quotes are in Table S1.

Figure 1.

Patient-centered care model for smoking cessation assistance.

Increased Clinician-patient Sharing of Power and Responsibility and Perceived Therapeutic Alliance can Promote Greater Understanding and Less Defensive Patient Reactions

A few surgical staff related that they would prescribe medications or discuss resources to support patients’ quit attempts, but generally not through a shared approach with patients, with little to no pushback from patients on the lack of sharing in the decision-making. Surgery staff reported framing cessation as the responsibility of the patient. Surgical staff member 22 explained, “the only thing I do tell [patients] is, ‘if you are going to quit smoking…stop buying cigarettes. Just tell yourself: I’m gonna stop buying cigarettes and I want to stop smoking.” Many reported discussing infection risk, and in one case, explicit discussion of amputation potential.

Some surgical staff felt that when patients understood that quitting was for their own benefit, they were more receptive to the need for the requirement and tobacco treatment engagement. As one stated, “Most [patients] understand if you present it to them that this is in your benefit. We are happy to do your operation, we want you to have a good outcome, let’s make sure you’re in the best condition before that…. We’re on the same team” (2S). Other surgical team members echoed that lack of patients’ understanding of how continued smoking can lead to adverse surgerical outcomes could result in negative reactions. One surgeon reported, “everybody sort of knows smoking, lung cancer, smoking, some other kinds of cancers. But beyond that, I’m not sure that they entirely understand the [surgical-related] implications… a few people get angry and upset about [the requirement].” Overall, surgeons recommended that orthopedic surgery staff discuss potential adverse outcomes of continued perioperative smoking with patients, including physician assistants or someone else on the surgical team other than the surgeons themselves.

Most PCPs and pharmacists reported having substantive, continual conversations with patients to decide on a quit plan together that works for the patient’s life and goals. PCPs and pharmacists both acknowledged that the ability to build longitudinal relationships with patients was a benefit of their role with patients, which may not be possible for surgical staff. Similar to surgical team responses, some PCPs felt that when patients understood the reasons for the requirement, they were more receptive and less antagonistic. Many PCPs felt “the majority of smokers know that (smoking is) bad for them and they know that they should quit, and so it’s not a surprise when we tell them that they need to quit smoking (in relation to surgery)” (25PC-non-VA).

Many patients acknowledged that smoking was bad for them and were therefore not surprised when they were told they had to quit prior to surgery, despite not knowing the details. However, a few patients mentioned how learning more about the reasons behind the requirement mitigated potential negative reactions to being told they had to quit. For instance, 21P said, “my initial reaction was mild annoyance… but then it was explained your chance of getting an infection.” Patients often brought up previous failed quit attempts to highlight their difficulty in quitting, and how important it was to have clinicians acknowledge the challenge. One patient expressed that one of his nurses used to smoke and would call and “talk about how I’m doing smoking-wise… it helps ‘cause you got somebody to talk to, that knows what you’re going through” (6P). Although a few patients mentioned wanting to speak with a surgeon directly about the reasons for cessation, in general, patients appreciated working together with PCPs to come up with a plan to quit, saying “I would much rather have that primary care doctor that I’ve at least developed some sort of relationship with and knows my history [to help make a plan]” (1P).

Other Aspects of Patients’ Lives Feed into Decisions Surrounding Smoking Behavior Change (Biopsychosocial; Patient as Person)

Most surgical staff did not inquire about patients’ other motivations for quitting beyond surgery. They described themselves as educators teaching patients, mostly briefly, about the relationship between smoking and surgical outcomes, despite also recognizing that they often do not see patients for consultations until they quit smoking. When asked if they thought the offer of surgery was a teachable moment, surgical staff mostly thought it could help. For elective orthopedic surgeries, many surgical staff indicated that patients are motivated to quit because of pain, although they were unsure whether or not patients remained abstinent after surgery.

A couple of PCPs reported explicitly emphasizing a “whole health” approach with patients, discussing all aspects of their lives and their goals for health. PCPs acknowledged how difficult it can be to quit smoking, and reported wanting to focus more on the patients’ personal motivations beyond surgery. They worried about their patients’ abilities to abstain from smoking both before and after surgery, and sometimes thought the requirement to quit just added anxiety. In general, PCPs did not seem to feel that surgery was a teachable moment that led to long-term cessation; however, they mostly agreed it was beneficial in facilitating short-term abstinence. One PCP said, “I’ve found people are very motivated because [pain is] something that hurts them, and they know they’ll feel better after it’s done” (35PC-VA).

Patients echoed these findings by saying that their PCPs would ask about non-medical-related motivations for quitting. Some patients reported quitting only for surgical reasons, but most had a mix of motivations. Often, motivations were unrelated to health or surgery, and had been considered for some time prior to knowing about the requirement to quit. For example, staying alive for grandchildren and financial reasons arose as other reasons to quit. Some patients report continued smoking to help with pain or as a coping mechanism. Patients appreciated clinicians asking about other motivations, offering resources, and providing information pertaining to surgical complications, as most were unaware of the direct consequences of continued smoking on perioperative outcomes. Patients also mostly reported thinking that the desire for surgery was a motivating factor in the short term. However, a few who had not yet had surgery said they might return to smoking the postoperative period. All participants recommended continued follow-up by someone on their care team to ensure abstinence after surgery.

Current Care Coordination is Fragmented Often due to Specialist-Primary Care Workflow Inconsistencies

Most surgical staff did not report working together with patients on a plan for cessation, mostly because they did not see providing tobacco use treatment as part of their role. Some surgical staff mentioned that patients need to be quit prior to the consultation and therefore, cessation should be within the PCP’s purview. Most surgical staff allowed the use of nicotine replacement therapy to aid in quitting prior to surgery, but a few did not due to concerns that it might increase risk of perioperative complications. Mostly PCPs felt that it was their role to help with cessation regardless of the reason (ie, surgery or otherwise), and described themselves as ‘gatekeepers’ for cessation treatments. All pharmacists considered smoking cessation to be under their purview, but also reported competing demands that sometimes took priority, such as diabetes or hypertension management. Despite willingness of primary care team members to provide cessation assistance, there was a lack of consensus regarding who should provide this care perioperatively. There was some pushback from PCPs about wanting surgical staff to do more in terms of seeing patients who smoke and explaining the reasons for preoperative cessation during consults, especially when the patient desired communication with the surgical department. A couple of PCPs mentioned that surgical staff disallowed nicotine replacement therapy, which can complicate care as nicotine replacement therapy is a guideline-recommended medication that PCPs and pharmacists routinely recommend to help patients quit.

Care coordination and knowing cessation requirements was especially difficult among rural-residing Veterans who were eligible for non-VA purchased care. Surgical teams stated that Veterans could “bypass the system” because if patients “opt to go to the local community providers, [cessation] rules are not always enforced” (6S). One surgical staff member (6S) suggested that VA should “negotiate, for example, [that] complications after surgery should be covered by the fee that [VA] get[s] at the index surgery,” noting that when patients get an infection due to smoking perioperatively in the community, they end up coming to VA to treat the infection. Most PCPs, VA and non-VA, reported lack of coordination and record sharing between VA and community clinicians making it difficult to co-manage patients. Further, some PCPs discussed lengthy times to receive payment authorizations from VA for patients to receive community care, delaying needed tobacco treatment services.

Patients generally reported that their PCPs helped them with cessation and did not report frustration if they saw surgical staff first and then were sent back to primary care for cessation assistance since they understood and desired that to be a central role of their PCP. There seemed to be some confusion about the requirement to quit smoking even when coordinating with community care. For instance, patient 26 explained, “I’m lined up though with [community care] because of VA doesn’t have a specialist anymore… I went to [community care] because I heard the doctor was pretty good and got all lined up, I got the MRI, I got the X-rays and the visits and everything, and then they were all lined up to go except for the smoking [requirement was unclear].”

Discussion

High-quality communication can facilitate a teachable moment for cessation if there is enough distress caused by the health event (eg, pain and desire for elective orthopedic surgery) to promote behavior change.^22,23 Although patients in the current study exhibited distress in relation to pain, they demonstrated differing opinions on whether such distress was a motivator for smoking behavior change. In previous studies,^22,23 though, patients were not required to quit. In contrast, in our study patients were not consistently given the opportunity to make the choice to quit, given that cessation was often required, ie, they may not have felt like they had autonomy or that they had made the choice on their own to quit. That could be a potential reason why all of our participants were unsure whether or not surgery was a teachable moment that would promote long-term abstinence.

The risk of relapse after surgery is high, and indeed, patients in our study agreed that follow-up was key in ensuring abstinence as part of the patient-as-person domain of communication. While health-related concerns are often the impetus for quitting smoking, negative health effects should still be emphasized through patient-clinician encounters to help patients change their smoking behavior,²⁴ and the emphasis should not end after an elective surgery. While some specialties have recommended smoking cessation to be mentioned as part of their core activities, clinicians often still remain unsure about their role.^25,26 The role of a pharmacist or someone outside of the acute surgical care team who has cessation assistance training and may have more time to address tobacco treatment may be beneficial in ensuring follow-up and creating lasting relationships with patients.

Overall, clinicians agreed that the more patients understood the rationale for requiring them to quit smoking during the perioperative period, the less resistance they perceived to the cessation requirement. Some patients and PCPs in our study reported wanting surgical staff to speak to patients about the reasons for the cessation requirement, which has been shown to make a difference in patient engagement.²⁷ The provision of information from a clinician in combination with other techniques like the 5A’s or motivational interviewing can be helpful for patients trying to quit,²⁸ although some studies have shown information alone to have a neutral effect.^29,30 In addition to providing information about the reasons for the cessation requirement, clinicians need to address other aspects of PCC such as the therapeutic alliance and patient-as-person domains to promote patient engagement in tobacco use treatment.²²

Our findings relating to community care highlight that coordination of tobacco use treatment is even more complex when patients are receiving care in nonintegrated health care systems,³¹ where surgical staff may not even be aware of cessation policies at other institutions. One workflow that has been successful for cessation assistance provision prior to total joint arthroplasty was implemented at the University of Pittsburgh Medical Center. Their surgical team created a pathway within the electronic health record to enable communication between a tobacco treatment specialist, clinical team, and the patient to facilitate the provision of cessation resources. It also included a handoff to primary care following the postoperative encounter to encourage abstinence.²⁷ Even within the same health care system, our participants did not largely agree on whose responsibility it was to provide cessation assistance. While surgeons in other studies have reported believing they should discuss and help manage cessation, they lacked the knowledge and skills needed to provide cessation resources effectively.³²

Our study has limitations. Our sample was comprised of an older, white, non-Hispanic population from two veterans integrated service networks that are not representative of all Veteran or clinician experiences, perspectives, and requirements. Indeed, Hispanic patients, for instance, have significantly lower odds of having smoking status assessed and lower odds of having cessation medications ordered when compared with non-Hispanic patients.³³ Although we found little variation in responses across pharmacists, we are limited in our comparisons due to the small number of pharmacists interviewed. This study may suffer from selection bias, moderator acceptance, where participants say what they think the interviewer wants to hear, and/or recall bias. Further, the timing of data collection may not have allowed us to capture all feelings and attitudes because each interview reflects one snapshot in time. We did not observe actual patient-clinician encounters; thus, we do not have an objective account of communication. Finally, we relied on the EHR to identify potentially eligible patients, which may not always be accurate although we attempted to verify criteria with patients prior to enrollment.

Implications

In addition to providing information, clinicians need to address other aspects of PCC such as the therapeutic alliance and patient-as-person domains to promote patient engagement in tobacco use treatment.²² Patients appreciated a shared approach to discussing and addressing tobacco use treatment in the context of elective surgery with their clinician. Some institutions have implemented processes to promote preoperative referrals to Quitlines or other resources, establishment of comprehensive smoking cessation programs,^34,35 clinician education³⁶ and increased electronic health record infrastructure to prompt and support ease of referrals,³⁷ which may be adapted in other settings using an integrated approach. Follow-up after surgery was important for patients in our study, and indeed, long-term support should be offered including interventions with longer-term delivery, more intervention sessions, and the use of behavioral techniques.³⁸

In order to implement these types of improvements, consideration would need to be taken of the setting and resources available. In VA, for example, pharmacists integrated within the primary care team are often trained to provide cessation counseling and medication provision. Thus, referrals could be made to ensure adequate time to address cessation strategies and follow-up over time. Importantly, in other settings, this person does not have to be a part of the current clinical team but it should be someone that the patient can develop a relationship with to promote PCC. It would also be helpful to have a clinical champion³⁹ who could facilitate implementation of cessation assistance and promote greater integration of clinicians’ workflows. Champions do not always need to be a clinicians, but do need to be given the power to implement solutions and be integrated with other disciplines to ensure continued coordination of care, among other aspects.⁴⁰

Conclusions

While clinician-provided information about the reasons behind the requirement to quit smoking preoperatively was beneficial, patients appreciated working with their clinicians on a plan for cessation and abstinence. Therefore, other aspects of PCC need to be considered such as the therapeutic alliance or patient-as-person. Innovative interventions, including using system-level infrastructure to seamlessly connect clinicians within and across disciplines and departments to support patients seeking elective surgeries, are likely to help ensure that patients are active participants in their own care, thus, enhancing the potential of this teachable moment and success in quitting.

Supplementary material

Supplementary material is available at Nicotine and Tobacco Research online.

Funding

This work was supported by an award from the Veterans Rural Health Resource Center-Portland, OR, Office of Rural Health, Department of Veterans Affairs (PI: Steffani Bailey, PhD). The Department of Veterans Affairs did not have a role in the conduct of the study, in the collection, management, analysis, interpretation of data, or in the preparation of the manuscript. The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs or the U.S. Government.

Declaration of Interests

All authors declare no conflicts of interest with the work presented in this manuscript.

Author Contributions

Sara Golden (Conceptualization [supporting], Data curation [lead], Formal analysis [lead], Funding acquisition [supporting], Investigation [equal], Methodology [equal], Software [equal], Supervision [equal], Validation [equal], Writing—original draft [lead], Writing—review & editing [lead]), Allison Young (Data curation [supporting], Investigation [supporting], Project administration [lead], Writing—review & editing [supporting]), Mark W. Vander Weg (Conceptualization [supporting], Funding acquisition [supporting], Investigation [supporting], Validation [supporting], Writing—review & editing [equal]), Marissa Song Mayeda (Investigation [supporting], Resources [supporting], Visualization [equal], Writing—review & editing [equal]), Kenneth R. Gundle (Conceptualization [supporting], Funding acquisition [supporting], Investigation [supporting], Resources [equal], Writing—review & editing [equal]), Christina Sun (Formal analysis [supporting], Methodology [supporting], Writing—review & editing [equal]), David Katz (Conceptualization [supporting], Funding acquisition [supporting], Investigation [supporting], Validation [supporting], Writing—review & editing [equal]), and Steffani Bailey (Conceptualization [lead], Formal analysis [supporting], Funding acquisition [lead], Investigation [equal], Methodology [equal], Project administration [equal], Resources [equal], Supervision [equal], Validation [equal], Visualization [supporting], Writing—original draft [supporting], Writing—review & editing [equal]).