Perioperative Considerations for Smokers
Cigarette smoking has a long and colorful history in the United States. While the social practice of smoking has transformed from a symbol of independent thought during the American Revolution to a symbol of teenage rebellion or workplace exhaustion today, there is no question that smoking tobacco has long been a component of this nation’s cultural framework.1 In fact, despite the fact that our society is much more aware of the cardiovascular and respiratory health risks associated with smoking today than it was back in the 1700’s, 12.5% of American adults—or 13 out of every 100 people over 18 living in the United States—self-reported as smokers in 2020.2 While an unfortunate truth, this fact makes it clear that it is absolutely critical that healthcare providers are aware of the specific health risks associated with smoking and how these risks can interact with medical procedures. In particular, there are a number of perioperative considerations that providers must be aware of for patients who are smokers.
With respect to surgical procedures, a comparative study by Schwilk et al. in the early 1990’s identified a higher risk of respiratory events under general anesthesia for patients who are smokers, necessitating special perioperative considerations, such as anesthetic choice. In a record of 26,961 operations involving the use of general anesthesia, it was found that certain respiratory events, such as re-intubation, laryngospasm, bronchospasm, aspiration, and hypoventilation/hypoxemia occurred at an incidence of 5.5% in tobacco smokers and at an incidence of 3.1% in non-smokers, with the relative risk of these respiratory events being 1.8 in all smokers, 2.3 in young smokers (defined as those between 16 and 39 years of age) , and 6.3 in obese young smokers.3 Because, as reported by the CDC in 2022, nearly 9 out of 10 adults who smoke cigarettes daily first try smoking by age 18, it is critical that this knowledge is applied and that such perioperative respiratory events are anticipated or prevented appropriately.4
In a 2006 article Drs. Ann Møller and Hanne Tønnesen identified that one way to mitigate the risk factors associated with regular smoking for patients who are facing a surgical operation was for the patients’ care team to perform a preoperative smoking intervention six to eight weeks prior to the operation—they found that such an effort reduced the complications risk significantly. Furthermore, four weeks of abstinence from smoking on the part of the patients was associated with a significantly improved wound healing process post-operation. While acknowledging that further studies with shorter periods of preoperative smoking interventions were necessary, due to the difficulty of such a long period of abstinence for many smokers, this study made it very clear that the physicians and care team surrounding a smoking patient could have a significant and meaningful impact. Taking into consideration the medical history of patients who are smokers and making an active and individualized effort to intervene in the patients’ habits can improve their perioperative outcomes.5
Smoking is both a public health and individual health issue. Many of the patients included in studies about how to reduce risk in surgical operations may never have needed such surgeries in the first place if their health were not damaged by their use of and dependence on tobacco. Nonetheless, it is at once empowering and humbling to realize that, despite the gravity and seeming universality of the problem of smoking among patient populations, individual physicians could have an immense impact on outcomes for smokers simply by taking the time to sit down and speak with them about their unique perioperative considerations and risks and to persuade them to make a decision conducive to good health.
References
(1) 2000 Surgeon General’s Report Highlights: Tobacco Timeline | Smoking & Tobacco Use | CDC. https://www.cdc.gov/tobacco/sgr/2000/highlights/historical/index.htm.
(2) Current Cigarette Smoking Among Adults in the United States | CDC. https://www.cdc.gov/tobacco/data_statistics/fact_sheets/adult_data/cig_smoking/index.htm .
(3) Schwilk, B.; Bothner, U.; Schraac, S.; Georgieff, M. Perioperative Respiratory Events in Smokers and Nonsmokers Undergoing General Anaesthesia. Acta Anaesthesiologica Scandinavica 1997, 41 (3), 348–355. https://doi.org/10.1111/j.1399-6576.1997.tb04697.x.
(4) Youth and Tobacco Use | Smoking and Tobacco Use | CDC. https://www.cdc.gov/tobacco/data_statistics/fact_sheets/youth_data/tobacco_use/index.htm .
(5) Møller, A.; Tønnesen, H. Risk Reduction: Perioperative Smoking Intervention. Best Practice & Research Clinical Anaesthesiology 2006, 20 (2), 237–248. https://doi.org/10.1016/j.bpa.2005.10.008.