Statement on the Effects of Tobacco Use on Surgical Complications and the Utility of Smoking Cessation Counseling

This statement was developed by the Patient Education Committee of the American College of Surgeons (ACS) Division of Education. It was approved by the ACS Board of Regents at its June 2014 meeting in Chicago, IL.

Approximately one in five American adults, or about 45.3 million people living in the U.S., smoke cigarettes.¹ After 50 years of steady decline in smoking prevalence, progress has stalled. Half of all smokers will die from tobacco-related illness. For every smoking-related death, another 20 individuals will suffer from a smoking-related disease. Tobacco causes one in 10 deaths globally. Worldwide, lung cancer accounts for nearly one-fifth of all cancer deaths, with 1.8 million new cases developing annually.² Exposure to secondhand smoke also causes cancer.³ Because of these adverse consequences, smoking costs the U.S. economy at least $133 billion each year for direct medical care for adults and more than $156 billion in lost productivity.⁴

The impact of smoking on surgical patients is considerable. Approximately 30 percent of all patients undergoing elective general surgery procedures smoke, which means that an estimated 10 million operations are performed on smokers annually.⁵ Smoking within one year of surgery has been associated with increased postoperative complications, increased hospital costs, and higher resource use.⁵ Deleterious effects on wound healing also occur and are thought to be related to the nicotine content of conventional tobacco products as well as tobacco substitutes containing nicotine.

Smoking cessation before surgery is associated with demonstrable benefits.⁶ Short-term cessation results in a measurable reduction in vasoconstriction and irregular heart activity due to an immediate decrease in nicotine.⁷ The lack of oxygen to surgical wound sites and increased risk of blood clots are also reversed with short-term smoking cessation.⁸ Smoking-related impairment in wound healing and pulmonary function improve within four to eight weeks of smoking cessation.⁹ In addition, there is no evidence that short-term cessation is harmful perioperatively.

Few surgeons in the U.S. provide smoking cessation counseling. While smoking cessation is a core quality measure and quitting before surgery improves patient outcomes, a survey revealed that only 13 percent of general surgeons provide smoking cessation counseling, and many surgeons are unaware of optimal methods of counseling and the reimbursement provided (or available) for such counseling.¹⁰

Surgeons should play an active role in smoking cessation counseling with their patients. Surgeons are in a unique position to leverage their influence at a critical time in their patient’s life, affording an opportunity to change smoking behavior. Most smokers want to quit, and surgical patients are typically highly motivated.

The perioperative time is a critical window of opportunity to help patients realize the importance of their role in their own surgical outcomes and how smoking cessation can influence the success of their operation. Only 5 percent of smokers can quit on their own, but guideline-driven interventions can boost cessation rates to 15 percent to 25 percent.¹¹ For example, smokers are more likely to quit when advised by a health professional, and cessation interventions as brief as three minutes can markedly increase quit rates.¹²

To reduce smoking-related surgical complications and smoking prevalence in general, the ACS supports the following:

• Smoking cessation counseling during all nonemergent patient consults
• Education programs on effective smoking cessation strategies and proper coding of interventions
• Development and dissemination of quality educational materials for surgeons to use in conjunction with their smoking cessation counseling
• Support for government regulation of tobacco products and incentives for individuals to avoid tobacco use
• Continued measurement and reporting of surgical outcomes of smokers versus nonsmokers

References

1. U.S. Centers for Disease Control and Prevention. Adult smoking in the US. CDC Vital Signs. Available at: http://www.cdc.gov/vitalsigns/pdf/2011-09-vitalsigns.pdf. Accessed May 12, 2014.
2. World Health Organization. International Agency for Research on Cancer. Latest world cancer statistics: Global cancer burden rises to 14.1 million new cases in 2012: Marked increase in breast cancers must be addressed. Press release. December 12, 2013. Available at: www.iarc.fr/en/media-centre/pr/2013/pdfs/pr223_E.pdf. Accessed June 18, 2014.
3. International Agency for Research on Cancer. Second-hand tobacco smoke. Available at: http://monographs.iarc.fr/ENG/Monographs/vol100E/mono100E-7.pdf. Accessed June 25, 2014.
4. U.S. Centers for Disease Control and Prevention. Economic facts about U.S. tobacco production and use. Available at: http://www.cdc.gov/tobacco/data_statistics/fact_sheets/economics/econ_facts/index.htm#costs. Accessed May 12, 2014.
5. Kamath AS, Vaughan Sarrazin M, Vander Weg MW, Cai X, Cullen J, Katz DA. Hospital costs associated with smoking in veterans undergoing general surgery. J Am Coll Surg. 2012;214(6):901-908.
6. Lindstrom D, Sadr Azodi O, Wladis A, et al. Effects of a perioperative smoking cessation intervention on postoperative complications: A randomized trial. Ann Surg. 2008;248(5):739-745.
7. Moller AM, Villebro N, Pedersen T, Tonnesen H. Effect of preoperative smoking intervention on postoperative complications: A randomised clinical trial. Lancet. 2002;359(9301):114-117.
8. Sorensen LT. Wound healing and infection in surgery. The clinical impact of smoking and smoking cessation: A systematic review and meta-analysis. Arch Surg. 2012;147(4):373-383.
9. Sorensen LT. Wound healing and infection in surgery: The pathophysiological impact of smoking, smoking cessation, and nicotine replacement therapy: A systematic review. Ann Surg. 2012;255(6):1069-1079.
10. Warner DO, Sarr MG, Offord KP, Dale LC. Anesthesiologists, general surgeons, and tobacco interventions in the perioperative period. Anesth Analg. 2004;99(6):1766-1773.
11. American Cancer Society. Guide to quitting smoking. A word about success rates for quitting smoking. Available at: http://www.cancer.org/healthy/stayawayfromtobacco/guidetoquittingsmoking/guide-to-quitting-smoking-success-rates. Accessed May 14, 2014.
12. The Tobacco Use and Dependence Clinical Practice Guideline Panel, Staff, and Consortium Representatives. A clinical practice guideline for treating tobacco use and dependence: A US Public Health Service report. JAMA. 2000;283(24):3244-3254.

Reprinted from Bulletin of the American College of Surgeons
Vol. 99, No. 8, August 2014