Society for Ambulatory Anesthesiology Section Editor: Tong J. Gan E REVIEW ARTICLE CME Smoking Cessation: The Role of the Anesthesiologist Amir Yousefzadeh, MD, Frances Chung, MD, FRCPC, David T. Wong, MD, FRCPC, David O. Warner, MD, and Jean Wong, MD, FRCPC * * * † * Smoking increases the risk of postoperative morbidity and mortality. Smoking cessation before surgery reduces the risk of complications. The perioperative period may be a “teachable moment” for smoking cessation and provides smokers an opportunity to engage in long-term smoking cessation. Anesthesiologists as the perioperative physicians are well-positioned to take the lead in this area and improve not only short-term surgical outcomes but also long-term health outcomes and costs. Preoperative interventions for tobacco use are effective to reduce postoperative complications and increase the likelihood of long-term abstinence. If intensive interventions (counseling, pharmacotherapy, and follow-up) are impractical, brief interventions should be implemented in preoperative clinics as a routine practice. The “Ask, Advise, Connect” is a practical strategy to be incorporated in the surgical setting. All anesthesiologists should ask their patients about smoking and strongly advise smokers to quit at every visit. Directly connecting patients to existing counseling resources, such as telephone quitlines, family phy- sicians, or pharmacists using fax or electronic referrals, greatly increases the reach and the impact of the intervention. (Anesth Analg 2016;122:1311–20) moking is a risk factor for several perioperative cessation using Medline (January 1946 to May 2015) and complications,1–5 which is a major concern because EMBASE (January 1974 to May 2015). The following text- smokers comprise a substantial proportion of surgi- word terms were used in our search strategies: smoking S 6,7 cal patients. Stopping smoking before surgery has been cessation , smoking quit , tobacco dependence cessation , shown to improve surgical outcomes. In addition, surgery tobacco use disorder cessation , nicotine cessation , periop- is a “teachable moment” for smoking cessation.7 Therefore, erat , postop* , preoperat*, intraoperat , operation?, opera*- preoperative interventions for smoking cessation may tive , surgical , anesthes , anaesthes* , preintervention* , reduce surgical complications and improve long-term randomized* *controlled trial,* clinical trial,* placebo, meta- health. Despite the available evidence suggesting the ben- analy* , metaanaly* , and systematic* review.* The exploded* efits of these interventions, anesthesiologists do not imple- index-word terms in our search strategy included “tobacco ment them routinely in their practice. The main objective use cessation,”* “electronic* cigarette,” “tobacco use cessa- of this narrative review was to provide a practical and tion product,” “perioperative care,” “preoperative period,” multidisciplinary strategy for implementing a periopera- “surgical procedures, operative,” “anesthesiology,” and tive smoking cessation program. We (1) examine available “anesthesia” (Appendix 1). We manually searched the bib- data on the relation between preoperative smoking status liographies of retrieved articles to identify additional pub- and postoperative complications; (2) provide an overview lished or unpublished data relevant to our review. This of previous preoperative interventions for tobacco use and search was limited to English-language articles on human current smoking cessation programs; (3) discuss strategies subjects. The search strategy yielded 1717 articles. After that can be practically applied in the preoperative clinics; we removed duplicate publications and evaluated the title, and (4) highlight the opportunities for anesthesiologists abstract, and full-text of studies, 95 articles were included in as perioperative physicians, to play an important role in this review (Fig. 1). improving surgical outcomes and public health. SEARCH STRATEGY In collaboration with a research librarian, we conducted a literature search for studies on perioperative smoking From the Department of Anesthesiology, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada; and Department* of Anesthesiology, Mayo Clinic College of Medicine, Rochester, Minnesota. † Accepted for publication December 15, 2015. Funding: None. The authors declare no conflicts of interest. Reprints will not be available from the authors. Address correspondence to Jean Wong, MD, FRCPC, Department of Anesthesiology, Toronto Western Hospital, 399 Bathurst St., Toronto, Ontario, Canada M5T 2S8. Address e-mail to [email protected]. Copyright © 2016 International Anesthesia Research Society DOI: 10.1213/ANE.0000000000001170 Figure 1. Flowchart for study selection. May 2016 • Volume 122 • Number 5 www.anesthesia-analgesia.org 1311 Copyright © 2016 International Anesthesia Research Society. Unauthorized reproduction of this article is prohibited. E REVIEW ARTICLE SMOKING AND PERIOPERATIVE COMPLICATIONS effects of nicotine and CO in common create an imbalance The pathophysiologic consequences of smoking on surgical between oxygen demand and delivery.13 In the long term, outcomes relate to both the toxic effects of recent smoke inha- smoking increases oxidative stress and inflammation, pro- lation and the cumulative chronic effects of tobacco exposure.2 motes endothelial damage, increases hypercoagulability, Cigarette smoke contains >250 toxic chemicals with nicotine, and reduces fibrinolysis. These effects lead to the progres- carbon monoxide (CO), hydrogen cyanide, and nitric oxide sion of atherosclerosis and thrombosis in the vasculature.14 being the 4 main harmful components.8 These chemicals Surgery and anesthesia place additional demands on the work in a synergistic manner to reduce tissue perfusion and heart and circulation and result in a greater risk of cardio- oxygenation, impair inflammatory cell function, and affect vascular complications such as cerebrovascular accidents synthesis and deposition of collagen.8,9 The net effect of these (OR = 1.55; 95% CI, 1.36–1.76) and myocardial infarction interactions is ultimately responsible for the greater incidence (OR = 1.77; 95% CI, 1.57–1.99) in smokers3 (Table 1). of postoperative complications in smokers9 (Table 1). Pathophysiologic Impact of Smoking on the EFFECTS ON SPECIFIC ORGAN SYSTEMS Respiratory System Pathophysiologic Impact of Smoking on Wound In the respiratory system, tobacco use damages cilia and mucus and Bone Healing transport, stimulates goblet cell hyperplasia and mucus over- In the setting of surgical wounds, these effects can manifest production,15 impairs pulmonary macrophage function,16 and as wound healing delay and dehiscence (odds ratios [OR] increases bronchial airway reactivity.17 Exposure to tobacco = 2.07; 95% confidence interval [CI], 1.53–2.81), hernia (OR causes delayed bacterial clearance and increased susceptibil- = 2.07; 95% CI, 1.23–3.47), necrosis of wound and tissue ity to infection.18 Smokers are predisposed to postoperative (OR = 3.60; 95% CI, 2.62–4.93), and surgical-site infection pulmonary complications (PPCs), such as pneumonia (OR = (SSI) (OR = 1.18; 95% CI, 1.13–1.24).2,9,10 Bone healing is also 1.77; 95% CI, 1.66–1.90) and prolonged mechanical ventilation impaired in smokers. Smoking inhibits neovascularization (OR = 1.55; 95% CI, 1.43–1.68)2 (Table 1). and osteoblast differentiation, contributing to delayed bone healing and bone fusion11,12 (Table 1). Reversibility of Smoking-Induced Pathologic Changes Pathophysiologic Impact of Smoking on the Smoking cessation can reverse some but not all smoking- Cardiovascular System induced pathologic changes that lead to an increased risk Three large multicenter studies reported increased odds of of perioperative complications.19 Although current smokers postoperative mortality and cardiovascular events in cur- with more than a 20 pack-year exposure are most likely to rent smokers.2,3,5 Smoking has both short-term and long- have postoperative morbidity and mortality, former smok- term harmful effects on the cardiovascular system. In the ers, even those with an extensive history, may not be at short term, nicotine increases the sympathetic activity, greater risk of postoperative mortality.2,3 For some morbid- leading to increased arterial blood pressure, heart rate, and ity, the duration of abstinence necessary for benefit is not myocardial contractility. CO decreases oxygen availability known, but for most, abstinence for at least 1 year before by shifting the oxygen-hemoglobin curve to the left. The surgery reduces the risk of postoperative mortality and Table 1. Odds Ratios of Postoperative Outcomes Among Current and Former Smokers Compared with Patients Who Never Smoked Smoking status before surgery, OR (95% CI) Postoperative outcomes Never Former Current Wound healing delay and dehiscence (10) 1a — 2.07 (1.53–2.81) Hernia (10) 1 — 2.07 (1.23–3.47) Necrosis of wound and tissue (10) 1 — 3.60 (2.62–4.93) Sepsis (5) 1 — 1.38 (1.11–1.72) Septic shock (5) 1 — 1.40 (1.33–1.47) Surgical-site infectionb (2) 1 1.11 (1.05–1.17) 1.18 (1.13–1.24) Long bone fracture nonunion (12) 1 — 2.32 (1.76–3.06) Cerebrovascular accident/strokec (3) 1 1.10 (0.96–1.26) 1.55 (1.36–1.76) Myocardial infarctionc (3) 1 1.28 (1.14–1.44) 1.77 (1.57–1.99) Ventilation for longer than 48 hb (2) 1 1.26 (1.16–1.38) 1.55 (1.43–1.68) Unplanned reintubation for respiratory/cardiac failureb (2) 1 1.36 (1.26–1.47) 1.67 (1.55–1.79) Pneumoniab