Interventions for preoperative smoking cessation

Citation: The Cochrane database of systematic reviews, 2014, vol./is. 3/(CD002294), 1469-493X (2014)

Author(s): Thomsen T., Villebro N., Moller A.M.

Abstract: Smokers have a substantially increased risk of postoperative complications. Preoperative smoking intervention may be effective in decreasing this incidence, and surgery may constitute a unique opportunity for smoking cessation interventions. The objectives of this review are to assess the effect of preoperative smoking intervention on smoking cessation at the time of surgery and 12 months postoperatively, and on the incidence of postoperative complications. We searched the Cochrane Tobacco Addiction Group Specialized Register in January 2014. Randomized controlled trials that recruited people who smoked prior to surgery, offered a smoking cessation intervention, and measured preoperative and long-term abstinence from smoking or the incidence of postoperative complications or both outcomes. The review authors independently assessed studies to determine eligibility, and discussed the results between them. Thirteen trials enrolling 2010 participants met the inclusion criteria. One trial did not report cessation as an outcome. Seven reported some measure of postoperative morbidity. Most studies were judged to be at low risk of bias but the overall quality of evidence was moderate due to the small number of studies contributing to each comparison.Ten trials evaluated the effect of behavioural support on cessation at the time of surgery; nicotine replacement therapy (NRT) was offered or recommended to some or all participants in eight of these. Two trials initiated multisession face-to-face counselling at least four weeks before surgery and were classified as intensive interventions, whilst seven used a brief intervention. One further study provided an intensive intervention to both groups, with the intervention group additionally receiving a computer-based scheduled reduced smoking intervention. One placebo-controlled trial examined the effect of varenicline administered one week preoperatively followed by 11 weeks postoperative treatment, and one placebo-controlled trial examined the effect of nicotine lozenges from the night before surgery as an adjunct to brief counselling at the preoperative evaluation. There was evidence of heterogeneity between the effects of trials using intensive and brief interventions, so we pooled these separately. An effect on cessation at the time of surgery was apparent in both subgroups, but the effect was larger for intensive intervention (pooled risk ratio (RR) 10.76; 95% confidence interval (CI) 4.55 to 25.46, two trials, 210 participants) than for brief interventions (RR 1.30; 95% CI 1.16 to 1.46, 7 trials, 1141 participants). A single trial did not show evidence of benefit of a scheduled reduced smoking intervention. Neither nicotine lozenges nor varenicline were shown to increase cessation at the time of surgery but both had wide confidence intervals (RR 1.34; 95% CI 0.86 to 2.10 (1 trial, 46 participants) and RR 1.49; 95% CI 0.98 to 2.26 (1 trial, 286 participants) respectively). Four of these trials evaluated long-term smoking cessation and only the intensive intervention retained a significant effect (RR 2.96; 95% CI 1.57 to 5.55, 2 trials, 209 participants), whilst there was no evidence of a long-term effect following a brief intervention (RR 1.09; 95% CI 0.68 to 1.75, 2 trials, 341 participants). The trial of varenicline did show a significant effect on long-term smoking cessation (RR 1.45; 95% CI 1.01 to 2.07, 1 trial, 286 participants).Seven trials examined the effect of smoking intervention on postoperative complications. As with smoking outcomes, there was evidence of heterogeneity between intensive and brief behavioural interventions. In subgroup analyses there was a significant effect of intensive intervention on any complications (RR 0.42; 95% CI 0.27 to 0.65, 2 trials, 210 participants) and on wound complications (RR 0.31; 95% CI 0.16 to 0.62, 2 trials, 210 participants). For brief interventions, where the impact on smoking had been smaller, there was no evidence of a reduction in complications (RR 0.92; 95% CI 0.72 to 1.19, 4 trials, 493 participants) for any complication (RR 0.99; 95% CI 0.70 to 1.40, 3 trials, 325 participants) for wound complications. The trial of varenicline did not detect an effect on postoperative complications (RR 0.94; 95% CI 0.52 to 1.72, 1 trial, 286 participants). There is evidence that preoperative smoking interventions providing behavioural support and offering NRT increase short-term smoking cessation and may reduce postoperative morbidity. One trial of varenicline begun shortly before surgery has shown a benefit on long-term cessation but did not detect an effect on early abstinence or on postoperative complications. The optimal preoperative intervention intensity remains unknown. Based on indirect comparisons and evidence from two small trials, interventions that begin four to eight weeks before surgery, include weekly counselling and use NRT are more likely to have an impact on complications and on long-term smoking cessation.


A perioperative smoking cessation intervention with varenicline: a double-blind, randomized, placebo-controlled trial.

Citation: Anesthesiology, Oct 2012, vol. 117, no. 4, p. 755-764, 1528-1175 (October 2012)

Author(s): Wong, Jean, Abrishami, Amir, Yang, Yiliang, Zaki, Amna, Friedman, Zeev, Selby, Peter, Chapman, Kenneth R, Chung, Frances

Abstract: The efficacy of perioperative tobacco interventions on long-term abstinence and the safety of smoking cessation less than 4 weeks before surgery is unclear. Our objective was to determine the efficacy and safety of a perioperative smoking cessation intervention with varenicline to reduce smoking in elective surgical patients. In a prospective, multicenter, double-blind, placebo-controlled trial, 286 patients were randomized to receive varenicline or placebo. Both groups received in-hospital and telephone counseling during 12 months. The primary outcome was the 7-day point prevalence abstinence rate 12 months after surgery. Secondary outcomes included abstinence at 3 and 6 months after surgery. Multivariable logistic regression was used to identify independent variables related to abstinence. The 7-day point prevalence abstinence at 12 months for varenicline versus placebo was 36.4% versus 25.2% (relative risk: 1.45; 95%: CI: 1.01-2.07; P = 0.04). At 3 and 6 months, the 7-day point prevalence abstinence was 43.7% versus 31.9% (relative risk: 1.37; 95% CI: 1.01 to 1.86; P = 0.04), and 35.8% versus 25.9% (relative risk: 1.43; 95%: CI 1.01-2.04; P = 0.04) for varenicline versus placebo, respectively. Treatment with varenicline (odds ratio: 1.76; 95% CI: 1.03-3.01; P = 0.04), and preoperative nicotine dependence (odds ratio: 0.82, 95% CI: 0.68 to 0.98; P = 0.03) predicted abstinence at 12 months. The adverse events profile in both groups was similar except for nausea, which occurred more frequently for varenicline versus placebo (13.3% vs. 3.7%, P = 0.004). A perioperative smoking cessation intervention with varenicline increased abstinence from smoking 3, 6, and 12 months after elective noncardiac surgery with no increase in serious adverse events.


Impact of smoking on early clinical outcomes in patients undergoing coronary artery bypass grafting surgery.

Citation: Journal of cardiothoracic surgery, Jan 2015, vol. 10, p. 16., 1749-8090 (2015)

Author(s): Ji, Qiang, Zhao, Hang, Mei, YunQing, Shi, YunQing, Ma, RunHua, Ding, WenJun

Abstract: To evaluate the impact of persistent smoking versus smoking cessation over one month prior to surgery on early clinical outcomes in Chinese patients undergoing isolated coronary artery bypass grafting (CABG) surgery in a retrospective study. The peri-operative data of consecutive well-documented patients undergoing isolated CABG surgery from January 2007 to December 2013 were investigated and retrospectively analyzed. All included patients were divided into either a non-smoking group or a smoking group according to preoperative smoking records. Furthermore, smokers were divided into either a former smoking subgroup (smokers with smoking cessation over 1 month before surgery) or a current smoking subgroup (persistent smokers). A total of 3730 consecutive patients (3207 male patients and mean 63.6 ± 9.5 years) undergoing isolated CABG surgery were analyzed. Persistent smokers had significantly higher incidence of postoperative pulmonary complications as compared to non-smokers (7.8% vs. 4.5%, p = 0.0002). No significantly differences in both surgical mortality and major postoperative morbidities between smokers with smoking cessation over 1 month before surgery and non-smokers were found. In multiple logistic regression analysis, the risk of postoperative pulmonary complications in persistent smokers was 2.41 times than that in non-smokers, whereas the risk of postoperative pulmonary complications in smokers with smoking cessation over 1 month before surgery was similar to non-smokers. Persistent smokers had a higher incidence of pulmonary complications following CABG as compared to non-smokers. Smoking cessation more than 1 month before surgery was expected to reduce early major morbidities following CABG surgery.


Perioperative smoking and alcohol intervention in relation to radical cystectomy: Effect on postoperative complications and quality of life

Citation: Asia-Pacific Journal of Clinical Oncology, December 2014, vol./is. 10/(254), 1743-7555 (December 2014)

Author(s): Thomsen T.T.T., Lauridsen S.S.V.L.V., Thind P.P.T., Tonnesen H.H.T.

Abstract: Background: Daily smoking and alcohol consumption exceeding 2 units per day increase the risk of postoperative complications, lifestyle-related morbidity and recurrence of cancer disease. Evidence indicates that smoking and alcohol cessation intervention lasting 4 weeks and more reduces the frequency of postoperative complications and increases long-term lifestyle change. Patients suffering from cancer are however scheduled for surgery within maximum 2 weeks of diagnosis. Preoperative intervention lasting 4 weeks or more is therefore not possible for these patients. Intervention initiated immediately before and continued at least 5 weeks postoperatively may hypothetically be equally effective. Aim: To examine the effect of an intensive smoking and/or alcohol intervention initiated immediately before and continued 5 weeks after radical cystectomy versus standard preoperative care on postoperative complications, lifestyle change and quality of life up to 12 months postoperatively. Methods: A single-blinded randomized controlled trial. Primary outcome: postoperative complications up to 90 days postoperatively assessed according to the Clavien-Dindo classification. Secondary outcomes: smoking and/or alcohol cessation, length of hospital stay, time to return to work, quality of life. Inclusion criteria: Patients scheduled for radical cystectomy, aged 18 years and above, who are daily smokers and/or drink more than 3 units of alcohol daily. The intervention includes behavioral counseling with trained cessation counselors and pharmacological support to stop smoking and/or drinking perioperatively. Patients are invited to attend 5 individual meetings over 6 weeks. The first meeting occurs shortly before surgery and the remaining meetings are scheduled postoperatively. Data analysis using non-parametric statistics and intention to treat analysis. Results: The study is ongoing. We plan to present preliminary feasibility results (inclusion rate, patient compliance, lifestyle changes short-term) at the World Cancer Congress. Conclusions: If effective for preventing postoperative complications and increasing smoking and alcohol cessation, the intervention may impact on quality of life in cancer survivors.


Preoperative smoking cessation can reduce postoperative complications in gastric cancer surgery.

Gastric Cancer. 2015 Oct;18(4):683-90. doi: 10.1007/s10120-014-0415-6. Epub 2014 Aug 20.

Jung KH(1), Kim SM(2), Choi MG(2), Lee JH(2), Noh JH(2), Sohn TS(2), Bae JM(3),Kim S(2).

Author information:

(1)Department of Surgery, Bundang Jesaeng Hospital, Seongnam, Republic of Korea.

(2)Department of Surgery, Samsung Medical Center, Sungkyunkwan University School

of Medicine, 50 Irwon-dong, Gangnam-gu, Seoul, 135-710, Republic of Korea.

(3)Department of Surgery, Samsung Medical Center, Sungkyunkwan University School

of Medicine, 50 Irwon-dong, Gangnam-gu, Seoul, 135-710, Republic of Korea.


BACKGROUND: Despite the close link between cigarette smoking and the development  of gastric cancer, little is known about the effects of cigarette smoking on surgical outcomes after gastric cancer surgery. The aim of this study was to investigate whether preoperative smoking status and the duration of smoking cessation were associated with short-term surgical consequences in gastric cancer surgery.

METHODS: Among 1,489 consecutive patients, 1,335 patients who underwent curative  radical gastrectomy at the Samsung Medical Center between January and December 2009 were included in the present study. The smoking status was determined using  questionnaires before surgery. Smokers were divided into four groups according to the duration of smoking cessation preoperatively (<2, 2-4, 4-8, and >8 weeks). The primary endpoint was postoperative complications (wound, lung, leakage, and bleeding); secondary endpoints were 3-year recurrence-free survival (RFS) and overall survival (OS).

RESULTS: Five hundred twenty-two patients (39.1 %) were smokers. Smokers had a significantly higher overall incidence of postoperative complications than nonsmokers (12.3 vs. 5.2 %, P < 0.001, respectively), especially in impaired wound healing, pulmonary problems, and leakage. Smokers also had more severe complications than nonsmokers. After adjusting for other risk factors, the odds ratio (95 % CI) for the development of postoperative complications in the subgroups who stopped smoking <2 weeks, 2-4, 4-8, and >8 weeks preoperatively were 3.35 (1.92-5.83), 0.99 (0.22-4.38), 2.18 (1.00-4.76), and 1.32 (0.70-2.48),  respectively, compared with the nonsmokers. There were no significant differences in 3-year RFS (P = 0.884) and OS (P = 0.258) between smokers and nonsmokers.

CONCLUSIONS: Preoperative smoking cessation for at least 2 weeks will help to reduce the incidence of postoperative complications in gastric cancer surgery.

PMID: 25139298  [PubMed – in process]


The effectiveness of a perioperative smoking cessation program: a randomized clinical trial.

Anesth Analg. 2013 Sep;117(3):605-13. doi: 10.1213/ANE.0b013e318298a6b0. Epub 2013 Jul 18.

Lee SM(1), Landry J, Jones PM, Buhrmann O, Morley-Forster P.

Author information:

(1)FRCPC, Department of Anesthesia and Perioperative Medicine, University of

Western Ontario, Smoking Cessation Study Linda Szabo University Hospital-B3-218,

339 Windermere Rd., London, Ontario, Canada N6A 5A5. suze.lee@utoronto.c.

BACKGROUND: Cigarette smoking by surgical patients is associated with increased complications, particularly perioperative respiratory problems and poor wound healing. In this study, we sought to determine whether a pragmatic perioperative  smoking cessation intervention designed for a busy preadmission clinic would be successful in reducing smoking rates and intraoperative and immediate postoperative complications.

METHODS: This randomized controlled trial was conducted at a university-affiliated hospital in London, Ontario, Canada. Patients seen in the preadmission clinic at least 3 weeks preoperatively were randomized to either the control group (84 patients) or the intervention group (84 patients). The control  group received no specific smoking cessation intervention. The intervention group received (1) brief counseling by the preadmission nurse, (2) brochures on smoking cessation, (3) referral to the Canadian Cancer Society’s Smokers’ Helpline, and (4) a free 6-week supply of transdermal nicotine replacement therapy. All outcome assessors and caregivers on the operative day were blinded to group assignment. The primary outcome was the rate of smoking cessation as confirmed by exhaled carbon monoxide breath test. Secondary outcomes included perioperative complications and smoking status at 30 days postoperatively.

RESULTS: Between October 2010 and April 2012, 168 patients were recruited into the study. Smoking cessation occurred in 12 patients (14.3%) in the intervention  group as compared with 3 patients (3.6%) in the control group (relative risk 4.0; 95% confidence interval [CI], 1.2-13.7; P = 0.03). The overall rate of combined intraoperative and immediate postoperative complications was not significantly different between intervention and control groups (13.1% and 16.7%, respectively; relative risk 0.79; 95% CI, 0.38-1.63; P = 0.67). At follow-up 30 days postoperatively, smoking cessation was reported in 22 patients (28.6%) in the intervention group compared with 8 patients (11%) in controls (relative risk 2.6; 95% CI, 1.2-5.5; P = 0.008).

CONCLUSIONS: One of the objections to widespread use of smoking cessation interventions in the preadmission clinic is that it is too labor-intensive. The results of this study show that a smoking cessation intervention, designed to minimize additional use of physician or nursing time, results in decreased smoking rates on the day of surgery and promotes abstinence 30 days postoperatively.

PMID: 23868890  [PubMed – indexed for MEDLINE]


Mediation of smoking-associated postoperative mortality by perioperative complications in veterans undergoing elective surgery: data from Veterans Affairs Surgical Quality Improvement Program (VASQIP)–a cohort study.

BMJ Open. 2013 Apr 18;3(4). pii: e002157. doi: 10.1136/bmjopen-2012-002157. Print 2013.

Singh JA(1), Hawn M, Campagna EJ, Henderson WG, Richman J, Houston TK.

Author information:

(1)Medicine Service, Birmingham VA Medical Center and Department of Medicine,

University of Alabama at Birmingham, Birmingham, Alabama, USA.

OBJECTIVE: To assess the mediation of smoking-associated postoperative mortality by postoperative complications.

DESIGN: Observational cohort study.

SETTING: Using data from the Veterans Affairs (VA) Surgical Quality Improvement

Programme, a quality assurance programme for major surgical procedures in the VA healthcare system, we assessed the association of current smoking at the time of the surgery with 6-month and 1-year mortality.

PRIMARY AND SECONDARY OUTCOME MEASURES: Using mediation analyses, we calculated the relative contribution of each smoking-associated complication to smoking-associated postoperative mortality, both unadjusted and adjusted for age, race/ethnicity, work relative value unit of the operation, surgeon specialty, American Society of Anesthesiologists class and year of surgery. Smoking-associated complications included surgical site infection (SSI), cardiovascular complications (myocardial infarction, cardiac arrest and/or stroke) and pulmonary complications (pneumonia, failure to wean and/or reintubation).

RESULTS: There were 186 632 never smokers and 135 741 current smokers. The association of smoking and mortality was mediated by smoking-related complications with varying effects. In unadjusted analyses, the proportions of mediation of smoking to 6-month mortality explained by the complications were as follows: SSIs 22%, cardiovascular complications 12% and pulmonary complications 89%. In adjusted analyses, the per cents mediated by each complication were as follows: SSIs 2%, cardiovascular complications 4% and pulmonary complications 22%. In adjusted analyses for 1-year mortality, respective per cents mediated were 2%, 3% and 16%.

CONCLUSIONS: Pulmonary complications, followed by cardiovascular complications and SSIs were mediators of smoking-associated 6-month and 1-year mortality. Interventions targeting smoking cessation and prevention and early treatment of pulmonary complications has the likelihood of reducing postoperative mortality after elective surgery.


Effects of a perioperative smoking cessation intervention on postoperative complications: a randomized trial.

Lindström D1, Sadr Azodi O, Wladis A, Tønnesen H, Linder S, Nåsell H, Ponzer S, Adami J.



To determine whether an intervention with smoking cessation starting 4 weeks before general and orthopedic surgery would reduce the frequency of postoperative complications.


Complications are a major concern after elective surgery and smokers have an increased risk. There is insufficient evidence concerning how the duration of preoperative smoking intervention affects postoperative complications.


A randomized controlled trial, conducted between February 2004 and December 2006 at 4 university-affiliated hospitals in the Stockholm region, Sweden. The outcome assessment was blinded. The follow-up period for the primary outcome was 30 days. Eligibility criteria were active daily smokers, aged 18 to 79 years. Of the 238 patients assessed, 76 refused participating, and 117 men and women undergoing surgery for primary hernia repair, laparoscopic cholecystectomy, or a hip or knee prosthesis were enrolled.


Smoking cessation therapy with individual counseling and nicotine substitution started 4 weeks before surgery and continued 4 weeks postoperatively. The control group received standard care. The main outcome measure was frequency of any postoperative complication.


An intention-to-treat analysis showed that the overall complication rate in the control group was 41%, and in the intervention group, it was 21% (P = 0.03). Relative risk reduction for the primary outcome of any postoperative complication was 49% and number needed to treat was 5 (95% CI, 3-40). An analysis per protocol showed that abstainers had fewer complications (15%) than those who continued to smoke or only reduced smoking (35%), although this difference was not statistically significant.


Perioperative smoking cessation seems to be an effective tool to reduce postoperative complications even if it is introduced as late as 4 weeks before surgery.

Smoking cessation reduces postoperative complications: a systematic review and meta-analysis.

Mills E1, Eyawo O, Lockhart I, Kelly S, Wu P, Ebbert JO.

Author information

  • 1Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada. Edward.mills@uottawa.ca



We aimed to review randomized trials and observational evidence to establish the effect of preoperative smoking cessation on postoperative complications and to determine if there is an optimal cessation period before surgery.


We conducted a systematic review of all randomized trials evaluating the effect of smoking cessation on postoperative complications and all observational studies evaluating the risk of complications among past smokers compared with current smokers. We searched independently, in duplicate, 10 electronic databases and the bibliographies of relevant reviews. We conducted a meta-analysis of randomized trials using a random effects model and performed a meta-regression to examine the impact of time, in weeks, on the magnitude of effect. For observational studies, we pooled proportions of past smokers in comparison with current smokers.


We included 6 randomized trials and 15 observational studies. We pooled the 6 randomized trials and demonstrated a relative risk reduction of 41% (95% confidence interval [CI], 15-59, P = .01) for prevention of postoperative complications. We found that each week of cessation increases the magnitude of effect by 19%. Trials of at least 4 weeks’ smoking cessation had a significantly larger treatment effect than shorter trials (P = .04). Observational studies demonstrated important effects of smoking cessation on decreasing total complications (relative risk [RR] 0.76, 95% CI, 0.69-0.84, P < .0001, I(2) = 15%). This also was observed for reduced wound healing complications (RR 0.73, 95% CI, 0.61-0.87, P = .0006, I(2) = 0%) and pulmonary complications (RR 0.81, 95% CI, 0.70-0.93, P = .003, I(2) = 7%). Observational studies examining duration of cessation demonstrated that longer periods of cessation, compared with shorter periods, had an average reduction in total complications of 20% (RR 0.80, 95% CI, 3-33, P = .02, I(2) = 68%).


Longer periods of smoking cessation decrease the incidence of postoperative complications.

Copyright © 2011 Elsevier Inc. All rights reserved.

Short-term preoperative smoking cessation and postoperative complications: a systematic review and meta-analysis.

Wong J1, Lam DP, Abrishami A, Chan MT, Chung F.

Author information

  • 1Department of Anesthesia, Toronto Western Hospital, University Health Network, University of Toronto, 399 Bathurst Street, Toronto, Ontario, Canada. jean.wong@uhn.ca



The literature was reviewed to determine the risks or benefits of short-term (less than four weeks) smoking cessation on postoperative complications and to derive the minimum duration of preoperative abstinence from smoking required to reduce such complications in adult surgical patients.


We searched MEDLINE, EMBASE, Cochrane, and other relevant databases for cohort studies and randomized controlled trials that reported postoperative complications (i.e., respiratory, cardiovascular, wound-healing) and mortality in patients who quit smoking within six months of surgery. Using a random effects model, meta-analyses were conducted to compare the relative risks of complications in ex-smokers with varying intervals of smoking cessation vs the risks in current smokers.


We included 25 studies. Compared with current smokers, the risk of respiratory complications was similar in smokers who quit less than two or two to four weeks before surgery (risk ratio [RR] 1.20; 95% confidence interval [CI] 0.96 to 1.50 vs RR 1.14; CI 0.90 to 1.45, respectively). Smokers who quit more than four and more than eight weeks before surgery had lower risks of respiratory complications than current smokers (RR 0.77; 95% CI 0.61 to 0.96 and RR 0.53; 95% CI 0.37 to 0.76, respectively). For wound-healing complications, the risk was less in smokers who quit more than three to four weeks before surgery than in current smokers (RR 0.69; 95% CI 0.56 to 0.84). Few studies reported cardiovascular complications and there were few deaths.


At least four weeks of abstinence from smoking reduces respiratory complications, and abstinence of at least three to four weeks reduces wound-healing complications. Short-term (less than four weeks) smoking cessation does not appear to increase or reduce the risk of postoperative respiratory complications.

Smoking and perioperative outcomes.

Turan A1, Mascha EJ, Roberman D, Turner PL, You J, Kurz A, Sessler DI, Saager L.

Author information

  • 1Department of Outcomes Research, The Cleveland Clinic, Cleveland, Ohio 44195, USA. alparslanturan@yahoo.com



Patients are often concerned about the effects of smoking on perioperative risk. However, effective advice may be limited by the paucity of information about smoking and perioperative risk. Thus, our goal was to determine the effect of smoking on 30-day postoperative outcomes in noncardiac surgical patients.


We evaluated 635,265 patients from the American College of Surgeons National Surgical Quality Improvement Program database; 520,242 patients met our inclusion criteria. Of these patients, 103,795 were current smokers; 82,304 of the current smokers were propensity matched with 82,304 never-smoker controls. Matched current smokers and never-smokers were compared on major and minor composite morbidity outcomes and respective individual outcomes.


Current smokers were 1.38 (95% CI, 1.11-1.72) times more likely to die than never smokers. Current smokers also had significantly greater odds of pneumonia (odds ratio [OR], 2.09; 95% CI, 1.80-2.43), unplanned intubation (OR, 1.87; 95% CI, 1.58-2.21), and mechanical ventilation (OR, 1.53; 95% CI, 1.31-1.79). Current smokers were significantly more likely to experience a cardiac arrest (OR, 1.57; 95% CI, 1.10-2.25), myocardial infarction (OR, 1.80; 95% CI, 1.11-2.92), and stroke (OR, 1.73; 95% CI, 1.18-2.53). Current smokers also had significantly higher odds of having superficial (OR, 1.30; 95% CI, 1.20-1.42) and deep (OR, 1.42; 95% CI, 1.21-1.68) incisional infections, sepsis (OR, 1.30; 95% CI, 1.15-1.46), organ space infections (OR, 1.38; 95% CI, 1.20-1.60), and septic shock (OR, 1.55; 95% CI, 1.29-1.87).


Our analysis indicates that smoking is associated with a higher likelihood of 30-day mortality and serious postoperative complications. Quantification of increased likelihood of 30-day mortality and a broad range of serious smoking-related complications may enhance the clinician’s ability to motivate smoking cessation in surgical patients.

The attributable risk of smoking on surgical complications.

Hawn MT1, Houston TK, Campagna EJ, Graham LA, Singh J, Bishop M, Henderson WG.

Author information

  • 1Center for Surgical, Medical Acute Care Research and Transitions, Birmingham Veterans Affairs Hospital, Birmingham, AL 35294, USA. mhawn@uab.edu



This study aimed to assess the attributable risk and potential benefit of smoking cessation on surgical outcomes.


Risk reduction with the implementation of surgical care improvement project process measures has been the primary focus for improving surgical outcomes. Little emphasis has been placed on preoperative risk factor recognition and intervention.


A retrospective cohort analysis of elective operations from 2002 to 2008 in the Veterans Affairs Surgical Quality Improvement Program for all surgical specialties was performed. Patients were stratified by current, prior, and never smokers. Adjusted risk of complication and death was calculated using multilevel, multivariable logistic regression.


Of 393,794 patients, 135,741 (34.5%) were current, 71,421 (18.1%) prior, and 186,632 (47.4%) never smokers. A total of 6225 pneumonias, 11,431 deep and superficial surgical-site infections, 2040 thromboembolic events, 1338 myocardial infarctions, and 4792 deaths occurred within 30 days of surgery. Compared with both never and prior smokers individually and controlled for patient and procedure risk factors, current smokers had significantly more postoperative pneumonia, surgical-site infection, and deaths (P < 0.001 for all). There was a dose-dependent increase in pulmonary complications based on pack-year exposure with greater than 20 pack years leading to a significant increase in smoking-related surgical complications.


This is the first study to assess the risk of current versus prior smoking on surgical outcomes. Despite being younger and healthier, current smokers had more adverse perioperative events, particularly respiratory complications. Smoking cessation interventions could potentially reduce the occurrence and costs of adverse perioperative events.


Smokers know little of their increased surgical risks and may quit on surgical advice

ANZ Journal of Surgery, October 2013, vol./is. 83/10(753-757), 1445-1433;1445-2197 (October 2013)

Webb A.R.; Robertson N.; Sparrow M. English

Background: Smoking cessation before surgery improves perioperative outcomes and some smokers may quit if undergoing surgery. Quitting smoking in community settings is influenced by physician quit advice and knowledge of smoking hazards, but there are few data on whether this applies in perioperative settings. Method: Survey on day of surgery of elective patients who reported being a smoker at the time of wait-list placement. Duration of smoking abstinence before surgery (if any) and length timing of failed quit attempts was determined. Sources of any quit advice before surgery, including from physicians, and patient knowledge on hazards of smoking and surgery were questioned. Results: While on the waiting list, 44/177 smokers reported quitting (>24h) before surgery and 42/177 others made an attempt. Quitting was usually brief. Fewer than 40% of smokers answered yes (correct answer) to questions on whether smoking increased wound infection rates, worsened wound healing, increased anaesthetic complications or increased post-operative pain. Incorrect answers (no) were less likely in quitters than those smoking until surgery (OR 0.41, 95% CI 0.25-0.68). Patients still smoking by admission recalled quit advice from a surgeon in 22.6% of cases, while wait-list quitters recalled surgical quit advice in 43.2% of cases (OR 2.6 95% CI 1.2-5.4 P = 0.01). Effects of general practitioner quit advice were significant (OR 3.2 95% CI 1.5-6.8 P = 0.004 while anaesthetists, nurse and hospital brochure advice were not. Discussion: Improving patient knowledge of the perioperative risks of smoking and increased physician advice to quit may improve smoking abstinence at surgery. ; 2013 Royal Australasian College of Surgeons.

Preoperative smoking cessation in patients with lung cancer

Pneumologie (Stuttgart, Germany), Nov 2010, vol. 64, no. 11, p. 694-700, 1438-8790 (November 2010)

Raupach, T; Quintel, M; Hinterthaner, M

Successful smoking cessation is associated with a survival benefit for patients with lung cancer. However, smokers newly diagnosed with non-small cell lung cancer and scheduled for curative resection are frequently discouraged from stopping smoking in the immediate preoperative period. This recommendation is based on the results of one single prospective cohort study published in 1998 which reported an increased risk of perioperative pulmonary complications in patients undergoing non-thoracic surgery who had reduced their tobacco consumption within the two months leading up to the operation. During the past 12 years, numerous observational studies have investigated the impact of preoperative smoking cessation on perioperative risk for thoracic and non-thoracic surgery. However, no more than six studies included patients with pulmonary neoplasms. Owing to methodological limitations and considerable heterogeneity of the included patient groups, the existing data are insufficient to support or refuse any recommendation regarding cessation advice for patients during the immediate preoperative phase. In view of the post-cessation recovery time-course of pathophysiological alterations relevant to the occurrence of perioperative complications, a smoke-free preoperative interval of 2 – 6 weeks appears most favourable. However, this is difficult to achieve as a curative resection should not be postponed. Since there is no scientific evidence demonstrating a negative impact of preoperative smoking cessation on prognosis, patients newly diagnosed with lung cancer should be encouraged to make an attempt to quit while waiting for thoracic surgery.