Smoking

Smokers are over-represented amongst adults presenting for major surgery. Approximately 20-30% of patients presenting for major non-cardiac surgery are smokers compared to 12.9% of the population who smoke.

Evidence demonstrates that when addressed early, effective preoperative smoking cessation can be achieved leading to substantial reductions in postoperative morbidity. The sooner that smoking cessation can occur, the greater the benefit.

Although measurable reduction in perioperative risk requires smoking cessation to have occurred at least 4 weeks prior to surgery, it is never too late to encourage smoking cessation. There is no increased risk from smoking cessation occurring immediately before surgery.

Patients requiring treatment are more receptive to intervention and are more motivated to quit. It may be the stimulus they require to stop smoking resulting in significant long-term health benefits.

Full cessation should be the goal for all smokers preoperatively to substantially reduce surgical risk. The longer the period of preoperative abstinence the better, however any effort to reduce or abstain from smoking is advisable.

Smoking has widespread systemic effects meaning an increased risk of significant postoperative complications. Postoperative mortality is 40% greater in smokers compared to non-smokers.

Smokers vs. Non-Smokers - increased risk of perioperative complications:

Cardiovascular

• Increased risk of arterial and venous thrombosis due to endothelial injury, platelet activation and increased blood viscosity
• Impaired blood oxygen transport capacity due to presence of carboxyhaemoglobin
• Increased heart rate and blood pressure in response to nicotine

Respiratory

• Increased mucous production and poor clearance due to mucociliary dysfunctoin
• Impaired gas exchange through alveolar destruction
• Bronchial hyper-reactivity

Wound Healing

• Direct cellular injury in healing tissues due to free radical release
• Poor blood supply to healing wound due to local vasoconstriction
• Impaired collagen synthesis in healing tissue

Patients should be provided advice that:

Stopping smoking is important for improved surgical outcomes and long-term health

The best way of quitting is with a combination of support and stop smoking medication

Support with stopping smoking and/or managing any tobacco withdrawal symptoms is available - patients can self-refer to 'Quit Your Way' (see below)

Patients can self refer to Quit your Way Scotland.

Search "Quit Your Way" for more information.

NHS Lothian Quit Your Way services are available in:

• Hospital Service (Inpatients and NHS Staff) - Royal Infirmary Edinburgh
• North Edinburgh - Pennywell All Care Centre (0131 286 5113)
• Midlothian and East Lothian - Bonnyrigg Health Centre (0131 537 9914)
• West Lothian - Bathgate Primary Care Centre (01506 651 829)

Cochrane Review

• Intensive interventions (multiple contacts for behavioural support and the offer of pharmacotherapy) initiated at least four weeks before surgery are beneficial for reducing the incidence of complications and changing smoking behaviour both perioperatively and in the long-term.

• Brief interventions offered closer to the time of surgery are likely to have a small benefit on smoking behaviour.

• The current evidence supports giving smokers scheduled for surgery advice to quit and offering them effective interventions, including behavioural support and pharmacotherapy, at least four weeks ahead of surgery if possible.