Stop Smoking for Safer Surgery Dr John Oyston

SUMMARY People still smoke. Smoking is the #1 cause of preventable deaths in Canada. Perioperative smoking is bad. Perioperative smoking cessation is good. Anesthesiologists should promote perioperative smoking cessation.

How bad is smoking? 18% of Canadians still smoke. The average smoker loses 8 years of life. In Ontario, smoking costs us $1.7 billion in healthcare costs and $2.6 b in lost productivity and uses up 500,000 hospital days. One out of every two smokers will die of smoking-related diseases.

45,000 smoking deaths versus: SARS - 44 deaths H1N1 – 78 deaths (so far) West Nile Virus –10 deaths in bad year Homicide –561 deaths/yr AIDS –1,325 deaths/yr

So smoking is a big Public Health problem. Why should I care?

Risks of Perioperative Smoking

Cardiac Respiratory Wound infections Wound healing Disease recurrence

Woehlck HJ et al, Anes and Analg 1999;89:856 CARDIAC RISK FROM SMOKING

Carbon monoxide a “quick fix” The half life of carbon monoxide is four hours. Not smoking for four hours before surgery cuts the level one half Not smoking for eight hours before surgery cuts the level by ¾. Cut out smoking before surgery !

Woehlck HJ et al, Anes and Analg 1999;89:856

Cardiac benefits of quitting Studies of preop quitting are too small to have significant result: –E.g. Smokers 10% Postop cardiac events, Quitters 0% p<0.08 Stopping smoking decreases overall mortality in CAD patients by one third. Postoperative quitting reduces long-term mortality after CABPG.

Post-operative Pulmonary Complications (PPCs) PPCs are much more common in smokers. Takes weeks/months to get benefits of stopping smoking.

Duration of Cessation and Risk of PPCs 8 wks reduces PPC risk from 48% to 17% –Compared to 11% in non-smokers 4 wks reduces PPC risk to 1.03x non- smokers –Continuing to smoke -> 2.09x non-smoker 2 wks abstinence -> risk is1.9x that of a non-smoker –Continuing to smoke -> risk 4.2x non-smoker

Wound Infections Six times more common in smokers. Smokers 12%. Non-smokers 2% (p<0.05). 4 weeks of non- smoking equivalent to never smoking. RCT by Sorensen, Annals of Surgery, Vol 238 July 2003: 1-5

Wound Healing Delayed in smokers: –Back fusion. –Vascular grafts. Worse long term outcome of ACL repair. –5 years after surgery, smokers had significantly worse overall knee function, and more severe pain, more often, than matched non-smokers (Karim,A JBJS 2006;8-B:1027).

Disease Recurrence Peripheral vascular or cardiac vessel disease will continue to get worse if patient continues to smoke. Is it an ethical use of scarce health care resources to re- operate on smokers?

Anesthesiologists should encourage our patients to stop smoking because: It is good for our patients. It is good for our hospitals. It is good for the healthcare system. It is good for us as a profession.

How?

Inform Patients: Ask, Advise, Refer Ask – “How much do you smoke?” Advise – “Smoking increases the risk of surgery.” Refer – “Call this number for help quitting.”

Quit Card Available by ing from the Johnson and Johnson booth or by ing John Oyston at

Smokers’ Helpline: Help by phone, web and

What else can we do? Inform the public –Interviews on CBC Radio and TV –Global and CTV –Toronto Sun –Metro –Globe and Mail

Inform colleagues and administrators: OA Action Plan i)Identify smokers preoperatively. ii)Explain that smoking increases the risk of surgery. iii)Refer smokers to smoking cessation services. iv)Consider delaying surgery in patients who have smoked recently. v)Follow up on smokers to encourage them to continue not smoking after surgery. vi)Encourage non-smoking hospitals.

No Smoking at TSH No smoking anywhere on hospital property Staff education and help quitting Preoperative teaching for elective patients NRT available on formulary Feb 1st 2010

Ongoing Policy Development Patient handout being developed. Working with CAS to develop national strategy. Working with Accreditation to make Perioperative Smoking Cessation support a required organizational practice.

Please – do your part! Ask, Advise, and Refer. What else can you do in the Preadmission Clinic which will: –Reduce perioperative complications (52% ->18%). –Improve wound healing and decrease wound infection rate (six fold). –Save your patient’s life!

Thank You Questions? StopSmokingForSaferSurgery.ca

Additional Info

Does cessation immediately before surgery increase pulmonary risk? Clinical impression only… Some studies have higher rate of PPCs in pts who quit shortly before surgery. NOT statistically significant. NOT randomised. “The evidence suggesting an increased risk during the first weeks of quitting is insufficient to support any recommendation that smokers do not strive for preoperative abstinence” - Warner

Is perioperative NRT safe? YES –NRT does not produce adverse cardiac effects in volunteers or smokers –NRT reduces exercise-induced ischaemia –NRT does not affect patency of CABG grafts –NRT is safe in patients with cardiovascular disease –But NRT may exaggerate cardiovascular response to intubation