1. Thank You For Not Smoking October 14 th, 2009 Sylvain Gagné

2. Conflicts of Interest  None

3. Objectives  Re-announce the “Stop Smoking for Safer Surgery” Campaign  Discuss the impact of smoking on surgery and perioperative complications  Explore the role of the Anesthesiologist in smoking cessation  Present a plan for implementing a smoking cessation program in the PAU

4. “Stop Smoking for Safer Surgery”  2008 Ontario’s Anesthesiologists launch campaign  June 30 th,2009 letter from Steve Bodley  Email from Dr Yang  Why? Decrease perioperative complications Simple and inexpensive Increase visibility of anesthesiologists

5. www.StopSmokingForSaferSurgery.ca

6. Ontario’s Anesthesiologists’ Action Plan  Identify smokers preoperatively and encourage patients not to smoke before surgery;  Explain that smoking increases risks during and after surgery;  Refer smokers to free smoking cessation services which are available;  Ask patients who are scheduled for surgery when they last smoked. When appropriate, delay surgery to allow them to flush out the poisons in tobacco smoke;  Follow up with patients to encourage them to continue not smoking after surgery  Call on all hospitals to become totally smoke-free, indoors and out

7. Smoking is bad for you!  Respiratory  Cardiac  Wound healing  Length of Stay  Cancer  Yellow teeth and fingers

8. 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.

10. 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

12. Smoking is bad for your lungs!  1944: six fold increase in postoperative chest complications, Morton  Impaired ciliary beating and mucus clearance  Increased sputum production  Small airway narrowing  Emphysema  Chronic Bronchitis  Lung cancer

13. Smoking is bad for your lungs!  Smokers have an increase in post surgical pulmonary complications

14. Smoking is bad for your lungs!  Impact of smoking cessation before resection of lung cancer: a Society of Thoracic Surgeons General Thoracic Surgery Database Study. Mason et al, Ann Thorac Surg. 2009 Aug;88(2)  1999-2007, 7990 primary lung resections  Current smoker compared to non-smoker OR 1.8 (p=0.03)

15. Smoking Cessation Decreases Pulmonary Complications  Preoperative Cessation of Smoking and Pulmonary Complications in Coronary Artery Bypass Patients, Warner et al. Anesthesiology, v60, 4, Apr 1984. 3 fold decrease in complications in patients who stopped smoking for more than 8 weeks compared to those who stopped for less than that time Stopping for 8 wks was the same as never smoking Stopping for less than 8 wks gave no benefit

16. Smoking Cessation Decreases Pulmonary Complications  But I thought that stopping for less than 4 weeks would increase complications?

17. Smoking Cessation Decreases Pulmonary Complications  What about stopping for less than 8 weeks making things worse? Warner et al. Anesthesiology, v60, 4, Apr 1984.

18. Smoking Cessation Decreases Pulmonary Complications  Evidence based practice table Evidence Based Practice of Anesthesiology,

19. Smoking Cessation Decreases Pulmonary Complications  Smoking and timing of cessation: impact on pulmonary complications after thoracotomy. Barrera et al. Chest. 2005 Jun;127(6): 1873-5  Complications: non-smokers 8%, quit >2 months (19%), <2 months (23%), never quit (23%)  *no paradoxical increase in complications  Complications:respiratory failure requiring ICU admission and/or intubation; pneumonia; atelectasis requiring bronchoscopy; pulmonary embolism; and the need for supplemental oxygen at hospital discharge

20. Smoking Cessation Decreases Pulmonary Complications  Impact of smoking cessation before resection of lung cancer: a Society of Thoracic Surgeons General Thoracic Surgery Database Study. Mason et al, Ann Thorac Surg. 2009 Aug;88(2)  1999-2007, 7990 primary lung resections  Current smoker OR 1.8 (p=0.03)  Quit 2 wks-4 wks OR 1.62 (p=0.14)  Quit 1-12 monthsOR 1.51 (p=0.20)  Quit >12 months OR 1.29 (p=0.3)

21. Smoking Cessation Decreases Pulmonary Complications  Relationship between the duration of the preoperative smoke free period and the incidence of postoperative pulmonary complications after pulmonary surgery, Nakagawa M, et al., Chest 2001, 120  Risk of developing complication  Current smokers (<2wks) 2.09 (95% CI, 0.83-5.25)  Recent smokers (2-4wks) 2.44 (95% CI, 0.67-8.89)  Ex-smokers (>4 weeks) 1.03 (95% CI, 0.47- 2.26)

22. So Is there an optimal timing?  Editorial by Susan Murin, Chest 2005 “Does this study definitively lay to rest questions about smoking cessation, its timing, and pulmonary complications after thoracic surgery? No. But it’s good enough to allow us, as clinicians caring for and advising patients who smoke and who require lung resection surgery, to strongly advise them to quit, without concern that we may be doing harm if the interval before surgery is <1 to 2 months. We can maximize the value of the teachable moment posed by a lung cancer diagnosis without serious concern that we are exposing patients to an increased risk of clinically important postoperative pulmonary complications. So when it comes to smoking cessation before pulmonary resection surgery, the answer is yes, and the time is now.” Susan Murin, MD, MSc

23. Smoking is bad for your heart!  Carbon monoxide t 1/2 is 4-6 hours Within 12hrs P 50 increases from 22.9-26.4 and carboxyhemoglobin decreases from 6.5%-1.1% Possible negative inotropic effects  Nicotine Pressor effect lasts 20-30min  Short term (1 day) abstinence results in increased physical work capacity by 10-20%

24. Smoking is bad for your heart!

25.  Acute Smoking Increases ST Depression in Humans During General Anesthesia Woehlck et al. 89 (4): 856. (1999)  Calculated relative risk of ST depression of 9.0 for the acute smokers compared with nonsmokers.  In patients with ischemic heart disease, myocardial ischemia during exercise is increased by only 2%–6% COHb (1– 4) which is in the range typical for smokers  More research is needed in this area  Are ST depressions alone a significant outcome – maybe not but they are predictors of post-op ischemia

26. Smoking is bad for your heart!  Effect of preoperative smoking intervention on postoperative complications: a randomised clinical trial, Moller, et al., The Lancet, Jan 2002  Smoking intervention group vs. control 6-8 before surgery  Cardiovascular complications 0% vs. 10%, p=0.08

27. Smoking is bad for your wound!  Wound infection rates for smokers vs. non-smokers drop from 12% to 2%. Sorensen et al. Annals of Surgery 2003 July: 1-5  Wound related complications 5% vs. 31%, p=0.001 Moller et al. The Lancet 2002 Jan:114-117

28. Smoking is bad for our budget!  The median length of stay for patients who quit smoking in the 6-8 weeks leading up to surgery was 11 days compared to 13 days for patients who had simply reduced smoking by at least 50%. Moller et al. The Lancet 2002 Jan:114- 117

29. Smoking cessation IS good for your recovery!  Do we agree that smoking cessation provides medical benefits? YES  Why aren’t we promoting this?

30. Barriers to smoking cessation  Not worth it ( we already covered this one)  Not my job  No time  Don’t know how  Won’t work  No follow-up

31. “Not my job”  Ontario Anesthesiologist campaign  Decreasing periop complications  Perioperative specialists  Increasing role outside OR  ABx, Anticoagulation, periop b-blockade, post-op pain control  We are physicians –Doctors help prevent illness  October 8 th : New directive from Champlain LIHN – 80% of units must have smoking cessation “program”  Why not?

32. No Time  3 minute intervention – the 5 A’s Ask Advise Assess Assist Arrange  Fiore et al, JAMA 2008;299:2083-5  Intervention can take as little as 30 seconds 2 A’s – Ask and Act  US Department of Health and Human services, Public Health services. Treating tobacco use and dependance:2008 update

33. “I’m not trained to do this”  You will be  Help in the PAU  Dr Andrew Pipe, President of Physicians for a Smoke Free Canada Rounds November 18th

34. They won’t quit anyways!  Evidence for cessation  Actually is good moment for change  Effects of a perioperative smoking cessation intervention on postoperative complications: a randomized trial., Lindström, D, et al.  20/55 (36%) patients the intervention group vs 1/62 (2%) in the control group became completely abstinent (p<0.001)

35. No follow-up/Not the place  Creation of program  Follow-up by the Ottawa Heart Institute Smoking Cessation Clinic  Hopefully – smoking cessation clinic at the TOH (we can help)

36. Quit Card

37. Questions?  Any reasons not to encourage smoking cessation now?

38.  Benefits beyond OR

39. brainstorm  Increasing role outside OR  Perioperative specialists  Decreasing periop complications  ABx, Anticoagulation, periop b-blockade, post-op pain control  Why not?  Evidence for cessation  Benefits beyond OR  Actually is good moment for change  Complications of smoking  Ontario Anesthesiologist campaign  PR

40.  Effects of a perioperative smoking cessation intervention on postoperative complications: a randomized trial.  Lindström D, Sadr Azodi O, Wladis A, Tønnesen H, Linder S, Nåsell H, Ponzer S, Adami J. Lindström DSadr Azodi OWladis ATønnesen HLinder SNåsell HPonzer SAdami J  Surgery Section, Department of Clinical Science and Education, Södersjukhuset, Karolinska Institute, Stockholm, Sweden. David.lindstrom@ki.se  OBJECTIVE: To determine whether an intervention with smoking cessation starting 4 weeks before general and orthopedic surgery would reduce the frequency of postoperative complications. SUMMARY BACKGROUND DATA: 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. METHODS: 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. INTERVENTION: 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. RESULTS: 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. CONCLUSION: 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.

41. Smoking is bad for your lungs!  Relationship between

42. Smoking is bad for your lungs!  How does smoking cessation compare with giving prophylactic bronchodilators to asthmatics?  There is no evidence for the use of b- agonist pre-op in a well controlled asthmatic -- but we do it because we believe it will decrease pulmonary complications