1. Stopping Smoking Before Surgery: Advantages and Issues Dr. John Oyston Assistant Professor University of Toronto Department of Anesthesia 3 rd Ottawa Model Conference February 4 th 2011

2. How Important is Smoking? It is the #1 cause of preventable death It consumes 15% of health care budget It is more important than Breast Cancer

3. More women die of lung cancer due to smoking than from breast cancer.

6. Why do anesthesiologists across Canada care about smoking?

7. Anesthesiologists see the problems caused by smoking every day We provide anesthesia for patients who would not have needed surgery if they had never smoked – Obvious examples Peripheral and cardiac vascular disease Lung and ENT cancers – Less obvious Bladder tumours (3 x risk: Smoking causes 50%) Cataracts (20% due to smoking, 50,000 per year) Fractures (84% increase hip fractures in smokers)

8. Chronic smokers have chronic health problems: COPD CAD Arteriosclerosis

9. Smokers do less well in the operating suite

10. ST Depression v CO level Anesthesia and Analgesia 1999; 89 856 HJ Woehlck et al

12. Smokers do less well postoperatively Short Term - Worse wound healing (Mastectomy flap necrosis 18.9% v 9.0 in NS) (DW Chang Plastic & Reconstr Surg. 2000 p2374) - More infections (12% in smokers, v 2% NS) (Sorensen, Ann Surg, 2003) Long Term - Worse outcome (more pain, poorer function) one year after ACL repair (Karim, JBJS, 2006) “We found that smoking was the single most important risk factor for the development of postoperative complications” (Moller JBJS 2002)

13. … and smokers are more likely to come back for repeat surgery Failure of original operation Spinal fusion: Non-union twice as common in smokers (Glassman Spine 2000) Postoperative complications Abdominal wall necrosis (Smokers 7.9% Ex-smokers 4.3% NS 1.0 %). (Padubidri Plastic & Recon Surgery: 2001: p342) Progression of underlying disease Fem-pop graft -> Revision/Endarterectomy - >Sympathectomy ->Toe amputation ->BKA -> AKA

14. Smokers are a pain in the butt for anesthesiologists. Can we do anything about that?

16. 120 patients for elective joint replacement Randomised to control or smoking cessation intervention: Control Routine preoperative preparation 4 stopped smoking anyway Intervention Routine preoperative preparation plus weekly meetings with nurse, NRT therapy 36 stopped smoking, 14 reduced, 6 continued

17. Results Control Intervention Wound problems: 31% 5% CV Insufficiency10%0% Avg. days in hospital 1311 Total days in ICU 32 2

18. Stopping smoking reduces risk:

19. When to stop? Ideally 6 – 8 weeks or longer Definite advantage of 4 weeks For carbon monoxide elimination, 4 -8 hours – “No smoking after midnight”? – Risk of stopping shortly before surgery? Postoperative quitting aids wound healing

20. How and when to educate patients about preoperative smoking cessation: In community, healthy With a surgical condition, in GPs office In surgeon’s office

21. My recommendation: At least one preoperative smoking cessation counselling session should be mandatory before elective surgery. Surgery should be scheduled no sooner than six weeks after attending that session.

22. How and when to educate patients about preoperative smoking cessation: In community, healthy With a surgical condition, in GPs office In surgeon’s office During preadmission process – Phone/MD/Pharmacy In hospital Post-surgical follow-up Back in community

23. Three quick issues:

24. Should anesthesiologists prescribe anti-smoking drugs (e.g. Bupropion, Varenicline)? In my clinical setting, where: – I see patients only once – I rely on their self-reported medical and psychiatric history – It is difficult for patients or their families to get back in touch with me – There is no out-of-hours coverage I do not feel it is appropriate to prescribe medications which have significant risks. Some colleagues in academic teaching centres disagree.

25. Does nicotine impair bone healing? Yes, in experimental models – Vasoconstriction – Parasympathetic system – Effect on stem cells Is this a reason to avoid NRT in Ortho patients? – Probably not – Some studies showing benefit of quitting used NRT

26. Is it worth quitting before minor surgery? There is no evidence that quitting before minor surgery improves outcome BUT … if patients quit when they have an arthroscopy or D & C, when they need a joint replacement or hysterectomy, they will have been smoke free for weeks or months!

27. Can we use surgery as a tool to promote smoking cessation? It’s a reason to quit at a specific date Suddenly convert from being healthy to being a patient It’s a way to regain an element of control in a stressful situation Less withdrawal symptoms Surgery forces interaction with a variety of health care workers

28. Does surgery make smokers quit? (Crouse & Hagaman, Am J Epidemiology, 991 p 699)

29. How important is surgery as a reason to quit? 8% of all quitting is related to surgery 100,000 patients/yr in US quit due to surgery (Yu Shi, Anesthesiology, 2010) But 42% of pts said they were not informed about the effects of preop smoking and 43% of anesthesiologists don’t routinely advise smokers to quit.

30. There are specific health and economic benefits to perioperative smoking cessation 1.3 m operations are performed in Canada every year (~ 250,000 on smokers) We are not leveraging this opportunity to get smokers to quit We need a national strategy!

31. An independent not-for-profit organization Evidence-based, focussed on patient safety and organizational excellence 600 surveyors ensure proper policies in place in 1000 health service organizations across Canada and world wide Now becoming interested in smoking policies!

32. www.stopsmokingforsafersurgery.ca john7@oyston.com THANK YOU FOR LISTENING Anesthesiology 2006, 104;356-67

33. ADDITIONAL SLIDES

43. Should anesthesiologists prescribe anti-smoking drugs?