Complications of Tobacco Smoking

Surgery and anesthesia are associated with exacerbating the body's stress response, which can lead to several postoperative complications and an increased hospital stay. As a future anesthesia provider, I know that it is imperative for patients to abstain from tobacco use prior to anesthesia or any surgical procedure. Preoperative screening of patients offers an opportunity to educate patients on the intraoperative risks associated with smoking, as well as providing resources and interventions that can aid with compliance and abstinence. Although cigarette smoking has declined over the past decade, tobacco use remains a common recreational activity among Americans.

The 2018 National Health Interview Survey reported that 18.1% of adults in the United States smoke cigarettes. Generally, smokers who use tobacco regularly are addicted to nicotine. They will continue to smoke despite knowing the negative health consequences. Most smokers would like to stop smoking, and each year, about 50% attempt to quit permanently. However, only about 6% of tobacco users succeed (NIDA, 2018). Surgical morbidity and mortality rates increase significantly in those who consume tobacco. Detrimental perioperative complications include poor wound healing, increased infection, delayed fracture healing, and increased intraoperative bleeding. Therefore, to combat this modifiable surgical risk factor, surgical patients should be educated and encouraged to abstain from tobacco use prior to any orthopedic procedure.

More specifically, McCunniff, Young, Ahmadinia, Ahn, and Ahn (2015) suggested that surgical patients should be screened for nicotine in their system on the day of surgery to identify those at risk. The harmful effects of tobacco use have been confirmed in a multitude of orthopedic procedures, such as arthroplasty, hand surgery, spine surgery, fracture healing, and foot surgery (Lampley et al., 2016). Tobacco use has been attributed to altering vascular homeostasis and the normal clotting cascade, resulting in thromboembolisms. Research studies have also linked smoking to increased surgical blood loss in major orthopedic surgeries. Tobacco directly leads to alterations in the platelet membranes, impairing their natural function (McCunniff et al.). A study conducted in 2012 after rotator cuff restoration showed that active smokers have an increased rate of comorbidities, such as diabetes mellitus, peripheral vascular disease, and rheumatoid arthritis, compared to non-smokers (Kukkonen, Kauko, Virolainen & Aarimaa, 2012). This contributes to a higher rate of wound complications postoperatively.

Current practice recommendations by the American Society of Anesthesiologists (ASA) state that surgical patients should abstain from smoking for four to eight weeks prior to anesthesia; this time frame allows the body to rid itself of toxic substances and metabolites that affect the cardiac and circulatory systems (ASA, 2018). Despite this recommendation, patients continue to smoke tobacco leading up to the day of surgery. Thomsen, Villebro, and Merete Moller (2014) found that the adoption of smoking cessation methods such as transdermal patches, chewing gum, lozenges, inhalers, sprays, bupropion, and varenicline in the perioperative period should be recommended to patients who smoke prior to surgery. Perioperative smoking cessation seems to be an effective tool to reduce postoperative complications even if it is introduced as late as four weeks before surgery (Thomsen et al., 2014).

In conclusion, orthopedic perioperative complications of tobacco smoking include impaired wound healing, augmented infection, delayed and/or impaired fracture union, and fusion. Research must be conducted to improve current smoking cessation interventions prior to orthopedic surgery.

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