Practice Perfect 802
When Should Patients Stop Smoking Before Surgery?

Throughout my time in podiatry, I’ve always felt issues surrounding smoking to be somewhat enigmatic. It is a well-known fact that cigarette smoking is one of the worst things a person can do to their body, so “don’t smoke” is clearly the best advice anyone can give. However, in the real world, a percentage of our patients will smoke to varying degrees. They’re not going to stop and sometimes we’re going to have to treat them surgically.

Now, like anyone who does surgery, I’ve had patients who smoked cigarettes, had foot or ankle surgery, and healed uneventfully and others with healing issues. I’ve also had patients who never smoked who had complications. Obviously, healing bone and soft tissue surgery presents a number of risks that might lead to healing complications, only one of which is the use of tobacco products. As a result of this complexity, there is no consensus in how to handle these patients. Some surgeons demand 6-8 weeks without smoking before they’ll elect to do surgery, while others argue for 3-6 months, and others yet refuse elective surgery entirely for those who use tobacco products.

Some surgeons refuse to do elective surgery on patients who use tobacco products. Other’s demand that they refrain for varying periods of time pre-op.

Time frames such as 6-8 weeks sound conveniently similar to other parameters such as non-weightbearing periods after surgery, so one must wonder from where these recommendations arise. Let’s take a quick look at the available literature and see if there’s some guidance on this important and complex topic.

In a randomized controlled trial of 788 healthy patients with punch biopsy wounds of the sacrum, 4 weeks smoking cessation preoperatively reduced the risk of wound infections to the same level as those who did not smoke.1 As this is not a lower extremity-related study, we must be cautious about generalizing this to our patients.

Immune function has been shown to return after 2-6 weeks of abstinence, wound healing improves after 3-4 weeks, and pulmonary function normalizes after 6-8 weeks.2

There is evidence that immune function returns after 2-6 weeks of abstinence from tobacco, wound healing improves after 3-4 weeks, and pulmonary function normalizes after 6-8 weeks.

Effects of Smoking on the Foot and Ankle

Kim and Patel performed a systematic review of the literature, including 46 articles, and found smoking had an adverse effect on foot and ankle procedures that required fracture fixation, fusion, or plastic surgery. They additionally found that surgeries that did not require these types of procedures (for example, total ankle arthroplasty and amputations) were less likely to experience smoking-related complications.3 These researchers rightly pointed out the challenges in determining a minimum cessation period, citing four different studies, each stating different effects at different time periods.

A comprehensive review article in the orthopedic literature instructs physicians to “encourage all patients who are contemplating elective procedures to quit smoking four to six weeks in advance of the proposed procedure and should advise them of the serious negative outcomes associated with active smoking in the perioperative period.”2

Unfortunately, there is not one simple guideline or recommendation other than “stop smoking entirely for as long as possible.” When it comes to elective surgery, the longer a person can stop smoking before surgery the less likely they are to have complications, and it’s fair to use that 8-week time period since it’s been published in a high-profile journal (JBJS). It’s also fair to fully counsel patients on the dangers of smoking to their overall health and as to the increased risk of nonunion in fusions and fracture fixation as well as potential soft tissue healing complications.

How to Counsel Patients to Stop Smoking

A major clinical practice guideline suggests the following.4

First, they provide a 5A approach for treatment of tobacco abuse and dependence.

  • Ask – screen all patients for tobacco use.
  • Advise – counsel all smokers to quit. The guidelines ask providers to be clear, strong, and personalized in their advice of smokers to quit.
  • Assess – assess the willingness of a patient to quit. Simply ask the patient, “Are you willing to give quitting a try?”
  • Assist – help the patient to quit. 
  • Arrange – schedule follow up.

The guidelines also demonstrate the effectiveness of several medications to enhance smoking cessation, including bupropion, various nicotine substitution methods, and varenicline. At first, I found it disheartening that the medication with the highest abstinence rate (long-term patches with the ad lib use of a nicotine gum or spray) was only 36.5% effective. However, as it is allowable to combine various medications and methods, that number has a strong chance of increasing.

It appears to be reasonable to have patients stop smoking at least 6-8 weeks before surgery.

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Finally, these consensus guidelines recognize the importance of the psychological and behavioral aspects of smoking cessation, stating the combined use of counseling and medication are more effective than either alone. It may be challenging for a busy podiatrist to add this aspect of patient care to their already busy practice, especially if surgery is being considered, but as it is well known that physician involvement improves the chances of smoking cessation, so there is a strong opportunity to affect long-term health, even beyond that surgery. At the very least, it appears to be reasonable to have patients stop smoking at least 6-8 weeks before surgery.

Best wishes.

Jarrod Shapiro, DPM
PRESENT Practice Perfect Editor
jarrod@podiatry.com

References
  1. Sorensen LT, Karlsmark T, Gottrup F. Abstinence from smoking reduces incisional wound infection: a randomized controlled trial. Ann Surg. 2003 Jul;238(1):1-5.
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  2. Lee JJ, Patel R, Biermann JS, Dougherty PJ. The musculoskeletal effects of cigarette smoking. J Bone Surg Am. 2013 May 1;95(9):850-859.
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  3. Kim JH, Patel S. Is it Worth Discriminating Against Patients Who Smoke? A Systematic Literature Review on the Effects of Tobacco Use in Foot and Ankle Surgery. J Foot Ankle Surg. May-Jun 2017;56(3):594-599.
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  4. Tobacco TC. A clinical practice guideline for treating tobacco use and dependence: 2008 update: A U.S. Public Health Service report. Am J Prev Med. 2008 Aug;35(2):158-176.
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