3.15 The impact of smoking on treatment of disease

Last updated: April 2020
Suggested citation: Just, J, Hurley, S, Greenhalgh, EM & Winstanley, MH. 3.15 The impact of smoking on treatment of disease. In Greenhalgh, EM, Scollo, MM and Winstanley, MH [editors].  Tobacco in Australia: Facts and issues. Melbourne: Cancer Council Victoria; 2020. Available from  http://www.tobaccoinaustralia.org.au/3-15-smoking-and-complications-in-medical-treatmen


3.15.1 Surgery

Smoking increases the risk of intraoperative (anaesthetic) and postoperative complications. Smokers’ higher prevalence of chronic diseases, impaired pulmonary reserve and altered immune responses are thought to contribute to these complications. Poorer surgical outcomes result.1

In 2020, the World Health Organization released an updated review of tobacco and post-surgical outcomes that suggested that smokers who quit around 4 weeks prior to surgery have a lower risk of operative complications. However, the ideal cessation time varies according to the specific complication.2 Anaesthesia

The effectiveness of a number of commonly used anaesthetic drugs is reduced in smokers. Higher doses are therefore required. These drugs include opioids,3 neuromuscular blocking agents and some of the volatile agents that are administered by inhalation (via a mask or endotracheal tube). The polycyclic aromatic hydrocarbons in cigarette smoke induce the liver enzymes that metabolise anaesthetics, at least partly accounting for these effects.4 Smoking does however decrease postoperative nausea and vomiting, possibly because of the increased metabolism of volatile anaesthetics.4

Smoking also increases the risk of intraoperative respiratory complications, including bronchospasm, aspiration, hypoventilation and hypoxaemia.5-7

The Australian and New Zealand College of Anaesthetists recommends that patients who smoke be encouraged to quit at any time before surgery.8  Research suggests that recent quitters are no worse off than continuing smokers in terms of pulmonary complications. (see Section, 10 Postoperative complications

It is well-established that smoking results in a significantly increased risk of many postoperative complications. These complications include a higher risk of general morbidity, wound complications, lung complications, infections, neurological complications and an increased risk of intensive care unit (ICU) admission post-surgery.11

-Wound and surgical site complications

Smoking delays wound healing after surgery. Complications for which smokers have a greater risk include: wound infection;12 dehiscence (bursting of sutures);13 erosions (destruction of tissue surfaces) and necrosis (death of most of the cells of a piece of tissue or an organ);14 hernia (protuberance of organs through cavity walls); poor healing of broken bones and poor healing of fistulae (abnormal openings from body organs to the surface of the skin).15-17

Smoking has an impact on wound healing via several different pathophysiological mechanisms, including:18, 19

  • Reduced blood flow to, and oxygenation of, peripheral tissues
  • Impaired inflammatory processes that are part of normal healing
  • Impaired proliferation of fibroblasts and collagen production
  • Impaired immune function, which may increase the risk of wound infection2

Such wound complications are particularly problematic after plastic and reconstructive surgery, bariatric surgery,  bowel surgery, hernia repair surgery, dental surgery (see Section 3.11.4), microsurgery, and organ transplantation.14, 20-23


-Complications following cardiac surgery

A meta-analysis found smokers undergoing cardiac surgery were at increased risk of pulmonary complications and pneumonia following surgery, but had a reduced risk of kidney complications, compared to ex-smokers.24

A systematic review and meta-analysis of patients undergoing repair of an aneurysm (enlargement or ballooning of an artery due to a weakness in the artery wall) found that smoking was protective again endovascular leaks post-surgery.25 The paper proposed possible explanations for this; smokers are more likely to have extensive atherosclerosis, potentially protecting against leakage, and smoking increases aggregation of platelets, increasing clot formation, so leakage becomes less likely.

-Complications following orthopaedic surgery

Smokers have an increased risk of complications following several types of orthopaedic surgery (see Section 3.13.2), including shoulder surgery, and hip and knee arthroplasty.26-29

A meta-analysis found smokers had a higher risk of loosening of prostheses (artificial body parts inserted during surgery), deep infection, and the need for revision following total hip arthroplasty (hip replacement).26 Another study found an increased risk of periprosthetic joint infection (infection around the artificial body part) in smokers undergoing total hip or knee arthroplasty.28

A study also found smoking increases the risk of venous thromboembolism (VTE) (blood clots that form in veins) following anterior cruciate ligament (ACL) reconstruction surgery.30 Another study found smokers had higher rates of wound infection, VTE and subsequent ACL reconstruction compared to non-smokers.31

-Complications following plastic and reconstructive surgery

Following breast reconstruction, smoking has been associated with a doubling of the risk of complications (such as mastectomy flap necrosis and infection) and a five-fold increase in the risk of implant failure.32 Such poor surgical outcomes have led to a call for caution when undertaking breast reconstruction in smokers.33 Similarly, impaired wound healing and wound infection in smokers undergoing breast reduction surgery34, 35 have led to a suggestion that pre-operative smoking cessation be an essential eligibility criterion for this surgery.35 In another study of patients undergoing reduction mammaplasty (breast reduction), smoking was associated with an increased risk of wound complications including dehiscence.36, 37

-Complications following transplant surgery

Smokers undergoing organ transplantation have poorer outcomes,38 including increased mortality after liver transplantation,21 increased kidney transplant rejection,39 and poorer survival after heart transplantation if either the donor was, or the recipient is, a smoker.22, 40, 41

Unsurprisingly, solid organ transplant recipients who smoke post-transplant are at higher risk of newly diagnosed cardiovascular disease, cancer and overall shorter survival time, and  mortality.41

The poorer organ transplantation outcomes in smokers, combined with the high demand for donated organs, have led to suggestions that smokers be given lower priority for organ transplants and debate about the ethics of such a policy.42-44

-Complications following other types of surgery

Smoking increases the risk of complications following other types of surgery including: a higher failure rate for oral mucosa graft urethroplasty (repair of the urethra with a graft from the lining of the mouth);45 worse hearing and the need for repeat operations after ear surgery;46 increased complications post appendicectomy47 and hernia repair;23, 48 and increased risk of complications following bariatric surgery including prolonged intubation (insertion of a tube through the mouth to support artificial breathing) and organ space infection (a type of surgical site infection).49 Another study suggested that in patients undergoing sleeve gastrectomy (surgery involving removal of part of the stomach) for weight management, smokers had an increased risk of morbidity and mortality compared to non-smokers (of note, ‘smokers were those who had smoked  at least one cigarette in the year prior to surgery, ‘non-smokers’ were those that had not).50 Impact of smoking cessation

A systematic review published in 2012 explored the relationship between short-term preoperative smoking cessation and postoperative complications and concluded that at least four weeks of abstinence from smoking reduces respiratory complications, and abstinence of at least three to four weeks reduces wound-healing complications. Short-term (less than four weeks) smoking cessation did not appear to increase or reduce the risk of postoperative respiratory complications.51

A 2014 Cochrane Review examined interventions for smoking cessation preoperatively, and the impact of this on postoperative complications.52 Thirteen RCTs, with over 2000 participants, were included in the review. Intensive behavioural interventions (face-to-face counselling delivered over multiple sessions) were found to reduce the risk of any postoperative complications, and wound complications specifically. However, brief interventions did not have an impact. The authors concluded that although the ideal cessation time is not entirely clear, evidence suggests that interventions that commence at least four weeks before surgery, and that involve weekly counselling and pharmacotherapy, can reduce the risk of complications.

A study of over 6000 patients undergoing coronary artery bypass graft (CABG) surgery also found that cessation of at least four weeks’ reduced the risk of lung complications following surgery, including lung infection and reintubation.53 A further study demonstrated that smoking abstinence following CABG reduced the 5 year mortality rate by 35%.54

The Australian and New Zealand College of Anaesthetists recommend that, based on the current available evidence, anaesthetists and surgeons should not be dissuaded from advising patients to quit at any time before surgery.8

3.15.2 Drug interactions

Smoking alters the effects of a number of medications (see also Section on interactions with anaesthetics). Doctors and other health professionals need to be aware of these interactions when medications are prescribed and also when patients quit smoking, as drug dosages may need to be adjusted.55

Drug interactions fall into two categories: (i) pharmacokinetic interactions, which occur when cigarette smoke alters a drug’s metabolism; or (ii) pharmacodynamic interactions, which occur when the physiological effects of cigarette smoke modify the physiological effects of the drug.56, 57

Pharmacokinetic interactions include increased metabolism of caffeine, heparin, warfarin, theophylline, beta-blockers (such as propranolol), a number of antipsychotic drugs (such as clozapine, chlorpromazine and olanzapine) and benzodiazepines.58-60 A meta-analysis of the interaction between smoking and warfarin, for example, found that smoking increased warfarin dosage requirements by about 12%.61

Although it is difficult to know which of the estimated 7000 compounds in cigarette smoke cause these interactions,62 the polycyclic aromatic hydrocarbons are suspected. These hydrocarbons induce liver enzymes (see Chapter 3, Section and thereby hasten the clearance of any drug (or substance) whose metabolism requires the enzymes.56, 57 Conversely, upon smoking cessation, dosages of these medications may need adjustment, as clearance will slow. For example, upon stopping smoking, smokers may need to reduce caffeine consumption.58

The pharmacokinetic interaction between tobacco smoke and the antiplatelet medication clopidogrel has been described as a ‘smoking paradox’ as there is some evidence to suggest that smokers have higher clinical responsiveness to clopidogrel than non-smokers.58 A meta-analysis of over 70,000 patients with established cardiovascular disease found that smokers taking clopidogrel had a 25% lower risk of cardiovascular events compared to an 8% reduced risk in non-smokers.63  Another study suggested that doubling the dose of clopidogrel in smokers was effective in reducing the risk of cardiovascular events, without an increase in the risk of bleeding.64 Dosages of clopidogrel and other antiplatelet medications (such as prasugrel) may need to be adjusted upon stopping smoking.63

Pharmacodynamic interactions include: reduced response to corticosteroids in smokers who are asthmatic,65, 66 decreased effectiveness of benzodiazepines (a common sleeping medication) (possibly due to the stimulant effects of nicotine), slowed absorption of sub-cutaneous insulin among diabetics (possibly due to reduced blood flow to the skin, mediated by nicotine), and an increased risk of cardiovascular adverse effects in women taking oral contraceptives.56, 57

In the above examples, smoking modifies the effects of particular drugs. It has also been hypothesised that bronchodilator drugs (mainly beta-2-agonists), prescribed for people with chronic obstructive pulmonary disease (COPD), may worsen the effects of cigarette smoke. The theory is that bronchodilation improves smoke inhalation, and may increase the deposition of cigarette smoke on the lungs, thereby increasing cardiovascular disease morbidity and mortality. This hypothesis is yet to be tested.67

3.15.3 Cardiovascular disease

As detailed in Section 3.1, smoking causes cardiovascular disease, and generally, if a person continues to smoke after developing cardiovascular disease their prognosis is worse than if they had quit.

For example, a study of more than 18,000 patients who were receiving a statin drug for coronary disease found that over a five-year period those who continued to smoke had about a 50% higher chance of a major cardiovascular event (heart attack, stroke, cardiac arrest or death) than patients who quit.68  However, a more recent meta-analysis found that the risk of major cardiovascular events in people using statins was similar for smokers and non-smokers.69

Poorer treatment outcomes have been reported for people who continue to smoke after coronary artery bypass grafting (CABG)70 or a diagnosis of heart failure,71 compared with people who quit.

A 2019 meta-analysis involving over 120,000 patients undergoing either percutaneous coronary intervention (i.e. placement of a stent, a small device to open up an artery) or CABG found that smokers had a higher risk of all-cause mortality compared to non-smokers.72 However, there was no statistically significant difference in the rate of heart attacks, all cardiovascular events or cardiovascular deaths . The increased risk of all-cause mortality was also true of ex-smokers, compared to non-smokers.

3.15.4 Cancer

As detailed in Section 3.5, smoking causes numerous cancers.

The 2014 Surgeon General’s report was the first in its series to review the associations between cigarette smoking and health outcomes in cancer patients and survivors. It concluded that smoking causes adverse health outcomes in people with cancer, while cessation improves their prognosis. Smoking increases all-cause mortality and cancer-specific mortality in cancer patients and survivors, and increases the risk of second primary cancers that are caused by cigarette smoking, including lung cancer. Smoking may increase the risk of recurrence, result in a poorer response to treatment, and increase treatment-related toxicity.73

A 2018 review published by the World Health Organization identified some of the mechanisms by which smoking affects outcomes of cancer treatment.74 These mechanisms include increased cancer cell proliferation, migration and metastasis (development of secondary cancers), acceleration of systemic clearance of cancer therapies (potentially impacting efficacy of cancer treatment), increased complications associated with treatment, and an increased risk of co-morbidities related to tobacco.

The review also reinforced findings from the Surgeon General’s report, regarding the impact of smoking on cancer outcomes, including increased risk of all-cause mortality, cancer-specific mortality, recurrence, and reduced quality of life. Specifically, this included studies of patients with lung cancer, head and neck cancers, bladder cancer and breast cancer.74

A 2018 meta-analysis of patients with colorectal cancer found that current and former smokers had lower overall survival compared with never smokers. In the same study, smoking cessation, compared to current smoking, was linked with an improvement in overall and colorectal cancer-specific survival.75 Smoking has also been identified as a risk factor for superficial surgical site resections in patients undergoing rectal cancer resection.76

More severe pain has been associated with smoking in patients with cancer,77 and specifically for lung cancer78 and head and neck cancer.79 This may be because of the decreased effectiveness of opioids (due to increased drug metabolism caused by cigarette smoke components) described in Chapter 3, Section, and failure to increase the dose in response.

Of note, a 2019 meta-analysis did not find any difference in response to immunotherapy (for treatment of advanced solid organ cancers) between ever smokers and never smokers.80

Smoking cessation improves outcomes in cancer patients. Cessation is associated with  an improved quality of life (in patients with lung or head and neck cancers), reduced risk of cancer-specific mortality (in patients with breast cancer) and improvement in survival (for patients with lung cancer, head and neck, colorectal and bladder cancer).81 Patients who stop smoking also experience reduced treatment-related toxicity.81, 82

A 2019 retrospective study on patients with primary lung cancer who had undergone lung resection, found that smoking cessation reduced the risk of lung complications following surgery and mortality rate at 90 days. The longer the period of cessation, the lower the risk of lung complications.83

For an overview of smoking cessation interventions for people with cancer, see Section 7.19.5.

3.15.5 Treatment of infertility including assisted reproduction

As detailed in Section 3.6.2, women who smoke have reduced fertility, as smoking has been found to affect ovarian function and reserve,84 and there is emerging evidence that fertility may also be reduced in male smokers.62

 Smoking also has a negative impact on the outcomes of infertility treatment.85 In women participating in assisted reproduction programmes, smoking is associated with lower pregnancy rates, higher chances of miscarriage , and a lower probability of a live birth.85, 86  Another meta-analysis found that smokers had a lower number of oocytes retrieved compared to non-smokers, and a reduced rate of fertilisation.86

There is also evidence that smokers undergoing assisted reproduction also have an increased risk of ectopic pregnancy.87

 Interestingly, there is some evidence that paternal smoking can increase the rate of pregnancy loss, likely as a result of damage to spermatozoa.88

One study found that for couples who smoked (either female, male or both), the risk of not achieving a pregnancy was about twice as high as for non-smokers.89  Researchers have estimated that women who smoke need up to twice the number of in vitro fertilisation (IVF) cycles to conceive and suggest there is a correlation between the number of smoking years and the risk of not conceiving through IVF.90 Smoking cessation for both women and men is recommended for couples aiming to become pregnant91 and it has been suggested that access to fertility treatment should be conditional on quitting smoking.90

Of note, smoking appears to affect infant outcomes in assisted reproduction pregnancies in the same way as unassisted pregnancies.92

3.15.6 Contraception

As detailed in Section 3.2, smoking causes coronary heart disease, increasing the risk two- to four-fold.1 The ‘combined’ oral contraceptive pill (which contains the hormone oestrogen) also increases the risk of myocardial infarction two-fold.93 Women who take the oral contraceptive pill and smoke have a 20-fold increase in the risk of coronary heart disease, compared with non-smokers who are not taking the contraceptive pill.94 The impact of smoking and the contraceptive pill is therefore ‘synergistic’, meaning that the risk of disease is multiplicative rather than additive. Heavier smokers have an even higher risk of coronary heart disease.95

Although the newer ‘lower dose’ versions of the contraceptive pill may be associated with a lesser risk of developing coronary heart disease, risk is still elevated in smokers. There is insufficient evidence to evaluate the risk profile of the ‘third-generation’ pills (containing 30 μg or less of ethynyl estradiol and either gestodene or desogestrel) combined with smoking, but clinicians are advised to be wary when prescribing oral contraceptives to smokers aged in their mid-30s and to exercise extreme caution or avoid using them altogether in smokers aged over 40 years.95

In past decades the risk of stroke, particularly subarachnoid haemorrhage, has been significantly higher among smokers using the contraceptive pill. However research published since the 1990s following up women using lower dose pills is conflicting; some studies show increased risk, other studies have shown no significant effect.95

There is some evidence to suggest that the combined contraceptive pill has a higher failure rate in smokers than in non-smokers.94

3.15.7 Other conditions

A meta-analysis published in 2011 found that in patients receiving long-term haemodialysis (use of an artificial kidney machine to clean the blood) or peritoneal dialysis (an alternative to haemodialysis, uses the lining of the abdomen to clean the blood), smoking increased the death rate (all-cause mortality) by 65%.96

A 2019 meta-analysis and systematic review found that burns patients who smoke have higher rates of complications compared to non-smokers, including an increased risk of intubation (insertion of a tube through the mouth to support artificial breathing) and skin infections.97

Relevant news and research

For recent news items and research on this topic, click  here. ( Last updated March 2020)



1. US Department of Health and Human Services. The health consequences of smoking: a report of the Surgeon General. Atlanta, Georgia: US Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2004. Available from: http://www.cdc.gov/tobacco/data_statistics/sgr/2004/index.htm.

2. Yoong S, Tursan d'Espaignet E, Wiggers J, St Claire S, Mellin-Olsen J, et al. WHO tobacco knowledge summaries: tobacco and postsurgical outcomes Geneva: World Health Organisation, 2020. Available from: https://apps.who.int/iris/bitstream/handle/10665/330485/9789240000360-eng.pdf

3. Woodside JJ. Female smokers have increased postoperative narcotic requirements. Journal of Addictive Diseases, 2000; 19(4):1–10. Available from: http://www.tandfonline.com/doi/abs/10.1300/J069v19n04_01

4. Sweeney B and Grayling M. Smoking and anaesthesia: the pharmacological implications. Anaesthesia, 2009; 64(2):179–86. Available from: https://www.ncbi.nlm.nih.gov/pubmed/19143696

5. Moller AM, Maaloe R, and Pedersen T. Postoperative intensive care admittance: the role of tobacco smoking. Acta Anaesthesiologica Scandinavica, 2001; 45(3):345–8. Available from: https://onlinelibrary.wiley.com/doi/abs/10.1034/j.1399-6576.2001.045003345.x

6. Schwilk B, Bothner U, Schraag S, and Georgieff M. Perioperative respiratory events in smokers and nonsmokers undergoing general anaesthesia. Acta Anaesthesiologica Scandinavica, 1997; 41(3):348–55. Available from: http://www.ncbi.nlm.nih.gov/pubmed/9113178

7. Al-Sarraf N, Thalib L, Hughes A, Tolan M, Young V, et al. Effect of smoking on short-term outcome of patients undergoing coronary artery bypass surgery. Annals of Thoracic Surgery, 2008; 86(2):517–23. Available from: https://www.ncbi.nlm.nih.gov/pubmed/18640326

8. Australian and New Zealand College of Anaesthetists (ANZCA). Guidelines on Smoking as Related to the Perioperative Period. 2013. Available from: http://www.anzca.edu.au/resources/professional-documents/pdfs/ps12-2013-guidelines-on-smoking-as-related-to-the-perioperative-period.pdf

9. Chow CK and Devereaux PJ. The Optimal Timing of Smoking Cessation Before Surgery: Comment on "Smoking Cessation Shortly Before Surgery and Postoperative Complications". Archives of Internal Medicine, 2011; 171(11):989–90. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21403012

10. Myers K, Hajek P, Hinds C, and McRobbie H. Stopping smoking shortly before surgery and postoperative complications: a systematic review and meta-analysis. Archives of Internal Medicine, 2011; 171(11):983-9 Available from: https://www.ncbi.nlm.nih.gov/pubmed/21403009

11. Gronkjaer M, Eliasen M, Skov-Ettrup LS, Tolstrup JS, Christiansen AH, et al. Preoperative smoking status and postoperative complications: A systematic review and meta-analysis Annals of Surgery, 2014; 259(1):52-71. Available from: https://www.ncbi.nlm.nih.gov/pubmed/23799418

12. Araco A, Gravante G, Sorge R, Araco F, Delogu D, et al. Wound infections in aesthetic abdominoplasties: the role of smoking. Plastic and Reconstructive Surgery, 2008; 121(5):e305–10. Available from: http://www.plasreconsurg.com/pt/re/prs/abstract.00006534-200805000-00045.htm;jsessionid=LX1cvKLdqrlv69R8HlLPKKjXJJRQvmJGznxJLQJYYGvzQFvbZy1W!932896411!181195628!8091!-1

13. Abbas SM and Hill AG. Smoking is a major risk factor for wound dehiscence after midline abdominal incision; case-control study. Australian and New Zealand Journal of Surgery, 2009; 79(4):247–50. Available from: https://www.ncbi.nlm.nih.gov/pubmed/19432709

14. Pluvy I, Panouilleres M, Garrido I, Pauchot J, Saboye J, et al. Smoking and plastic surgery, part II. Clinical implications: A systematic review with meta-analysis. Annales de Chirurgie Plastique et Esthetique, 2014; 60(1):e15-49. Available from: / https://www.ncbi.nlm.nih.gov/pubmed/25447218

15. Araco F, Gravante G, Sorge R, Overton J, De Vita D, et al. The influence of BMI, smoking, and age on vaginal erosions after synthetic mesh repair of pelvic organ prolapses. A multicenter study. Acta Obstetricia et Gynecologica Scandinavica, 2009; 88(7):772-80. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19452293

16. Cundiff G, Varner E, Visco A, Zyczynski H, Nager C, et al. Risk factors for mesh/suture erosion following sacral colpopexy. American Journal of Obstetrics and Gynecology, 2008; 199(6):688 e1–5. Available from: http://linkinghub.elsevier.com/retrieve/pii/S0002-9378(08)00810-7

17. Sorensen LT. Wound healing and infection in surgery. The clinical impact of smoking and smoking cessation: a systematic review and meta-analysis Archives of Surgery, 2012; 147(4):373-83. Available from: https://www.ncbi.nlm.nih.gov/pubmed/22508785

18. Sorensen LT. Wound healing and infection in surgery: The pathophysiological impact of smoking, smoking cessation and nicotine replacement therapy. A systematic review. Annals of Surgery, 2012; 255(6):1069-79. Available from: https://www.ncbi.nlm.nih.gov/pubmed/22566015

19. McRobert J. Smoking and its effects on the healing process of chronic wounds Wound Care, 2013; March (S18):S20-3. Available from: https://www.ncbi.nlm.nih.gov/pubmed/23682498

20. Australian and New Zealand College of Anaesthetists. Statement on smoking as related to the perioperative period. Review PS12 (2007). Melbourne: Australian and New Zealand College of Anaesthetists, 2007. 

21. Leithead J, Ferguson J, and Hayes P. Smoking-related morbidity and mortality following liver transplantation. Liver Transplantation, 2008; 14(8):1159–64. Available from: https://www.ncbi.nlm.nih.gov/pubmed/18668649

22. Arora S, Aukrust P, Andreassen A, Simonsen S, Gude E, et al. The prognostic importance of modifiable risk factors after heart transplantation. American Heart Journal, 2009; 158(3):431–6. Available from: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=19699867

23. Kubasiak JC, Landin M, Schimpke S, Poirier J, Myers JA, et al. The effect of tobacco use on outcomes of laparoscopic and open ventral hernia repairs: a review of the NSQIP dataset. Surgical Endoscopy, 2016. Available from: http://www.ncbi.nlm.nih.gov/pubmed/27752819

24. Bayfield NGR, Pannekoek A, and Tian DH. Preoperative cigarette smoking and short-term morbidity and mortality after cardiac surgery: a meta-analysis. Heart Asia, 2018; 10(2):e011069. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6203009/pdf/heartasia-2018-011069.pdf

25. Lalys F, Durrmann V, Dumenil A, Goksu C, Cardon A, et al. Systematic Review and Meta-Analysis of Preoperative Risk Factors of Type II Endoleaks after Endovascular Aneurysm Repair. Annals of Vascular Surgery, 2016; 41:284-93. Available from: http://www.ncbi.nlm.nih.gov/pubmed/27903482

26. Teng S, Yi C, Krettek C, and Jagodzinski M. Smoking and risk of prosthesis-related complications after total hip arthroplasty: a meta-analysis of cohort studies. PLoS ONE, 2015; 10(4):e0125294. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25909602

27. Santiago-Torres J, Flanigan DC, Butler RB, and Bishop JY. The Effect of Smoking on Rotator Cuff and Glenoid Labrum Surgery: A Systematic Review. American Journal of Sports Medicine, 2014; 43(3):745-51. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24859982

28. Bedard NA, DeMik DE, Owens JM, Glass NA, DeBerg J, et al. Tobacco Use and Risk of Wound Complications and Periprosthetic Joint Infection: A Systematic Review and Meta-Analysis of Primary Total Joint Arthroplasty Procedures. Journal of Arthroplasty, 2018; 34(2):385-96. Available from: https://www.arthroplastyjournal.org/article/S0883-5403(18)30872-6/pdf

29. Cancienne JM, Brockmeier SF, and Werner BC. Tobacco use is associated with increased rates of infection and revision surgery after primary superior labrum anterior and posterior repair. Journal of Shoulder and Elbow Surgery, 2016; 25(11):1764-8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/27262413

30. Novikov DA, Swensen SJ, Buza Iii JA, Gidumal RH, and Strauss EJ. The Effect of Smoking on ACL Reconstruction: A Systematic Review. Physician and Sportsmedicine, 2016; 44(4):335-41. Available from: http://www.ncbi.nlm.nih.gov/pubmed/27456300

31. Cancienne JM, Gwathmey FW, Miller MD, and Werner BC. Tobacco Use Is Associated With Increased Complications After Anterior Cruciate Ligament Reconstruction. American Journal of Sports Medicine, 2016; 44(1):99-104. Available from: http://www.ncbi.nlm.nih.gov/pubmed/26526974

32. McCarthy C, Mehrara B, Riedel E, Davidge K, Hinson A, et al. Predicting complications following expander/implant breast reconstruction: an outcomes analysis based on preoperative clinical risk. Plastic and Reconstructive Surgery, 2008; 121(6):1886–92. Available from: http://www.plasreconsurg.com/pt/re/prs/abstract.00006534-200806000-00002.htm;jsessionid=LVLGDPrp2BnPy2Mmj4GQLXggJRl2pPDFcLRVFbh2JMn43x1vTY27!982088527!181195629!8091!-1

33. Padubidri A, Yetman R, Browne E, Lucas A, Papay F, et al. Complications of postmastectomy breast reconstructions in smokers, ex-smokers, and nonsmokers. Plastic and Reconstructive Surgery, 2001; 107(2):342–9. Available from: https://www.ncbi.nlm.nih.gov/pubmed/11214048

34. Bartsch R, Weiss G, Kästenbauer T, Patocka K, Deutinger M, et al. Crucial aspects of smoking in wound healing after breast reduction surgery. Journal of Plastic, Reconstructive and Aesthetic Surgery, 2007; 60(9):1045–9. Available from: https://www.ncbi.nlm.nih.gov/pubmed/17662466

35. Bikhchandani J, Varma S, and Henderson H. Is it justified to refuse breast reduction to smokers? Journal of Plastic, Reconstructive and Aesthetic Surgery, 2007; 60(9):1050–4. Available from: https://www.ncbi.nlm.nih.gov/pubmed/17512812

36. Zhang MX, Chen CY, Fang QQ, Xu JH, Wang XF, et al. Risk Factors for Complications after Reduction Mammoplasty: A Meta-Analysis. PLoS ONE, 2016; 11(12):e0167746. Available from: http://www.ncbi.nlm.nih.gov/pubmed/27936188

37. Hillam JS, Borsting EA, Chim JH, and Thaller SR. Smoking as a risk factor for breast reduction: An analysis of 13,503 cases. Journal of Plastic, Reconstructive and Aesthetic Surgery, 2017; 70(6):734-40. Available from: http://www.ncbi.nlm.nih.gov/pubmed/28237520

38. Anis KH, Weinrauch LA, and D'Elia JA. Effects of smoking on solid organ transplantation outcomes American Journal of Medicine, 2019; 132(4):413-9. Available from: https://www.amjmed.com/article/S0002-9343(18)31068-4/fulltext

39. Nogueira J, Haririan A, Jacobs S, Cooper M, and Weir M. Cigarette smoking, kidney function, and mortality after live donor kidney transplant. American Journal of Kidney Diseases, 2010; 55(5):907-15. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20176427

40. Tsao C, Chen R, Chou N, Ko W, Chi N, et al. The influence of donor characteristics on survival after heart transplantation. Transplantation Proceedings, 2008; 40(8):2636–7. Available from: http://linkinghub.elsevier.com/retrieve/pii/S0041-1345(08)01076-2

41. Duerinckx N, Burkhalter H, Engberg SJ, Kirsch M, Klem ML, et al. Correlates and Outcomes of Posttransplant Smoking in Solid Organ Transplant Recipients: A Systematic Literature Review and Meta-Analysis. Transplantation, 2016; 100(11):2252-63. Available from: http://www.ncbi.nlm.nih.gov/pubmed/27479162

42. Bright R. Denial of hepatic transplantation on the basis of smoking: is it ethical? Current Opinion in Organ Transplantation, 2010; 15(2):249-53. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20154621

43. Ehlers S. Ethical analysis and consideration of health behaviors in organ allocation: focus on tobacco use. Transplantation Reviews, 2008; 22(3):171–7. Available from: https://www.ncbi.nlm.nih.gov/pubmed/18631873

44. Sharkey K and Gillam L. Should patients with self-inflicted illness receive lower priority in access to healthcare resources? Mapping out the debate. Journal of Medical Ethics, 2010; 36(11):661-5. Available from: http://jme.bmj.com/content/early/2010/09/03/jme.2009.032102.long

45. Sinha R, Singh V, and Sankhwar S. Does tobacco consumption influence outcome of oral mucosa graft urethroplasty? Urology Journal, 2010; 7(1):45–50. Available from: http://www.urologyjournal.org/index.php/uj/article/view/574/430

46. Kaylie D, Bennett M, Davis B, and Jackson C. Effects of smoking on otologic surgery outcomes. Laryngoscope, 2009; 119(7):1384-90. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19418530

47. Sadr Azodi O, Lindström D, Adami J, Bellocco R, Linder S, et al. Impact of body mass index and tobacco smoking on outcome after open appendicectomy. British Journal of Surgery, 2008; 95(6):751–7. Available from: https://bjssjournals.onlinelibrary.wiley.com/doi/pdf/10.1002/bjs.6079

48. Landin M, Kubasiak JC, Schimpke S, Poirier J, Myers JA, et al. The effect of tobacco use on outcomes of laparoscopic and open inguinal hernia repairs: a review of the NSQIP dataset. Surgical Endoscopy, 2016; 31(2):917-21. Available from: http://www.ncbi.nlm.nih.gov/pubmed/27351659

49. Haskins IN, Amdur R, and Vaziri K. The effect of smoking on bariatric surgical outcomes. Surgical Endoscopy, 2014; 28(11):3074-80. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24902816

50. Haskins IN, Nowacki AS, Khorgami Z, Schulz K, Heinberg LJ, et al. Should recent smoking be a contraindication for sleeve gastrectomy? Surgery for Obesity and Related Diseases, 2017; 13(7):1130-5. Available from: http://www.ncbi.nlm.nih.gov/pubmed/28420587

51. Wong J, Lam DP, Abrishami A, Chan MT, and Chung F. Short-term preoperative smoking cessation and postoperative complications: a systematic review and meta-analysis. Canadian Journal of Anesthesia/Journal canadien d'anesthésie, 2012; 59(3):268-79. Available from: http://link.springer.com/article/10.1007/s12630-011-9652-x#page-1

52. Thomsen T, Villebro N, and Moller AM. Interventions for preoperative smoking cessation Cochrane Database of Systematic Reviews, 2014; 3(CD002294 ). Available from: https://www.ncbi.nlm.nih.gov/pubmed/24671929

53. Benedetto U, Albanese A, Kattach H, Ruggiero D, De Robertis F, et al. Smoking cessation before coronary artery bypass grafting improves operative outcomes. Journal of Thoracic and Cardiovascular Surgery, 2014; 148(2):468-74. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24189314

54. Masoudkabir F, Yavari N, Pashang M, Sadeghian S, Jalali A, et al. Smoking Cessation after Surgery and Mid-Term Outcomes of Surgical Revascularization. Annals of Thoracic Surgery, 2019; S0003-4975(19):31615-7. Available from: https://www.ncbi.nlm.nih.gov/pubmed/31706875

55. Schaffer SD, Yoon S, and Zadezensky I. A review of smoking cessation: potentially risky effects on prescribed medications. Journal of Clinical Nursing, 2009; 18(11):1533–40. Available from: http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2702.2008.02724.x/abstract

56. Benowitz N. Drug therapy: pharmacologic aspects of cigarette smoking and nicotine addiction. New England Journal of Medicine, 1988; 319(20):1318–30. Available from: https://www.ncbi.nlm.nih.gov/pubmed/3054551

57. Kroon LA. Drug interactions with smoking. American Journal of Health-System Pharmacy, 2007; 64(18):1917–21. Available from: http://www.ncbi.nlm.nih.gov/pubmed/17823102

58. Anderson GD and Chan LN. Pharmacokinetic Drug Interactions with Tobacco, Cannabinoids and Smoking Cessation Products. Clinical Pharmacokinetics, 2016; 55(11):1353-68. Available from: http://www.ncbi.nlm.nih.gov/pubmed/27106177

59. Sohn HS, Kim H, Song IS, Lim E, Kwon M, et al. Evidence supporting the need for considering the effects of smoking on drug disposition and effectiveness in medication practices: a systematic narrative review. International Journal of Clinical Pharmacology and Therapeutics, 2015; 53(8):621-34. Available from: http://www.ncbi.nlm.nih.gov/pubmed/26104035

60. Zevin S and Benowitz NL. Drug interactions with tobacco smoking: An update Clinical Pharmacokinetics, 1999; 36(6):425-38. Available from: https://www.ncbi.nlm.nih.gov/pubmed/10427467

61. Nathisuwan S, Dilokthornsakul P, Chaiyakunapruk N, Morarai T, Yodting T, et al. Assessing evidence of interaction between smoking and warfarin: a systematic review and meta-analysis. Chest, 2011; 139(5):1130–9. Available from: https://www.ncbi.nlm.nih.gov/pubmed/21540214

62. US Department of Health and Human Services. How tobacco smoke causes disease: the biology and behavioral basis for smoking-attributable disease. A report of the US Surgeon General, Atlanta, Georgia: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2010. Available from: http://www.surgeongeneral.gov/library/tobaccosmoke/report/index.html.

63. Gagne JJ, Bykov K, Choudhry NK, Toomey TJ, Connolly JG, et al. Effect of smoking on comparative efficacy of antiplatelet agents: systematic review, meta-analysis and indirect comparison BMJ (Clinical Research Ed.), 2013; 347(f5307). Available from: https://europepmc.org/article/pmc/pmc3775704

64. Bossard M, Granger CB, Tanguay JF, Montalescot G, Faxon DP, et al. Double-Dose Versus Standard-Dose Clopidogrel According to Smoking Status Among Patients With Acute Coronary Syndromes Undergoing Percutaneous Coronary Intervention. J Am Heart Assoc, 2017; 6(11):pii:e006577. Available from: https://www.ncbi.nlm.nih.gov/pubmed/29101117

65. Ahmad T, Barnes PJ, and Adcock IM. Overcoming steroid insensitivity in smoking asthmatics. Current Opinion in Investigational Drugs, 2008; 9(5):470–7. Available from: https://europepmc.org/article/med/18465656

66. Braganza G, Chaudhuri R, and Thomson N. Treating patients with respiratory disease who smoke. Therapeutic Advances in Respiratory Disease, 2008; 2(2):95–107. Available from: http://tar.sagepub.com/cgi/reprint/2/2/95

67. van Dijk W, Heijdra Y, Scheepers P, Lenders J, van Weel C, et al. Interaction in COPD experiment (ICE): a hazardous combination of cigarette smoking and bronchodilation in chronic obstructive pulmonary disease. Medical Hypotheses, 2010; 74(2):277–80. Available from: https://www.ncbi.nlm.nih.gov/pubmed/19800175

68. Frey P, Waters D, Demicco D, Breazna A, Samuels L, et al. Impact of smoking on cardiovascular events in patients with coronary disease receiving contemporary medical therapy (from the Treating to New Targets [TNT] and the Incremental Decrease in End Points Through Aggressive Lipid Lowering [IDEAL] trials). American Journal of Cardiology, 2011; 107(2):145–50. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21129718

69. Ursoniu S, Mikhailidis DP, Serban MC, Penson P, Toth PP, et al. The effect of statins on cardiovascular outcomes by smoking status: A systematic review and meta-analysis of randomized controlled trials. Pharmacological Research, 2017; 122:105-17. Available from: http://www.ncbi.nlm.nih.gov/pubmed/28602797

70. Lindsay GM, Tolmie EP, Martin WM, Hutton IM, and Belcher PR. Smoking after coronary artery bypass: high three-year mortality. Thoracic and Cardiovascular Surgeon, 2009; 57(3):135–40. Available from: https://www.ncbi.nlm.nih.gov/pubmed/19330749

71. Conard M, Haddock C, Poston W, and Spertus J. The impact of smoking status on the health status of heart failure patients. Congestive Heart Failure, 2009; 15(2):82–6. Available from: https://www.lenus.ie/handle/10147/207816

72. Ma WQ, Wang Y, Sun XJ, Han XQ, Zhu Y, et al. Impact of smoking on all-cause mortality and cardiovascular events in patients after coronary revascularization with a percutaneous coronary intervention or coronary artery bypass graft: a systematic review and meta-analysis. Coronary Artery Disease, 2019; 30(5):367-76. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30629001

73. US Department of Health and Human Services. The health consequences of smoking - 50 years of progress. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014. Available from: https://www.cdc.gov/tobacco/data_statistics/sgr/50th-anniversary/index.htm.

74. Togawa K, Bhatti L, Tursan d’Espaignet E, Leon Roux M, Ullrich A, et al. WHO tobacco knowledge summaries: tobacco and cancer treatment outcomes. Geneva: World Health Organization, 2018. Available from: https://apps.who.int/iris/bitstream/handle/10665/273077/WHO-NMH-PND-TKS-18.1-eng.pdf?ua=1.

75. Ordonez-Mena JM, Walter V, Schottker B, Jenab M, O'Doherty MG, et al. Impact of pre-diagnostic smoking and smoking cessation on colorectal cancer prognosis: a meta-analysis of individual patient data from cohorts wtihin the CHANCES consortium Annals of Oncology, 2018; 29:472-83. Available from: https://www.ncbi.nlm.nih.gov/pubmed/29244072

76. Sutton E, Miyagaki H, Bellini G, Shantha Kumara HM, Yan X, et al. Risk factors for superficial surgical site infection after elective rectal cancer resection: a multivariate analysis of 8880 patients from the American College of Surgeons National Surgical Quality Improvement Program database. Journal of Surgical Research, 2017; 207:205-14. Available from: http://www.ncbi.nlm.nih.gov/pubmed/27979478

77. Bastian L. Pain and smoking among cancer patients: the relationship is complex but the clinical implication is clear. Pain, 2011; 152(1):10–1. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3053043/

78. Daniel M, Keefe F, Lyna P, Peterson B, Garst J, et al. Persistent smoking after a diagnosis of lung cancer is associated with higher reported pain levels. Journal of Pain, 2009; 10(3):323–8. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2684817/

79. Logan H, Fillingim R, Bartoshuk L, Sandow P, Tomar S, et al. Smoking status and pain level among head and neck cancer patients. The Journal of Pain, 2010; 11(6):528-34. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20015696

80. Wallis CJD, Satkunasivam R, Butaney M, Khan UA, Goldberg HA, et al. Association Between Smoking and Survival Benefit of Immunotherapy in Advanced Malignancies: A Systematic Review and Meta-Analysis. American Journal of Clinical Oncology, 2019; 42(9):711-6. Available from: https://www.ncbi.nlm.nih.gov/pubmed/31335350

81. Warren GW, Sobus S, and Gritz ER. The biological and clinical effects of smoking by patients with cancer and strategies to implement evidence-based tobacco cessation support. Lancet Oncology, 2014; 15(12):e568-e80. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25439699

82. US Department of Health and Human Services. Smoking cessation. A Report of the Surgeon General Atlanta, GA U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Centre for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health  2020. Available from: https://www.hhs.gov/sites/default/files/2020-cessation-sgr-full-report.pdf.

83. Fukui M, Suzuki K, Matsunaga T, Oh S, and Takamochi K. The Importance of Smoking Cessation on Surgical Outcome in Primary Lung Cancer. Annals of Thoracic Surgery, 2019; 107(4):1005-9. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30610851

84. Budani MC and Tiboni GM. Ovotoxicity of cigarette smoke: A systematic review of the literature. Reproductive Toxicology, 2017; 72:164-81. Available from: https://www.ncbi.nlm.nih.gov/pubmed/28684319

85. Budani MC, Fensore S, Di Marzio M, and Tiboni GM. Cigarette smoking impairs clinical outcomes of assisted reproductive technologies: A meta-analysis of the literature. Reproductive Toxicology, 2018; 80:49-59. Available from: https://www.ncbi.nlm.nih.gov/pubmed/29906539

86. Zhang RP, Zhao WZ, Chai BB, Wang QY, Yu CH, et al. The effects of maternal cigarette smoking on pregnancy outcomes using assisted reproduction technologies: An updated meta-analysis. J Gynecol Obstet Hum Reprod, 2018; 47(9):461-8. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30142473

87. Waylen A, Metwally M, Jones G, Wilkinson A, and Ledger W. Effects of cigarette smoking upon clinical outcomes of assisted reproduction: a meta-analysis. Human Reproduction Update, 2009; 15(1):31–44. Available from: http://humupd.oxfordjournals.org/content/15/1/31.long

88. Firns S, Cruzat VF, Keane KN, Joesbury KA, Lee AH, et al. The effect of cigarette smoking, alcohol consumption and fruit and vegetable consumption on IVF outcomes: a review and presentation of original data. Reproductive Biology and Endocrinology, 2015; 13:134. Available from: https://rbej.biomedcentral.com/track/pdf/10.1186/s12958-015-0133-x

89. Klonoff-Cohen H, Natarajan L, Marrs R, and Yee B. Effects of female and male smoking on success rates of IVF and gamete intra-Fallopian transfer. Human Reproduction, 2001; 16(7):1382–90. Available from: http://humrep.oxfordjournals.org/cgi/content/full/16/7/1382

90. Dondorp W, de Wert G, Pennings G, Shenfield F, Devroey P, et al. Lifestyle-related factors and access to medically assisted reproduction. Human Reproduction, 2010; 25(3):578–83. Available from: http://humrep.oxfordjournals.org/content/25/3/578.full.pdf

91. Barbieri RL. The initial fertility consultation: recommendations concerning cigarette smoking, body mass index, and alcohol and caffeine consumption. American Journal of Obstetrics and Gynecology, 2001; 185(5):1168–73. Available from: https://www.ncbi.nlm.nih.gov/pubmed/11717652

92. Tong VT, Kissin DM, Bernson D, Copeland G, Boulet SL, et al. Maternal Smoking Among Women With and Without Use of Assisted Reproductive Technologies. J Womens Health (Larchmt), 2016; 25(10):1066-72. Available from: http://www.ncbi.nlm.nih.gov/pubmed/27243366

93. Keeling D. Combined oral contraceptives and the risk of myocardial infarction. Annals of Medicine, 2003; 35:413-18. Available from: http://www.ncbi.nlm.nih.gov/pubmed/14572165

94. British Medical Association Board of Science and Education & Tobacco Control Resource Centre, Smoking and reproductive life.  The impact of smoking on sexual, reproductive and child health. London: British Medical Association; 2004. Available from: https://www.rauchfrei-info.de/fileadmin/main/data/Dokumente/Smoking_ReproductiveLife.pdf.

95. US Department of Health and Human Services. Women and smoking. A report of the US Surgeon General, Atlanta, Georgia: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2001. Available from: https://www.cdc.gov/tobacco/data_statistics/sgr/2001/index.htm.

96. Liebman S, Lamontagne S, Huang L, Messing S, and Bushinsky D. Smoking in dialysis patients: a systematic review and meta-analysis of mortality and cardiovascular morbidity. American Journal of Kidney Diseases, 2011; 58(2):257–65. Available from: http://www.ajkd.org/article/S0272-6386%2811%2900810-9/fulltext

97. Klifto KM, Shetty PN, Slavin BR, Gurno CF, Seal SM, et al. Impact of nicotine/smoking, alcohol, and illicit substance use on outcomes and complications of burn patients requiring hospital admission: systematic review and meta-analysis. Burns, 2019; S0305-4179(19):30286-4. Available from: https://www.ncbi.nlm.nih.gov/pubmed/31818513