Surgery has revolutionised the treatment of many diseases, saved countless lives and improved quality of life for many others. But surgical procedures, particularly major surgery, can cause severe stress to the body and require considerable healthcare prior to and during the surgery, as well as during recovery. A range of adverse events (complications) associated with surgery may also occur.1
There is a considerable body of evidence that smoking is a risk factor for poorer surgical outcomes (where the benefits of surgery are less for people who smoke) and for an increased risk of complications.1,2 In particular, people who smoke are more likely to have wound healing problems after surgery and respiratory complications.3 The higher prevalence of chronic diseases, impaired pulmonary reserve and altered immune responses in people who smoke are thought to contribute to these effects.2
There is evidence that smoking cessation for at least four weeks or longer prior to surgery reduces some of the risks of post-operative complications (see Section 3.15.4). Some clinicians require their patients to cease smoking before surgery commences and are reluctant to operate on those who do not quit,4-7 which is considered by some commentators as an unfair disadvantage for people who smoke.6,8
In 2020, the World Health Organization released an updated review of tobacco and post-surgical outcomes that suggested that quitting around four weeks prior to surgery leads to a lower risk of operative complications. However, the ideal cessation time varies according to the specific complication.2
General anaesthesia is a medically induced loss of consciousness used for people undergoing surgery. A variety of drugs are used to induce unconsciousness, relieve pain, induce amnesia and block movement (neuromuscular blocking agents). Pain relief is often required during recovery after surgery.
There is evidence that nicotine and polycyclic aromatic hydrocarbons from tobacco smoke can affect the cytochrome p450 system— a group of enzymes in the liver that break down drugs.9,10 These drugs include opioids,11 neuromuscular blocking agents and some of the volatile agents that are administered by inhalation (via a mask or endotracheal tube).10 Effects of smoking on the cytochrome p450 system could potentially increase the amount of drugs needed for anaesthesia and pain relief after surgery. The current evidence shows that higher levels of pain relief after surgery are often required by people who smoke (discussed below in Section 3.15.1.3).
Studies of the effects of smoking on anaesthetic drugs are limited and have produced mixed results. Smoking may be a risk factor for increased amount of propofol used for induction of anaesthesia12 and for longer motor block onset times and shorter motor block durations for women undergoing C-section.13 One study found that a higher concentration of remifentanil was needed for people who smoke to prevent coughing during waking from anaesthesia for gall bladder removal, compared to non-smokers,14 and another found that the dose of vecuronium to maintain neuromuscular block was higher in people who smoke than in non-smokers.15 However, there also studies showing that smoking does not affect the amount of rocuronium or vecuronium (neuromuscular blockers) orsevoflurane (induces unconsciousness) needed during surgery.16-18 Overall, more robust evidence is needed as to whether and how smoking may be a risk factor for increased drug requirements during general anaesthesia.
There is a higher risk of intra-operative (during surgery) and perioperative complications (before, during and after) surgery for people who smoke, particularly for respiratory complications.19-22
People who smoke have a higher risk of respiratory complications during surgery, including bronchospasm (sudden narrowing of airways), aspiration (inhaling foreign material), hypoventilation (slow/shallow breathing) and hypoxaemia (low oxygen in the blood).20,22 Smoking damages the airways and lungs, increasing mucus production and causing the small-airways to narrow, making them more prone to collapse.23 These changes may restrict oxygen flow to the lungs, increasing the need for ventilation. Smoking can also increase airway sensitivity,24 which can lead to increased risk of cough and bronchospasm during wakening from surgery.
Numerous studies have found that people who smoke are more likely than non-smokers to experience other complications during or immediately after specific types of surgery. These include adverse cardiac events during surgery,21 longer surgery time for joint replacements,25 higher sputum volume (coughed up mucus etc) during elective minor surgery26 and higher blood loss during spinal surgery for people with metastatic tumours.27
The Australian and New Zealand College of Anaesthetists recommends that patients who smoke be encouraged to quit at any time before surgery.28 In contrast to concerns that quitting very close to surgery may be detrimental for outcomes, research suggests that recent quitters are no worse off than those who continue to smoke in terms of respiratory complications. (see Section 3.15.1.4).29,30
Surgical outcomes are the results of surgery, such as improving a patient's health and quality of life. Surgical outcomes are measured by factors such as mortality, illness, functionality of repaired organs or limbs, and patient-reported outcomes. There is considerable evidence showing that people who smoke are more likely than non-smokers to have poorer outcomes after surgery. Table 3.15.1 lists the results of many studies of the effects of smoking and smoking cessation on surgical outcomes for a range of surgery types: orthopaedic surgery, surgery for cancer, heart and vascular surgery, organ transplantations and other types. Given the large body of evidence, this table is not an exhaustive list of studies.
There are some issues with interpretation of many studies of surgical outcomes. Much of this evidence comes from retrospective studies using data from patient admissions. In many cases, patients were only asked if they currently smoked or not, rather than for a detailed smoking history. The non-smokers group in these studies would contain people who had never smoked as well as former smokers. In some cases, people were only asked if they had smoked in the past 30 days. Furthermore, people who smoke may have had incentive to lie about their smoking in order to have the surgery, as some surgeons may not to operate on people who smoke.4-7 Additionally, people who use nicotine e-cigarettes (“vape”) or are exposed to secondhand smoke would not have this history recorded in most of these studies. These issues may mean that some studies in Tables 3.15.1 and 3.15.2 miss real differences between people who smoke, those who have quit and never-smokers. In one study, self-reported smoking status was not associated with adverse outcomes, but nicotine exposure, as measured using blood cotinine levels, was associated with adverse effects after surgery.31 In Tables 3.15.1 and 3.15.2, priority was given to studies that minimised smoking misclassification and adjusted for confounding factors, where possible. Additional evidence for the benefits of cessation come from randomised controlled trials of smoking cessation, as detailed in Section 3.15.1.4.
Patient reported outcomes are direct reports from patients about their health status, such as symptoms, daily functioning, and quality of life, without interpretation by a clinician.32 Standard measures of quality of life and surgery-type-specific surveys are used as patient reported outcomes. Poorer patient reported outcomes are associated with smoking for numerous types of surgery (Table 3.15.1).33,34 People who smoke have reported worse outcomes after bladder removal (cystectomy)35 and stomach reduction (bariatric surgery)36 than non-smokers (Table 3.15.1). Smoking cessation is associated with improved patient reported outcomes for numerous types of surgery (Table 3.15.1)36-40.
Orthopaedic surgery treats musculoskeletal conditions and injuries, including joint replacements and fracture repair. Functionality is often measured to gauge the success of orthopaedic surgery, such as how well a person can use their legs and knees in the long term, after a knee replacement. People who smoke are more likely to report poorer function after shoulder surgery, knee or spinal surgery compared to non-smokers, with some better results for people who have quit smoking in studies that included former smokers (Table 3.15.1).37,38,40-42
When assessed in the long term, pain can be a measure of the success of specific types of surgery. People who smoke report less improvement in joint pain after numerous types of orthopaedic surgery than non-smokers (Table 3.15.1).38,39,41,43,44 People who have quit may have improved pain outcomes compared to those who smoke.37,39,41
One study found that people who smoke had a lower rate of return to work than non-smokers after lumbar spinal surgery. Those who quit for six months or more had the same return to work rate as non-smokers.45
People who smoke have a higher chance of delayed bone union and of non-union after treatment/surgery for fractures (Table 3.15.1 and also Section 3.13.2).45-50,67,68,51-54
People who smoke have a higher risk of their cancer returning after bladder removal (for bladder cancer),55,56 oesophagus surgery (for oesophagus cancer)57 and prostate removal (for prostate cancer)58-60 (Table 3.15.1). Many of the chemicals in smoke are carcinogens, meaning that their exposure leads to DNA changes that cause cancer. People who smoke are more likely to see mutations in genes that drive cancer in various organs. Furthermore, smoking leads to inflammation and oxidative stress (see Section 3.3.2) which also contribute to the formation of cancer. These types of damage may underlie the increased risk of cancer recurrence for people who smoke after surgery to remove cancerous tissue.
Mortality, as a long-term measure, is considered a surgical outcome for the types of surgery that aim to decrease the rate of early death, such as removal of cancer. People who smoke have a higher risk of mortality compared to non-smokers for many different types of surgery (Table 3.15.1).56,58,59,61-84 There is evidence of an improvement in mortality rates for those who quit (Table 3.15.1).58,63,64,67-72,76,79,82-84
However, a meta-analysis has found that people who smoke have a 1.2-fold increased risk of bladder cancer recurrence and a 1.2-fold increased risk of death from bladder cancer after bladder removal surgery.56 People who smoke appear to be less likely to benefit from chemotherapy that aims to shrink tumours just before surgery.56
Smoking is also associated with an increased risk of early death after surgery for other conditions. For example, smoking was associated with an almost two-fold increased chance of poor outcomes (death, myocardial infarction, or stroke) within five years after coronary revascularisation (surgery to improve blood flow to the heart), whereas those who had quit were not at increased risk.87 People who smoke heavily before a heart transplant are more likely to get atrial fibrillation and die from infection/sepsis or cancer in the first 1 to 5 years after surgery, compared to non-smokers/light smokers (<20 per day).75
This section is not an exhaustive list of the effects of smoking on surgical outcomes: the body of research on this subject is enormous. Outcomes from dental surgery are described separately in Section 3.11.4.
Smoking is associated with an increased risk of many types of post-operative complications (adverse events). These include a higher risk of morbidity, mortality, wound complications, respiratory complications, infections, pain, intensive care unit (ICU) admission, readmission to hospital and need for additional (revision) surgery (Table 3.15.2).3,118 The 2004 US Surgeon General’s report concluded that ‘the evidence is sufficient to infer a causal relationship between smoking and increased risks for adverse surgical outcomes related to wound healing and respiratory complications.’3
This subsection focuses on the adverse events occurring after surgery (post-operative complications) for people with a history of smoking. The effects of smoking on the potential benefits of surgery are discussed in Section 3.15.1.2, and on adverse effects occurring during surgery are discussed in Section 3.15.1.1.
People who smoke have a higher risk of wound complications after surgery compared to non-smokers or never smokers, including delayed or impaired wound healing.1,3 Wound complications for which smoking is associated with higher risk include: surgical site infections;40,94,119-126 dehiscence (wound reopening);121,125,127-130 hernia or ulcer at incision site,131,132 necrosis (cell death in most of a tissue or an organ)125,133 and incomplete wound healing in people with critical limb ischemia undergoing endovascular interventions (see Table 3.15.2).134-137
Surgical site infections contribute significantly to postoperative morbidity and mortality rates. Three broad types of surgical site infections are superficial infections (on or just under the skin, including the wound) which are the most common, deep incisional infections, such as in places where muscles were cut, and organ/space infections which are deep and include implant sites.138
People who smoke have a higher risk of wound and surgical site infections and other complications after orthopaedic surgery (such as hip, knee, hand and shoulder replacement),51,120-123,139-141 surgery to remove cancer (such as bladder removal), heart surgery (such as bypass surgery)125,126 and some other types of surgery (see Table 3.15.2).142 Flap infection can be an increased risk for people who smoke after reconstructive surgery.143,144 A meta-analysis has found that people who smoke were at 1.5-fold increased risk of prosthetic joint infection requiring surgery after total hip replacement.145 For some of these surgery types, the risk was lower for people who have quit smoking (Table 3.15.2).31,123,146
The impact of smoking on wound healing may occur via several different mechanisms, including:2,147,148
On the induction of general anaesthesia, there are numerous stressors to the pulmonary system, including reduction in lung volume and respiratory drive, and partial lung collapse (atelectasis) in some patients. The respiratory system make take weeks to recover to pre-operative function.149
People who smoke are more likely that non-smokers or never smokers to have post-operative respiratory complications, including lower respiratory tract infections, pneumonia, collapsed lung and acute respiratory distress syndrome (ARDS) for specific surgery types (see Table 3.15.2).62,95,107,150-155 For some types of surgery, the risk of respiratory complications was lower for former smokers (Table 3.15.2).62,146,151,154,156,157 Pneumonia is a common post-operative respiratory complication for people who smoke, and the risk is higher after many surgery types, such as hip and knee replacement, prostate removal,156 bowel removal,128 craniotomy,158 gastric bypass159 compared to non-smokers or never smokers (Table 3.15.2).160
Smoking may increase the risk of post-operative respiratory complications by causing chronic obstructive pulmonary disease (COPD, see Section 3.2.4.1), which is also a risk factor for respiratory complications after surgery. Aside from COPD, smoking causes considerable damage to the airways. Impairment of mucociliary clearance, inflammation and disruption of innate immune responses in the lungs can increase the risks of infection (see Section 3.2.1.1).
People who smoke have a higher risk of post-operative pain and higher use of post-operative pain medications such as opioids, compared to non-smokers (Table 3.15.2).161,162 Higher pain and need for pain relief was found after orthopaedic surgery (hip and shoulder replacements and carpel tunnel surgery),44,99,146,163 hernia repair95 and ear surgery (Table 3.15.2).164
Exposure to cigarette smoke affects the metabolism of many types of opioids, including some of those used for pain relief after surgery.9,10 Some of these drugs are likely to be broken down more quickly, meaning that a higher dose is required for people who smoke.10 But one review has concluded that smoking-induced changes to drug metabolism do not fully explain the increased need for increased opioids after surgery.10
People who smoke risk needing a longer stay in hospital after surgery compared to non-smokers.165 Longer hospital stays have been shown for people who smoke who undergo hip replacement,150 craniotomy,166 lung surgery,63 bariatric surgery159 and Zenker’s diverticulectomy (Table 3.15.2).167
Smoking was also a risk factor for need for intensive care and longer stay in intensive care after surgery.165,168,169
Post-operative complications such as infections, bleeding and pain, as well as surgery-specific issues such as anastomotic leak can lead to unplanned readmission to hospital. Readmission is often defined as being within a certain time frame after surgery, such as ‘30-day readmission rate’.
Smoking was also associated with an increased risk of needing readmission after hip,121 knee124 or shoulder replacement,120,170 knee surgery,171 bariatric surgery,169,172,173 lung surgery,63 craniotomy (Table 3.15.2)174 and repair of small umbilical and epigastric hernias,175,176 and after hand surgery.142
People who smoke had a greater risk than non-smokers of needing revision surgery (to correct or improve previous surgery) after orthopaedic surgery (Table 3.15.2),40,100,101,120,122,170,177-181 a spinal procedure called posterior cervical decompression,182 and lumbar discectomy.183 For some surgery types, revision surgery rates are lower in people who have quit smoking than in people who currently smoke (Table 3.15.2).146
Smoking is a cause of heart disease and heart attack. Smoking causes a variety of damage to the cardiovascular system.184 Nicotine causes constriction of blood vessels, leading to high blood pressure and increased heart rate. Carbon monoxide from tobacco smoke binds to haemoglobin in the blood, taking up the space where oxygen should be. This reduces the oxygen delivery, such as to the arteries that supply the heart muscle, which may lead to abnormalities in the heart rhythm. Smoking also increases the risk of blood clots, hardening of arteries, and reactivity of platelets, which increase the risks of stroke and heart attack. It’s likely that these and other types of damage caused by smoking underlie the increased risk of cardiovascular events and bleeding after surgery in people who smoke.184
There is evidence for an increased risk of heart attack or other cardiac event soon after surgery for some types of surgery.128,170 People who smoke have a higher rate of heart attack and cardiac arrest after hip replacement, compared to non-smokers.185 A large study identified smoking history as an important clinical predictor of cardiac mortality following elective or urgent vascular surgery.186 But other studies have found that smoking was not a risk factor for cardiac events after general and vascular surgery,187 pancreas removal188 aortic valve replacement189 or kidney transplant.190 It may be that a reluctance to operate on people who smoke that are at higher risk of heart attack is reducing the relative risks seen in these studies.
The risk of post-operative haemorrhage (bleeding) appears to be higher for people who smoke, but only for specific types of surgery.172,191 Post-procedure stroke and haemorrhage risks were no higher for people who smoke compared to non-smokers after aortic valve repair or carotid endarterectomy (Table 3.15.2), polyp removal192 or Whipple procedure.193 But smoking was associated with increased risk of haemorrhage or haematoma occurring after tonsillectomy in adults194 and thyroid surgery.195
People who smoke have an increased risk of venous thromboembolism (VTE) (blood clots that form in veins) following anterior cruciate ligament (ACL) reconstruction (knee reconstruction) surgery.196 Smoking was also associated with a 4.6-fold higher chance of a thromboembolic event and pulmonary embolism (blood clot in the lungs), after shoulder replacement.197 An additional study found that people who smoke had higher rates of wound infection, VTE and subsequent ACL reconstruction compared to non-smokers.198 Deep vein thrombosis was also more common in people who smoke compared to non-smokers after shoulder replacement.170
Mortality soon after surgery is considered a complication of surgery, and is often measured as in-hospital mortality, 30-day or 90-day mortality.
People who smoke have a higher risk of dying soon after surgery than non-smokers, for numerous surgery types. The risk is higher after knee replacement,178 bladder removal,199 oesophagus removal, lung removal,63,200,201 bowel removal,153,202 heart transplantation76,77,79,203 bariatric surgery and hernia repair204 compared to non-smokers/never smokers (Table 3.15.2). There is some evidence for a reduced risk for people who have quit smoking, particularly for those who have quit for over 12 months (Table 3.15.2).67,79 The risk of post-operative death for people who smoke was no higher than non-smokers after aortic valve repair/replacement110,189 and results were mixed for studies of carotid endarterectomy71-74,112,205 (Table 3.15.2).
Unsurprisingly, solid organ transplant recipients who smoke after transplantation have a higher risk of newly diagnosed cardiovascular disease, cancer and overall shorter survival time, and mortality.206
Other complications after some types of surgery for people who smoke include increased risk of blood transfusion, urinary complications, sexual dysfunction,207-210 anastomotic leak,153,211,212 hernia at incision site,213 need for breast implant removal214 and bone fracture around surgical site (Table 3.15.2). People who smoke were more likely to experience structural valve degeneration after aortic valve replacement.215
People who smoke may have a decreased risk of postoperative nausea and vomiting compared to non-smokers after some types of surgery.10
Where a transplant donor smokes until the time of donation, there is an increased risk of poor outcomes. People with a history of smoking who donated a kidney during live kidney donation have 3.3-fold higher chance of developing chronic kidney disease after the surgery.216 A donor history of smoking is associated with an increased risk of clotting after liver transplant, increased risk of graft rejection and mortality in the recipient, and increased mortality and higher incidence of graft rejection after heart transplant.217,218
Numerous studies have measured complications during and after surgery for children exposed to secondhand smoke. A meta-analysis has found that children exposed to secondhand smoke are over 2.5-fold more likely to experience an adverse respiratory event, such as coughing, laryngospasm (contraction of vocal cords) or bronchospasm (sudden narrowing of airways).219
Quitting smoking has many short and long-term benefits for health (for more details, see Section 7.1).
There is evidence for numerous surgery types that the outcomes may be better for people who have quit compared to those who continue to smoke (see Table 3.5.1).123,146,210,225 Former smokers are also less likely to experience some of the complications from surgery than people who smoke (Table 3.15.2).79,151,154,249,254 The broad-reaching health benefits of quitting likely underlie the reduced risk of former smokers for poor outcomes and complications after surgery.
There are many surgery types for which there is little information about the risks for people who have quit smoking, as medical records for these people did not include information on smoking history before the surgery. Furthermore, some studies provide inconsistent results regarding the timing of cessation necessary for reducing risk. This may be due to misclassification of smoking status, based on limited information and under-reporting of smoking prior to surgery,259 as described in Section 3.15.1.2. More robust information on the benefits of quitting may come from studies that properly classify smoking status and from trials of smoking cessation interventions, as described below in this subsection.
Some studies of people who quit smoking before surgery compared outcomes over different time-periods of abstinence to predict the time of cessation needed to reduce the risks. Due to the low numbers of studies taking this approach, and the broad range of different surgeries and outcomes/complications examined, there is insufficient information from these studies to come to a consensus of the optimal cessation timing prior to surgery. However, these studies reinforce that cessation prior to surgery can reduce the risk of poor outcomes and complications.
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 change the risk of postoperative respiratory complications.260
People who quit three to six months before shoulder surgery had a similar risk of infection and need for revision surgery as those who had never smoking, but quitting less than six months before surgery did not reduce the risk.123 However, people who quit for at least three weeks before head and neck reconstruction had a lower risk of impaired wound healing compared to those who continued to smoke.249
Cessation for 90 days or more before oesophagus removal reduced the risk of pneumonia and severe morbidity compared to continued smoking, and cessation for at least 30 days reduced the risk of pneumonia. Cessation for less than 30 days did not reduce these risks.225
People who quit smoking for at least two months before lung surgery had reduced risk of pulmonary complications, and reduced the time of post-operative chest tube and hospital stay, compared to those who continued to smoke. Cessation within 30 days before surgery was not effective at reducing these risks. However, this study could not determine the optimal timing of cessation in the group who quit two months or more before surgery, due to variations in the time of cessation in that group.228 In another study of people undergoing lung surgery, the risk of death during hospital stay decreased gradually for increased quitting time before surgery, from two weeks up to 12 months cessation.200
Smoking cessation before surgery can also reduce the requirement for post-operative opioids, demonstrated in a study of people having laparoscopic distal gastrectomy with gastroduodenostomy (removal of part of the stomach). People who quit for longer than one month prior to surgery required less post-operative opioids than those who quit for less than one month prior to surgery.261
The risk of prostate cancer returning after initial treatment was higher in people who smoke and former smokers compared to never smokers. This risk was mitigated in people who had quit for at least 10 years.60
Cessation after surgery has been shown in some circumstances to protect from poor outcomes. A study showed that people who quit after surgery for at least six months had lower rates of spinal fusion failure compared to people who continued to smoke.45 People who quit soon after heart bypass surgery had a lower risk of heart attack and reoperation over 15 years post-surgery.233
A recent meta-analysis found that pre-operative smoking cessation programs probably increased the rates of cessation prior to surgery by about 2-fold.262 Systematic reviews have found some benefits of these programs in reducing post-operative complications, especially wound healing complications.
A 2014 Cochrane review examined interventions for pre-operative smoking cessation and the impact of these on postoperative complications.263 Thirteen randomised controlled trials, with over 2,000 participants, were included in the review. Intensive behavioural interventions (face-to-face counselling delivered over multiple sessions) were found to reduce the risk of postoperative complications, with a reduction in wound complications having the best evidence. Cessation interventions starting between 4 and 8 weeks prior to surgery and continuing for 4 weeks after surgery showed evidence of improving complication rates,264 but brief interventions (<4 weeks prior to surgery) did not have an impact. The authors concluded that although the ideal cessation time is not entirely clear, the 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 more recent review with over 4,700 participants found that pre-operative smoking cessation interventions probably increase the likelihood of smoking cessation before surgery, but there were inconsistencies between studies.262 This review found a 27% drop in the rate of post-operative complications after the cessation interventions, but the evidence for a reduced rate of wound healing complications was considered low quality.262
Results from another recent meta-analysis, however, found stronger evidence for benefits of short-term cessation prior to surgery, compared to continued smoking. Quitting within 2 or more weeks prior to surgery reduced the risk of pulmonary complications by 27%, and cessation eight or more weeks prior to surgery reduced this risk by 37%. Four or more weeks cessation was required for reduction of wound complications by 33% and mortality by 14%. Short-term cessation was insufficient to reduce the risks of infections or bleeding.265
A systematic review evaluated the economic benefits of preoperative smoking cessation interventions that aimed to prevent surgical complications.266 This study determined that pre-operative smoking cessation was cost-effective for preventing surgical complications from a payer or provider perspective when compared to standard care.266
The Australian and New Zealand College of Anaesthetists recommend that, based on the current available evidence: Practitioners are strongly encouraged to use every opportunity to address the subject of smoking with its inherent multiplicity of risks, encourage cessation of smoking preoperatively, and assist patients to quit.28
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