Smoking Cessation

Cigarette smoking is a risk factor for perioperative pulmonary, cardiovascular, bleeding and wound healing complications. (1,2) There is some evidence that vaping (or the use of e-cigarettes) is also associated with these complications. (3) The likelihood that quit-motivated patients can abstain from smoking is increased by use of nicotine replacement therapy (NRT). (4)

Screening Tools

Screening Questions:

  • Do you currently use products that contain tobacco or nicotine? (e.g., smoking cigarettes or e-cigarettes, vaping nicotine, or chewing tobacco)
  • If Yes, what type of tobacco/nicotine product?
  • If cigarettes, how many packs/day? If other, how much & how often?

Prehabilitation and Optimization Algorithm

Prehabilitation and Optimization Recommendations

Patient Education

5 A’s Algorithm for Smoking Cessation (5).

  • ASK about tobacco/nicotine use
    • See screening questions
  • ADVISE to quit
    • Strongly urge all tobacco users to quit in a clear, strong, personalized manner.
    • "It is extremely important for you to quit smoking before surgery. Smoking and vaping have a huge impact on your heart and lung health and increase the risk of complications after surgery. Quitting or cutting back on smoking before surgery can:
      • lower your risk of getting pneumonia after surgery,
      • reduce your risk of having a heart attack during/after surgery,
      • speed up your healing after surgery, which reduces your risk of infection."
  • ASSESS readiness to make a quit attempt
    • “Are you willing to try to quit before surgery?”
  • ASSIST with the quit attempt
    • “Stopping smoking is not solely about willpower. Your body may be addicted to or dependent on nicotine and quitting can be difficult.”
    • Quit Plan: Encourage patients to set a quit date, tell family/friends, remove tobacco products from the environment, plan for withdrawal symptoms and cravings
    • Recommend pharmacotherapies (6):  Medications & Nicotine Replacement Therapy can increase smoking cessation success and reduce withdrawal symptoms (e.g., patch, gum, sprays, or oral medication). Family doctors or pharmacists are able to arrange therapies and ensure these therapies are covered financially through PharmaCare. Refer to online patient resources for covered therapies.
    • Provide resources for quitting: (6)
      • Quit Now
      • Healthlink or *211 to access support through live chats, telephone and connection with local smoking cessation resources.
      • Online patient resources
  • ARRANGE follow-up care
    • See referral for follow-up below
Referral for Follow-up
  • Outpatient follow-up:
    • Encourage patients to schedule follow-up with their primary care provider for 2 weeks time to discuss progress.
  • Day of Surgery - revisit smoking cessation:
    • If still smoking: Normalize that lapses are very common and reassure that stopping smoking is not solely about willpower. Many people require more than one attempt. Reinforce the benefits of smoking cessation postoperatively, and offer further resources if appropriate (such as pharmacotherapy if it was not utilized with last quit attempt).

References

1. Eliasen, M., Grønkjær, M., Skov-Ettrup, L. S., Mikkelsen, S. S., Becker, U., Tolstrup, J. S., & Flensborg-Madsen, T. (2013). Preoperative alcohol consumption and postoperative complications: a systematic review and meta-analysis. Annals of surgery, 258(6), 930–942. https://doi.org/10.1097/SLA.0b013e3182988d59

2. Turan, A., Mascha, E., Roberman, D., Turner, P. L., You, J., Kurz, A., Sessler, D. I., Saager, L. (2011). Smoking and Perioperative Outcomes. Anesthesiology, 114(4), 837-846. https://doi.org/10.1098/ALN.0b013e318210f560

3. Rusy, D., Honkanen, A., Landrigan-Ossar, M. F., Chatterjee, D., Schwartz, L., Lalwani, K., Dollar, J., Clark, R., Diaz, C. D., Deutsch, N., Warner, D. O., Soriano, S. G., (2021). Vaping and E-Cigarette Use in Children and Adolescents: Implications on Perioperative Care from the American Society of Anesthesiologists Committee on Pediatric Anesthesia, Society for Pediatric Anesthesia, and American Academy of Pediatrics Section on Anesthesiology and Pain Medicine. Anesthesia & Analgesia, 133(3), 562-568. https://doi.org/10.1213/ANE.0000000000005519

4. Bush, K., Kivlahan, D. R., McDonell, M. B., Fihn, S. D., & Bradley, K. A. (1998). The AUDIT alcohol consumption questions (AUDIT-C): an effective brief screening test for problem drinking. Ambulatory Care Quality Improvement Project (ACQUIP). Alcohol Use Disorders Identification Test. Archives of internal medicine, 158(16), 1789–1795. https://doi.org/10.1001/archinte.158.16.1789

5. Fiore, M. C., Jaén, C. R., Baker, T. B., et al. (2008). Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. U.S. Department of Health and Human Services, Public Health Service. https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/clinicians-providers/guidelines-recommendations/tobacco/clinicians/update/treating_tobacco_use08.pdf

6. Government of British Columbia (n.d.). Smoking Cessation Program – information for health professionals. Retrieved October 18, 2024, from https://www2.gov.bc.ca/gov/content/health/practitioner-professional-resources/pharmacare/pharmacies/smoking-cessation-program-for-health-professionals

Surgical Prehabilitation Toolkit