Stop Smoking for Safer Surgery

1. Stop Smoking for Safer Surgery Dr JohnOyston

2. SUMMARY • People still smoke. • Smoking is the #1 cause of preventable deaths in Canada. • Perioperative smoking is bad. • Perioperative smoking cessation is good. • Anesthesiologists should promote perioperative smoking cessation.

3. How bad is smoking? • 18% of Canadians still smoke. • The average smoker loses 8 years of life. • In Ontario, smoking costs us $1.7 billion in healthcare costs and $2.6 b in lost productivity and uses up 500,000 hospital days. • One out of every two smokers will die of smoking-related diseases.

5. 45,000 smoking deaths versus: • SARS - 44 deaths • H1N1 • 78 deaths (so far) • West Nile Virus • 10 deaths in bad year • Homicide • 561 deaths/yr • AIDS • 1,325 deaths/yr

7. So smoking is a big Public Health problem.Why should I care?

8. Risks of Perioperative Smoking

9. Risks of Perioperative Smoking • Cardiac • Respiratory • Wound infections • Wound healing • Disease recurrence

10. CARDIAC RISK FROM SMOKING Woehlck HJ et al, Anes and Analg 1999;89:856

11. Carbon monoxide a “quick fix” • The half life of carbon monoxide is four hours. • Not smoking for four hours before surgery cuts the level one half • Not smoking for eight hours before surgery cuts the level by ¾. Cut out smoking before surgery !

12. Woehlck HJ et al, Anes and Analg 1999;89:856

13. Cardiac benefits of quitting • Studies of preop quitting are too small to have significant result: • E.g. Smokers 10% Postop cardiac events, Quitters 0% p<0.08 • Stopping smoking decreases overall mortality in CAD patients by one third. • Postoperative quitting reduces long-term mortality after CABPG.

14. Post-operative Pulmonary Complications (PPCs) • PPCs are much more common in smokers. • Takes weeks/months to get benefits of stopping smoking.

15. Duration of Cessation and Risk of PPCs • 8 wks reduces PPC risk from 48% to 17% • Compared to 11% in non-smokers • 4 wks reduces PPC risk to 1.03x non-smokers • Continuing to smoke -> 2.09x non-smoker • 2 wks abstinence -> risk is1.9x that of a non-smoker • Continuing to smoke -> risk 4.2x non-smoker

16. Wound Infections • Six times more common in smokers. • Smokers 12%. • Non-smokers 2% (p<0.05). • 4 weeks of non-smoking equivalent to never smoking. RCT by Sorensen, Annals of Surgery, Vol 238 July 2003: 1-5

17. Wound Healing • Delayed in smokers: • Back fusion. • Vascular grafts. • Worse long term outcome of ACL repair. • 5 years after surgery, smokers had significantly worse overall knee function, and more severe pain, more often, than matched non-smokers (Karim,A JBJS 2006;8-B:1027).

18. Disease Recurrence • Peripheral vascular or cardiac vessel disease will continue to get worse if patient continues to smoke. • Is it an ethical use of scarce health care resources to re-operate on smokers?

19. Anesthesiologists should encourage our patients to stop smoking because: • It is good for our patients. • It is good for our hospitals. • It is good for the healthcare system. • It is good for us as a profession.

20. How?

21. Inform Patients:Ask, Advise, Refer • Ask – “How much do you smoke?” • Advise – “Smoking increases the risk of surgery.” • Refer – “Call this number for help quitting.”

22. Quit Card Available by emailing from the Johnson and Johnson booth or by emailing John Oyston at john7@oyston.com

23. www.StopSmokingForSaferSurgery.ca

24. Smokers’ Helpline:Help by phone, web and email

25. What else can we do? • Inform the public • Interviews on CBC Radio and TV • Global and CTV • Toronto Sun • Metro • Globe and Mail

26. Inform colleagues and administrators: OA Action Plan i) Identify smokers preoperatively. ii) Explain that smoking increases the risk of surgery. • Refer smokers to smoking cessation services. • Consider delaying surgery in patients who have smoked recently. v) Follow up on smokers to encourage them to continue not smoking after surgery. vi) Encourage non-smoking hospitals.

27. No Smoking at TSH • No smoking anywhere on hospital property • Staff education and help quitting • Preoperative teaching for elective patients • NRT available on formulary Feb 1st 2010

28. Ongoing Policy Development • Patient handout being developed. • Working with CAS to develop national strategy. • Working with Accreditation to make Perioperative Smoking Cessation support a required organizational practice.

29. Please – do your part! • Ask, Advise, and Refer. • What else can you do in the Preadmission Clinic which will: • Reduce perioperative complications (52% ->18%). • Improve wound healing and decrease wound infection rate (six fold). • Save your patient’s life!

30. Thank You Questions? Email: john7@oyston.com StopSmokingForSaferSurgery.ca

31. Additional Info

32. Does cessation immediately before surgery increase pulmonary risk? • Clinical impression only… • Some studies have higher rate of PPCs in pts who quit shortly before surgery. • NOT statistically significant. • NOT randomised. • “The evidence suggesting an increased risk during the first weeks of quitting is insufficient to support any recommendation that smokers do not strive for preoperative abstinence” - Warner

34. Is perioperative NRT safe? • YES • NRT does not produce adverse cardiac effects in volunteers or smokers • NRT reduces exercise-induced ischaemia • NRT does not affect patency of CABG grafts • NRT is safe in patients with cardiovascular disease • But NRT may exaggerate cardiovascular response to intubation