Preoperative Smoking Cessation: Title and subTitle BreakImpact on Perioperative and Long-term Complications

Hypothesis:Smoking cessation at the time of diagnosis with an upper aerodigestive tract squamous cell carcinoma minimizes perioperative morbidity and improves long-term outcome.

Habitual tobacco use is the leading preventable cause of death in the United States and is responsible for 1 of every 5 deaths.¹ Although there has been a steady decline in the percentage of smokers since 1960, a plateau in this progress has been noted in the past decade. In 2000, 25.7% of males and 21.0% of females were smokers.² The physiologic impact of smoking is well described and includes impaired mucus transport and pulmonary macrophage function, increased bronchial reactivity and arterial carbon monoxide levels, reduced oxygen transport, and inhibited mitochondrial oxidative metabolism.³ In addition, active smoking, including heavy (≥20 cigarettes/d) and lighter users, has also been associated with an increased relative risk (1.44 overall) of the future development of type 2 diabetes mellitus.⁴

Attempts at smoking cessation are most successful in highly motivated individuals; however, even within established tobacco cessation programs, long-term abstinence rates are often low. In a study by Anthonisen et al,⁵ patients were involved in a 10-week smoking cessation program that included physician input, 12 group meetings with behavioral modification, and nicotine gum. At 5 years, 21.7% of the intervention participants had stopped smoking. Only 5.4% of the control group had stopped smoking during that same period. Not surprisingly, the death rates for both lung cancer and cardiovascular disease were noted to be significantly lower in the intervention group when compared with controls.⁵

The number of studies within the field of otolaryngology–head and neck surgery examining the impact of smoking cessation on surgery are limited. The question this article will explore is whether a short-term period of preoperative smoking cessation has an effect on the perioperative and postoperative results in head and neck surgery. The treatment of head and neck cancer requires that surgery be performed within a reasonable period of time after the establishment of diagnosis. As a result, it is not always possible to allow for extended periods of time to be dedicated to programs specifically addressing alcohol and tobacco dependence. Although not focused exclusively on head and neck cancer, a review of the literature concerning the surgical experience with preoperative smoking cessation can provide insight relative to this topic.

The oncologic evidence supporting the need for patients with head and neck cancer to stop smoking after treatment is compelling. The reported incidence of second malignant lesions (synchronous and metachronous) ranges from 5% to 19%.^{6 - 7} In a study by Moore,⁸ 40% of patients who continued to smoke after definitive treatment for an oral cavity malignant tumor experienced a recurrence or developed a second malignant lesion. In addition, continued tobacco use was shown to adversely affect survival after the occurrence of the second cancer. For patients who stopped smoking after treatment, only 6% went on to develop a recurrence.⁶ Induction of specific p53gene mutations within upper aerodigestive tract tumors has been noted in patients with habitual tobacco and alcohol use.^{9 - 10} However, evidence suggests that former smokers, defined as those individuals who had quit smoking more than 10 years prior to diagnosis, demonstrated a p53gene mutation status similar to that of nonsmokers.¹¹

In a large-scale prospective chemoprevention study, Khuri et al¹² noted that active smokers had a higher rate of developing second primary tumors (5.7%) compared with “never smokers” (3.5%). Significantly higher rates of smoking-related second primary tumors (eg, lung, esophagus, and bladder cancers) were also seen in active smokers, with intermediate rates noted in former smokers.

Nicotine dependence treatments have been shown to be more effective in patients with head and neck cancer when initiated at the time of diagnosis and in individuals who undergo surgery as their primary treatment. In a study by Garces et al,¹³ the rate of tobacco abstinence at the Mayo Clinic, Rochester, Minnesota, was 47% for those patients receiving a nicotine dependence consultation within 3 months of the diagnosis of their index cancer. This number fell to 22% when the consultation was performed more than 3 months after diagnosis. Individuals with less severe disease who undergo “less” aggressive treatment have been shown to be more likely to continue posttreatment tobacco use.¹⁴

Multiple articles exist that demonstrate the impact of smoking on the development of postoperative complications. Møller et al¹⁵ examined the impact of smoking on postoperative complications in a study of 811 patients undergoing orthopedic surgery. Smoking was found to be the single most important risk factor for the development of postoperative complications and the need for postoperative intensive care unit (ICU) admission. In those patients requiring a hospitalization of more than 15 days, the proportion of smokers with wound complications was twice that of nonsmokers. Kaplan et al¹⁶ reviewed 126 cases requiring head and neck microvascular reconstruction and assessed the risk factors associated with postoperative hematoma formation. Statistical associations were noted for smoking, nonsteroidal anti-inflammatory drug use, and preoperative corticosteroid use. Additional reports linking smoking status to the development of a postoperative complication with free-flap reconstruction of the head and neck have been published.^{17 - 18}

In a randomized trial using a preoperative smoking intervention program, including counseling and nicotine replacement therapy for 6 to 8 weeks, a significant reduction in postoperative morbidity was seen in patients undergoing hip and knee surgery. The overall complication rate was 18% in the smoking intervention group and 52% in controls. The wound-related complication rate was 5% for the intervention group compared with 31% in controls (P = .001).¹⁹ Other studies have noted that men and individuals with good social support systems are more likely to quit smoking. Additional factors that correlated with a lower rate of wound infection included more than 4 hours of exercise per week and level of education.²⁰

In a study specifically examining the effects of smoking on wound infection, Sørensen et al²¹ randomized subjects to continued smoking, abstinence while using a transdermal nicotine patch (25 mg/d), or abstinence with a placebo patch. A group of individuals classified as never smokers were used as controls. Punch biopsy samples were taken lateral to the sacrum at 1, 4, 8, and 12 weeks after randomization, and all sites were followed for development of wound complications. In smokers, the wound infection rate was 12% compared with 2% in never smokers (P < .05). No difference was found between groups using a transdermal nicotine patch or placebo. Sørensen et al²¹ concluded that smokers have a significantly higher wound infection rate than never smokers and that at 4 weeks of abstinence a reduction in the incidence of wound infection was noted.

Myles et al³ reported on 489 randomly selected patients undergoing ambulatory surgery in which the impact of smoking status on respiratory complications and wound infections was assessed. Smoking status was assessed by self-report and confirmed with end-expired carbon monoxide analysis. Smoking was found to be associated with an increased risk of respiratory complications (adjusted odds ratio [OR], 1.71) and postoperative wound infections (OR, 16.3). Smoking cessation (without a specific timeline or program) was associated with a decreased incidence of laryngospasm and bronchospasm yet was not associated with improvement in other pulmonary parameters (considered secondary long-term smoking-related injury). Obesity was also seen as a risk factor for respiratory and wound complications.

Smoking has been found to be associated with the development of wound infection after colorectal surgery.²² An increased rate of anastomotic dehiscence and microvascular disease has been reported.²³ In patients undergoing face-lift, smokers have 3 times the incidence of wound healing problems and a 12.5-fold chance of experiencing a skin slough postoperatively.²⁴ Smoking status has been reported to be predictive of postmastectomy wound infection, skin flap necrosis, and epidermolysis.²⁵ Platelet-derived nitric oxide release is significantly impaired in long-term smokers and results in augmentation of platelet aggregability,²⁶ yet resolution of this finding is noted with smoking cessation of just 2 weeks.²⁷

In a retrospective analysis of 132 patients who had undergone abdominoplasty, Manassa et al²⁸ reported on the rate of wound dehiscence. Patients were counseled to stop smoking 2 weeks prior to surgery and 2 weeks after; however, 85% of patients continued to smoke until the day of surgery. Postoperatively, 47.9% of smokers showed wound healing issues prior to hospital discharge, whereas only 14.8% of nonsmokers experienced problems. Interestingly, smoking quantity did not affect the incidence of wound healing problems. Smokers who smoked 3 to 9 cigarettes/d had the same risk as those who smoked more than 30 cigarettes/d.

In a retrospective review of 357 patients undergoing spinal fusion, the nonunion rate for smokers was 26.5% compared with 14.2% for nonsmokers. The quantity of cigarettes that a patient smoked and the period of preoperative cessation did not influence nonunion rates. For patients who quit for 6 months after surgery, nonunion and return-to-work rates eventually paralleled those of nonsmokers.²⁹

Nakagawa et al,³⁰ reporting on patients undergoing pulmonary surgery, noted that recent smokers (those who had smoked within 2 to 4 weeks of surgery) had an OR of 2.44 for developing a postoperative pulmonary complication compared with never smokers. This number fell to 1.03 for ex-smokers, described as individuals with cessation for more than 4 weeks prior to surgery. As a result, they advocated a period of preoperative smoking abstinence of at least 4 weeks to reduce the incidence of complications.

A history of long-term smoking carries with it a higher risk of postoperative ICU admission and pulmonary complications.³¹ In a prospective cohort study of general surgery patients admitted for more than 1 day, a smoking history of more than 51 pack-years was associated with ICU admission, lower respiratory tract infection, and in-hospital mortality.³² In a review of the literature by Moores³³ of 8 studies that included over 1700 patients on the incidence of postoperative pulmonary complications (eg, pneumonia, need for mechanical ventilation) associated with smoking, the author concluded that a 6- to 8-week period of smoking cessation prior to surgery was optimal.

In a retrospective study, Tomek and McGuirt³⁴ described 91 patients who had developed a second independent head and neck cancer. Ninety-seven percent of patients were tobacco users. Fifty-four patients were diagnosed as having metachronous lesions, of whom 51 had a history of tobacco use. Twenty-five patients had continued to smoke after diagnosis of their original cancer, whereas 26 had stopped smoking. Of the nonsmokers, one-half of the patients had even ceased tobacco use prior to the diagnosis of their original tumor. The authors³⁴ concluded that no difference existed in the frequency of developing a metachronous tumor in patients who continued to smoke after diagnosis of their index cancer relative to patients who had stopped. They suggested that a critical level of cumulative cellular damage existed for upper aerodigestive tract squamous carcinomas with prolonged tobacco exposure that was irreversible even with smoking cessation. In addition, the authors³⁴ noted that tobacco cessation efforts have the most benefit in individuals with a limited history of tobacco use (and who have yet not developed a tobacco-associated index cancer) compared with those patients with an extensive smoking history.

Current smokers have a 4-fold increased risk of a second aerodigestive tract cancer relative to nonsmokers and former smokers. Risk reduction was significant 5 years after smoking cessation. No reduction in risk was associated with cessation of smoking or drinking at or after the index cancer diagnosis.³⁵

To my knowledge, no study has specifically discounted the merits of smoking cessation on a patient's overall long-term health; however, the impact of perioperative cessation has been questioned. In particular, a study by Hald et al³⁶ using end-expired carbon monoxide and serum cotinine (a metabolite of nicotine) to gauge the effectiveness of pretreatment smoking cessation efforts noted that 50% of self-reported nonsmokers were found to be actively smoking. Such a finding could call into question the results generated in studies that rely on subjective reporting of smoking status without objective quantification.

Postoperatively, smokers deprived of nicotine have been found to require a greater amount of opiates in the first 48 hours after coronary artery bypass graft (CABG).³⁷ Patients who have stopped smoking in the weeks prior to surgery have been noted to have a higher risk of perioperative respiratory complications possibly secondary to a transient increase in sputum production.³⁸ Former smokers have been found to require up to 6 months to regain alveolar macrophage antimicrobial function to the level of nonsmokers.³⁹ Some authors have even shown that ex-smokers with a smoking history of more than 50 pack-years have the same risk of postoperative ICU admission as current smokers with similar smoking histories.³¹

Van Domberg et al⁴⁰ reviewed the effects of smoking cessation in 1041 patients who had undergone CABG surgery. Smoking status was not found to be associated with an increased risk of mortality with the procedure. However, patients who continued to smoke after CABG had a greater long-term death rate and required revascularization procedures more frequently during follow-up.

In a randomized trial of short-term preoperative smoking cessation, Sørensen and Jørgensen⁴¹ examined its effect on wound healing in patients undergoing colorectal surgery. Patients participated in a program 2 to 3 weeks prior to surgery in which they were randomized to abstinence, counseling, and nicotine replacement therapy, or maintenance of daily habit. The median of preoperative abstinence of patients was 15 days (range, 8-24 days). Eighty-nine percent of patients in the intervention group achieved their goal of abstained or reduced consumption. No reduction in the risk of wound healing or other complications was noted.

A history of tobacco use is not considered a risk factor for anastomotic failure after microvascular breast⁴² or oral cavity reconstruction.⁴³ Other authors^{32 ,43} have noted no statistical relationship between smoking status and surgical-site infection or length of hospital stay.

Although the literature on this topic is composed of predominantly retrospective reports on surgical patients within other disciplines, the published experience with smoking cessation does allow some general observations to be made. In the ideal situation, our patients would never start smoking or would quit well before the development of a condition requiring surgery. Although conflicting reports exist within the literature concerning the impact of short-term smoking cessation, it should be noted that the sheer number of articles reporting the negative impact of continued tobacco use on postoperative pulmonary function and wound healing far outweighs those minimizing this impact.

The number of studies examining the perioperative impact of smoking cessation from which to draw conclusions is limited. In an effort to examine the effect of timing of preoperative smoking cessation, Theadom and Cropley⁴⁴ performed a review of the literature and identified 12 prospective cohort trials meeting defined inclusion criteria (such as validation of smoking status, set definitions for smoking cessation, control for confounding variables, etc). The authors⁴⁴ concluded that an optimal period of preoperative cessation could not be defined based on the current available evidence. Despite this finding, several points can be taken from this review as it relates to patient care:

In the field of otolaryngology, the topic of smoking cessation requires additional investigation to better assess the impact on patients undergoing the variety of surgical procedures offered within the field. Pursuing preoperative smoking cessation can be a frustrating practice; however, its importance to the long-term health of our patients should not be underemphasized. The act of scheduling a surgical procedure should be viewed as an excellent opportunity for a patient to address his or her need to stop smoking and allows physicians the opportunity to reevaluate the resources available to their practices to support their patients' goal of cessation. Attempts should be made for patients to pursue true smoking cessation, rather than reduction, as soon as possible to maximize the length of preoperative cessation experienced. For elective procedures, the goal of seeking a minimal period of cessation prior to surgery is possible; however, in patients with a diagnosis of a head and neck cancer requiring surgical intervention this convenience is impractical. In those scenarios, although the impact of short-term (less than 2 weeks) preoperative smoking cessation on the immediate postoperative course may be modest, the long-term cardiopulmonary benefits and the potential decrease in the development of future smoking-related neoplasia with sustained cessation are undeniable.

Correspondence:Richard O. Wein, MD, Department of Otolaryngology–Head and Neck Surgery, Tufts Medical Center, 800 Washington St, Box 850, Boston, MA 02111 (rwein@tuftsmedicalcenter.org).

Submitted for Publication:June 29, 2005; final revision received September 20, 2008; accepted October 30, 2008.

Financial Disclosure:None reported.