Cigarette smoking is the number one cause of preventable deaths globally. This burden may be significantly reduced through smoking cessation.1–4 Although smoking prevalence is at a historic low in the United States at 18 percent, this number has plateaued.5 We know that health care professionals can positively influence this 18 percent,6,7 but to what extent does this role extend to the cosmetic surgeon?
Examples of negative surgical outcomes in those who smoke are abundant throughout the plastic surgery literature.8–16 Despite the known risks of perioperative cigarette consumption, approximately nine of 10 members of the American Society for Aesthetic Plastic Surgery still perform elective operations on smokers17; however, this number drops significantly when considering operations that require extensive soft-tissue dissection or skin undermining such as rhytidectomy, abdominoplasty, and breast reduction.17 Although the required duration of preoperative smoking cessation varies among surgeons, the majority of American Society for Aesthetic Plastic Surgery members suggest a cessation period of 2 weeks before surgery.17 This has proven difficult to enforce, as many smokers misrepresent their smoking status.18 Urine cotinine tests have been suggested in cases where suspicion of noncompliance is high.9,17,19–21
Given that many plastic surgeons advocate smoking cessation in patients before elective surgery, the preoperative consultation may provide a unique opportunity to promote healthy lifestyle modification and smoking cessation in the long term, especially because patients who smoke may be more likely to undergo cosmetic surgery.22 The success of such a recommendation is still unknown. A few studies have investigated long-term smoking cessation rates following surgery23–27; however, specific to the cosmetic surgery literature, there is currently no research that addresses the long-term smoking cessation rates in this population.
Cosmetic patients are a unique subset of surgical patients, as their operation is neither urgent nor medically necessary, and there may be an underlying psychological motivation to undergo cosmetic surgery for self-improvement. This study was motivated by our belief that the interaction that takes place between the plastic surgeon and the patient during cosmetic surgery is a unique opportunity to promote healthy lifestyle behaviors that may extend beyond the surgical interaction. In this article, we explore long-term smoking cessation patterns and compliance with preoperative smoking instructions in patients from the senior author’s (N.J.C.) cosmetic practice.
PATIENTS AND METHODS
This is a retrospective, cross-sectional cohort study. Patients were included in this study if they self-identified as a smoker at their preoperative consultation and underwent surgery between November of 2006 and December of 2014. Procedures included were those involving significant tissue elevation and undermining: rhytidectomy, abdominoplasty, and mastopexy. In some instances, patients underwent the above procedures in combination with other cosmetic operations such as blepharoplasty, augmentation, and other body contouring procedures.
To be eligible for surgery, all patients were required to refrain from smoking for at least 2 weeks before and 2 weeks after surgery. At the preoperative consultation, patients were advised their operation would be delayed if they continued to smoke. No biochemical confirmation of smoking status was performed. Patients were not given standard smoking cessation interventions but were free to pursue these on their own. Patients were defined as smokers if they admitted to smoking any amount of cigarettes on a daily basis at the time of their initial surgical consultation. Patient records were retrospectively reviewed for age at surgery, date of surgery, sex, medical history, type of surgery, wound complications, and smoking status during their preoperative consultation.
At the time of this study, all patients were contacted by means of e-mail and telephone. An online-survey through FluidSurveys (Ottawa, Ontario, Canada) structured around the World Health Organization’s MONICA project smoking cessation questionnaire,28 in conjunction with questions specific to smoking cessation and cosmetic surgery, was administered to those patients who were successfully contacted. Questions were either binary or multiple-choice format. An online consent was issued to all patients at that time. Patients were given a monetary honorarium for their time.
Descriptive statistics were used throughout the majority of our study. Where appropriate, statistical analysis was performed. The chi-square test was used to test whether an association existed between perioperative compliance and long-term smoking cessation/reduction. The odds ratio was calculated to compare the rate of complications between those compliant and those not compliant with preoperative cessation instructions. A value of p < 0.05 was considered statistically significant.
This study was approved by the Ethics Committee at the University of British Columbia (H12-01374). Consent was obtained by means of e-mail in conjunction with distribution of the online survey.
During the 8-year study period, a total of 85 active smokers underwent the above cosmetic procedures performed by the senior author, and all patients were contacted at long-term follow-up. Average follow-up was 63.3 months, with a range of 21.1 to 158.7 months. Forty-seven patients completed the survey, for a response rate of 55.3 percent. Patient demographic details of those who responded are listed in Table 1. The majority of patients were women (45 of the 47 respondents), with an average age of 40.3 years. Our study population was generally healthy. Two patients had a history of hypertension, three patients had a history of asthma, and six patients had a history of hypothyroidism. The distribution of surgical procedures undergone by the study population is outlined in Table 1. A total of 10 complications in eight patients were present at follow-up (Table 1). At long-term follow-up, 13 patients admitted to continued use of smoking cessation aids, with the majority using a nicotine product (Table 1).
Table 2 describes the daily amount of cigarette consumption and duration in our population before their cosmetic surgery. Five of the respondents did not smoke cigarettes on a daily basis before their surgical consultation and were removed from the analysis, giving us a sample size of 42 daily smokers. Of these 42 daily smokers, 21 smoked one to five cigarettes per day, and the next highest consumption rate was 10 to 15 cigarettes per day (Table 2). As outlined in Table 2, the largest group of respondents smoked cigarettes on a daily basis for 5 to 10 years, and the second largest group smoked cigarettes for greater than 20 years. All except for five patients smoked cigarettes on a daily basis for at least 5 years (Table 2).
Table 3 shows the rate of noncompliance with preoperative smoking cessation requirements. Despite all patients at the time of their surgery stating they had complied with the 2-week preoperative period of cigarette abstinence, when asked at follow-up, 21 of 42 (50.0 percent) admitted they did not quit smoking for the requested time before their operation. Of these, 10 of 42 patients (23.8 percent) continued to smoke cigarettes until the day of their operation. With respect to complications following surgery, five of 21 patients (23.8 percent) in the noncompliant group suffered complications, compared with three of 21 patients (14.3 percent) who were compliant with preoperative cessation instructions (OR, 1.9; 95 percent CI, 0.4 to 9.1; p = 0.44). No patients in the compliant group were diagnosed with infection or wound dehiscence, two patients in the noncompliant group experienced infection and wound dehiscence, and one patient in the noncompliant group was diagnosed with infection of the surgical site.
Table 4 describes the daily amount of cigarette consumption in our population at long-term follow-up. Of the 42 patients who consumed cigarettes on a daily basis before undergoing cosmetic surgery, 17 patients (40.5 percent) are no longer smoking cigarettes on a daily basis at long-term follow-up. Of these 17 patients, 14 (33.3 percent) have not smoked a cigarette within the past month at long-term follow-up, and 10 patients (23.8 percent) have not smoked a cigarette since their operation. The smoking cessation rate within our cosmetic practice at long-term follow-up is within the range of 23.8 to 40.5 percent, depending on the definition of smoking cessation. A total of 24 patients (57.1 percent) reduced their cigarette consumption by any amount (including cessation). One patient (2.4 percent) increased their cigarette consumption at long-term follow-up. We did not find a significant association between long-term smoking cessation/reduction with preoperative smoking cessation instruction compliance (p = 0.45) (Table 3).
We asked patients what motivated them to quit or reduce their smoking consumption. Of the 24 patients who had quit or reduced their cigarette consumption, 17 of 24 (70.8 percent) agreed that discussing the adverse effects of smoking on their surgical outcome influenced their ability to quit or reduce their cigarette consumption, whereas 10 of 24 patients (41.7 percent) were influenced by a discussion about the adverse effects of smoking on their overall health.
The negative effects of smoking on wound healing have become an axiom to plastic surgeons performing elective operations.8–16 This is reflected by the decrease in the number of plastic surgeons willing to perform cosmetic operations requiring extensive soft-tissue dissection on patients who smoke.17 In an attempt to avoid wound healing complications, many surgeons require a cessation rate of 2 weeks before surgery.17 When recommending smoking cessation before cosmetic surgery, there may be an opportunity for the plastic surgeon to promote healthy lifestyle modifications that may extend beyond the perioperative period.
Although information about the smoking cessation rate in all surgical patients is lacking, there is some suggestion that the rate at 12 months postoperatively may be in the range of 4 to 20 percent.23–27 This range may increase to approximately 12 to 37 percent23–27 in patients who are given preoperative smoking interventions. In a 2014 Cochrane Review, significant differences in the smoking cessation rate at 12 months after surgery were seen between control groups and those patients who received more intensive interventions, such as counseling and nicotine replacement therapy.27 The smoking cessation rate in our cosmetic surgical population is between 23.8 and 40.5 percent, depending on the definition of cessation used. These results compare favorably to those reported in the non–cosmetic surgery literature above.23–28 This is consistent with previous research showing that patients who seek cosmetic surgery are more motivated to sustain positive lifestyle changes.29
Physician advice on smoking cessation positively influences a patient’s ability to quit, and supplementation with pharmacotherapy and counseling further increases smoking abstinence.6,7 Our results show that of the patients who successfully quit smoking after surgery, a high percentage stated that they were influenced by the discussion around the negative effects of smoking on their surgical outcome (70.8 percent) compared with the negative effects on their overall health (41.7 percent). This suggests that targeted messaging with specific examples of the negative effects of smoking during smoking cessation counseling is more effective than a description of general cessation benefits, and previous qualitative research has indeed suggested this to be the case.6 Results from this study may therefore suggest that the dialogue between plastic surgeon and patient during the cosmetic surgery consultation serves as a unique moment to provide targeted smoking cessation counseling that may persist well beyond the surgical interaction. When coupled with smoking cessation interventions such as educational brochures with cessation advice, the cosmetic surgery consultation may be a powerful opportunity for intervention.30 Further qualitative research in this area is needed to determine how best to motivate patients to quit smoking during the cosmetic surgery consultation.
The second part of our study investigated compliance with preoperative smoking cessation instructions in our cosmetic population. The noncompliance rate in our cohort was 50 percent (Table 3). This was determined by means of a self-reported online survey, and we did not confirm the results of the survey with biochemical testing on the day of surgery. We did not find a significant association between preoperative smoking cessation compliance and long-term smoking cessation or reduction (Table 3). Noncompliance rates with preoperative smoking recommendations vary throughout the plastic surgery literature.19,20,31 Chan and colleagues studied a population of 65 patients who underwent reduction mammaplasty and found that nearly 80 percent of their patients admitted to not complying with the recommended 4-week preoperative smoking cessation period; they did not perform urine cotinine confirmatory testing.19 Other studies that used urine cotinine confirmatory testing report a lower rate of noncompliance preoperatively.20,31 Reinbold and colleagues studied a population of 76 patients undergoing free tissue transfer and had a 7.9 percent noncompliance rate, confirmed with urine cotinine testing.20 In a population of 362 patients undergoing elective plastic surgery procedures, Coon and colleagues found a noncompliance rate of 4.1 percent, confirmed with urine cotinine testing.31 It is interesting that those studies that used routine urine cotinine testing seem to have dramatically lower rates of noncompliance compared with studies that did not biochemically confirm smoking status. Perhaps this reflects that patients who are aware that they will receive urine confirmatory testing are more willing to comply with preoperative smoking cessation recommendations. When considered in context with the above, our results add to the mounting evidence suggesting that routine urine cotinine testing is effective at increasing compliance with preoperative smoking cessation recommendations.
We asked patients to refrain from smoking for 2 weeks before surgery. There is no evidence in the literature to suggest this duration of cessation reduces wound complications,32–34 despite 2 weeks being the most commonly recommended preoperative smoking cessation duration by plastic surgeons in North America.17 The ideal preoperative smoking cessation period is still unknown, with the majority of studies showing lower complication rates in patients who had quit smoking for at least 4 weeks before surgery.32–34 Our overall complication rate was 19.0 percent (eight of 42), with five of 21 patients (23.8 percent) in the noncompliant group suffering complications compared with three of 21 patients (14.3 percent) who were compliant with the preoperative 2-week cessation period. This difference did not reach statistical significance, suggesting that a 2-week cessation period may not be adequate to reduce the overall complication rate in smokers. Alternatively, it could be that our sample size was not powered for us to observe a significant difference between those who quit for the recommended 2-week cessation period versus those who did not. With respect to wound dehiscence and infection, complications traditionally thought to be more prevalent in smokers,32–34 these events were observed only in patients who were noncompliant with the 2-week preoperative cessation period. Nevertheless, larger prospective studies are needed in this area, and these data do not provide convincing evidence to recommend a preoperative smoking cessation period less than the current evidence-based 4-week duration.32–34
This study was limited by a small sample size and a potential nonresponse bias, as those who stopped smoking may be more willing to respond to communicate their accomplishment. Definitions of cessation vary from study to study23–27 and there is no gold standard. We have reported the cessation rate in our population by providing a range that reflects the range of definitions used in previous studies.23–27 Given the heterogeneity of the definition of smoking cessation among studies and within our own, it is difficult to directly compare our results to those reported in the literature. Our online survey was based on a validated survey,28 but the modifications made to this survey were not validated. These modifications were made because no validated survey tool that fit our research question and study population existed. Ideally, we would have performed biochemical confirmation at long-term follow-up to confirm whether patients were currently smoking, and correlated this with results from our questionnaire. A large number of our patients were not available for biochemical confirmation at long-term follow-up. However, we are encouraged by the fact that there was no significant association between noncompliance and smoking reduction/cessation (p = 0.45) (Table 3). To us, this suggests that the majority of the individuals in our cohort who were less forthcoming about their preoperative smoking status were not included in the group that stated that they had reduced or quit smoking long term. Nevertheless, the cessation rate in this study may still have been inflated for a number of reasons. It is possible that patients in our study falsified their results during the survey out of feeling ashamed or stigmatized about continuing to smoke,6,35 or perhaps patients wanted to maintain a good relationship with their surgeon because they may request future procedures. Further studies are needed in this area.
This study is the first to explore long-term smoking behaviors in a strictly cosmetic population. Our results are the first to show an association between cosmetic surgery and smoking cessation at long-term follow-up. As plastic surgeons performing cosmetic operations requiring extensive soft-tissue dissection, perhaps we should be required to request a period of preoperative smoking cessation, not just for better wound outcomes, but as a major intervention against smoking long term.
This study was funded by a 2016 University of British Columbia Division of Plastic Surgery Academic Research Grant. Amy Nguyen, Tammy Rathbone, Cherysse Cabilin helped contribute with patient contact, follow-up, and reminders for nonresponders.
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