Current practices were assessed by using a series of questions based on recommendations for brief interventions in the primary care setting (4) (Table 3). Approximately 90% of both anesthesiologists and surgeons reported almost always asking their patients whether they smoke cigarettes; this proportion was less for other forms of tobacco use. Only 30% of anesthesiologists and 58% of surgeons almost always advise their patients who use tobacco to quit. The minority of respondents provided assistance with attempts at quitting or arranged follow-up.
Strong majorities of both groups believed that prolonged (>6 mo) abstinence would be beneficial to postoperative outcome and that patients should refrain from smoking for as long as possible (Table 4). However, the benefit of a shorter period of abstinence (≤30 days) was less certain; only 52% of anesthesiologists and 70% of surgeons agreed or strongly agreed that a shorter duration of abstinence would be beneficial. Opinions were divided regarding the possibility of nicotine withdrawal symptoms complicating the perioperative course.
Most respondents agreed that they were responsible for advising their patients to quit and that the perioperative period was an opportune time for patients to stop smoking permanently (Table 4). However, a lesser proportion believed that they were responsible for actually helping them to quit, with more surgeons (60%) than anesthesiologists (20%) agreeing or strongly agreeing with this sentiment.
Only approximately 40% of respondents knew that nicotine patches are available without a prescription or that there are nonnicotine medications available to assist with quitting (Table 5). Approximately 35% agreed that nicotine-replacement therapy was safe to use during surgery; approximately 60% agreed that it was safe to use after surgery. Most did not know whether physician reimbursement was available for tobacco-use intervention in these patients.
Approximately 40% of respondents believed that interventions in general were not very effective (Table 5). Forty-four percent of anesthesiologists, but only 17% of surgeons, agreed that preoperative advice to quit would not be effective. Only 16% of anesthesiologists and 48% of surgeons believed they had sufficient time to counsel their patients regarding tobacco use.
Considerable numbers of both groups reported deficits in knowledge regarding how to help their patients achieve tobacco abstinence (Table 6). Approximately half of respondents expressed interest in learning more about interventions, and approximately 40% would be willing to attend a workshop to do so. Most would spend an extra 5 min before surgery to deliver an effective intervention, and almost all would refer smokers to an effective intervention service if it were readily available in their practice setting.
For almost every question, the practices, attitudes, and beliefs of general surgeons were overall more favorable to interventions than those of anesthesiologists. Results did not depend on years in practice (≤10 vs >10 yr) or practice setting (academic versus private settings) (data not shown), with the exception that surgeons in private practice were more likely to be interested in learning more about interventions than were their colleagues in academic practice.
Almost all survey respondents reported asking their patients whether they smoked cigarettes—this is similar to the reported practices of primary care physicians such as general internists and family practitio-ners (6). However, relatively few consistently counseled patients about how to stop. The reported frequency of counseling was less than noted in prior surveys of primary care physicians (6). Other studies have also noted that the frequency of counseling is less in surgical subspecialists compared with primary care physicians (7,8). Although most general surgeons believed that intervention was their responsibility, few anesthesiologists agreed. This belief persisted despite recognition of the adverse effects of smoking on perioperative outcome and the acknowledgment that the perioperative period is an opportune time to promote permanent smoking abstinence. A similar dichotomy between beliefs and practice has been noted in other studies of physician interventions for tobacco use (9).
Given the demonstrated effectiveness of even brief physician intervention in promoting smoking abstinence (5), considerable attention has been directed toward encouraging primary care physicians to provide such interventions, given their frequent contact with smokers (4). However, smokers also have contact with other physicians in diverse settings. In 1996, approximately 40 million visits occurred for surgical and diagnostic procedures in the United States (10). Al-though surgical rates in cigarette smokers are not known, simple estimates suggest that millions of smokers undergo surgical procedures annually. There is currently no consistent approach to helping surgical patients manage their tobacco dependence, and formal intervention programs for smoking are usually not part of standard surgical care. Our data suggest several reasons for this relatively infrequent intervention by anesthesiologists and surgeons, as well as possible steps to improve it.
First, physicians are more likely to address smoking behaviors when patients are seen for an illness recognized as related to smoking (11,12. Although the need for a surgical procedure is often linked to chronic tobacco use, there may not be a direct connection, or it may not be appreciated in many patients. Although most physicians recognize the long-term health benefits of smoking cessation, the effects of smoking on immediate postoperative outcomes may not be as well appreciated. This may affect the physician’s motivation to intervene. This study demonstrated that appreciation for the perioperative risks of smoking was greater in general surgeons than anesthesiologists, and general surgeons were more likely to report providing interventions. It is probably not coincidental that the volume of published surgical literature regarding tobacco use is largest for the subspecialties of reconstructive orthopedic, plastic, cardiac, and oral surgery, in which the consequences of continued smoking on surgical outcome are perhaps best recognized (2,13,14). Further research on postoperative morbidity directly related to smoking could increase physician motivation to intervene.
Second, the duration of preoperative abstinence needed to affect postoperative outcomes is often unclear. For example, some have interpreted a prior study by Warner et al. (15) as suggesting that the rate of postoperative pulmonary complications is increased in patients who quit smoking within eight weeks of cardiac surgery compared with those who continue smoking. However, this difference was not statistically significant, and these authors did not conclude that recent preoperative abstinence increased risk, but rather that the full benefits of smoking cessation may require longer periods than previously reported (15). This study may contribute to the uncertainty regarding the efficacy of short-term abstinence expressed by the anesthesiologists, although we agree with a review of postoperative pulmonary complications that recommends preoperative abstinence regardless of timing (16). Better studies defining the optimal duration of preoperative abstinence necessary to achieve improved early postoperative outcomes may strengthen the motivation to intervene if relatively brief abstinence improves postoperative outcomes.
Third, physicians who believe that smoking interventions can be effective will be more likely to offer such interventions (17). Consistent with this idea, anesthesiologists were more likely to believe that interventions would not be effective and were less likely to offer them compared with surgeons. Although overwhelming evidence shows that interventions are effective in multiple settings (5), relatively few efforts have been targeted to the hospitalized surgical patient (18) (compared with hospitalized patients in general) (17). No studies have addressed patients undergoing ambulatory surgery. Some studies have questioned the safety of nicotine-replacement therapy in the perioperative period, on the basis of the effects of nicotine (given in doses far larger than those achieved with nicotine-replacement therapy) on wound and bone healing in animal models (19,20). Although counterbalancing clinical data suggest the safety of nicotine replacement in this setting (21), the issue may not be resolved in the minds of many physicians. Further studies confirming the safety and effectiveness of pharmacologic interventions such as nicotine-replacement therapy in the perioperative period need to be performed. Designing strategies tailored to the surgical patient and demonstrating their efficacy could increase enthusiasm for offering such interventions.
Finally, it is apparent that many respondents are not familiar with available interventions (4). For example, a minority of respondents knew that nicotine patches are available without a prescription. Many respondents indicated that they do not know how to intervene effectively with tobacco users. This knowledge deficit may reflect a lack of training, because issues of tobacco use are still largely ignored in medical schools and in residency programs for these specialists. In addition, no formal requirements or suggested policies related to tobacco intervention are mandated by national educational regulatory committees for these specialties.
We also identified factors that auger well for future involvement of general surgeons and anesthesiologists in tobacco interventions. Few respondents were current smokers, and this is consistent with trends in physician smoking behavior in the United States (22). This factor, which is an important determinant of intervention implementation in other countries with more frequent rates of physician smoking (23), should not impede smoking interventions in this country. Many respondents indicated a willingness both to learn more about intervention strategies and to implement them in their practices if such interventions were relatively brief. This interest was not limited to physicians at any particular stage of their careers, because responses were similar regardless of the number of years in practice. Surgeons in general reported more concern with issues related to smoking compared with anesthesiologists. Several factors may contribute to this difference, including 1) the more direct concern of surgeons regarding how smoking affects their handiwork, 2) more patient contact before and after surgery that may permit more time to address tobacco-related issues, and 3) the role that many surgeons play in providing some aspects of primary care to their patients, a role not shared by most anesthesiologists.
Educating surgical subspecialists is only one component of a strategy to provide tobacco interventions to surgical patients. There is strong evidence that provider education, combined with health system changes such as provider reminder systems, are highly effective in increasing the rates of intervention and cessation (5). Such systems can be as simple as adding stickers to patient charts to ensure that smoking status is documented. Given the time pressures associated with modern practice and the trend toward ambulatory surgery, which is often associated with limited preoperative patient contact by anesthesiologists, there are very real challenges in implementing tobacco interventions. Ideally, interventions performed by surgeons and anesthesiologists should be one component of a comprehensive approach that includes collaborations with other health care providers. However, if such health system changes are to be implemented, surgical specialists must understand the relevance to their practice and must be enthusiastic proponents of and participants in the system change.
Surveys have important limitations. Survey response rates have been declining over time, and our response rate was within the range reported in other recent physician surveys (24), including those of anesthesiologists (25). However, this relatively small response rate introduces the possibility of response bias if those physicians most interested in tobacco use issues were more likely to respond. Thus, the survey may actually overestimate such interest in a general population of these specialists. There also may be recall bias on the part of the respondents. For example, although surveys indicate that up to 98% of physicians report routinely recording smoking status (6) and although most report routinely counseling patients to quit, actual contemporaneous assessment of practice shows that only approximately two thirds of primary care physicians identify patients’ smoking status and that only approximately one quarter actually provide counseling (11). Thus, physicians may overestimate the actual frequency of their implementation efforts. If our observations represent an overestimate of physician interest and recall, then our conclusion that there is a major opportunity for improving smoking cessation interventions in this practice setting is further strengthened.
In summary, the results of this survey can provide guidance in establishing critical research and education agendas that could improve the delivery of tobacco interventions in the surgical patient. Evidence-based educational programs need to be implemented that address the gaps in knowledge and skills identified in this survey. Combining education with changes in health care systems that promote tobacco interventions could have a major effect on both immediate perioperative morbidity and the long-term health of a large and currently undertreated population of tobacco users.
The authors acknowledge Susanna Stevens for her excellent assistance with statistical analysis and Janet Beckman for her superb secretarial help.
1. Egan TD, Wong KC. Perioperative smoking cessation and anesthesia: a review. J Clin Anesth 1992;4:63–72.
2. Moller AM, Villebro N, Pedersen T, Tonnesen H. Effect of preoperative smoking intervention on postoperative complications: a randomised clinical trial. Lancet 2002;359:114–7.
3. McBride CM, Emmons KM, Lipkus IM. Understanding the potential of teachable moments: the case of smoking cessation. Health Educ Res 2003;18:156–70.
4. A clinical practice guideline for treating tobacco use and dependence: a US Public Health Service report—the Tobacco Use and Dependence Clinical Practice Guideline Panel, Staff, and Consortium Representatives. JAMA 2000;283:3244–54.
5. Hopkins DP, Briss PA, Ricard CJ, et al. Reviews of evidence regarding interventions to reduce tobacco use and exposure to environmental tobacco smoke. Am J Prev Med 2001;20:16–66.
6. Wechsler H, Levine S, Idelson RK, et al. The physician's role in health promotion revisited: a survey of primary care practitioners. N Engl J Med 1996;334:996–8.
7. Goldberg RJ, Ockene IS, Ockene JK, et al. Physicians' attitudes and reported practices toward smoking intervention. J Cancer Educ 1993;8:133–9.
8. Easton A, Husten C, Elon L, et al. Non-primary care physicians and smoking cessation counseling: Women Physicians' Health Study. Women Health 2001;34:15–29.
9. Cummings SR, Stein MJ, Hansen B, et al. Smoking counseling and preventive medicine: a survey of internists in private practices and a health maintenance organization. Arch Intern Med 1989;149:345–9.
10. Hall MJ, Lawrence L. Ambulatory surgery in the United States, 1996. Adv Data 1998:1–16.
11. Thorndike AN, Rigotti NA, Stafford RS, Singer DE. National patterns in the treatment of smokers by physicians. JAMA 1998;279:604–8.
12. Frank E, Winkleby MA, Altman DG, et al. Predictors of physician's smoking cessation advice. JAMA 1991;266:3139–44.
13. Kwiatkowski TC, Hanley EN Jr, Ramp WK. Cigarette smoking and its orthopedic consequences. Am J Orthop 1996;25:590–7.
14. Rohrich RJ, Coberly DM, Krueger JK, Brown SA. Planning elective operations on patients who smoke: survey of North American plastic surgeons. Plast Reconstr Surg 2002;109:350–5.
15. Warner MA, Offord KP, Warner ME, et al. Role of preoperative cessation of smoking and other factors in postoperative pulmonary complications: a blinded prospective study of coronary artery bypass patients. Mayo Clin Proc 1989;64:609–16.
16. Moores LK. Smoking and postoperative pulmonary complications: an evidence-based review of the recent literature. Clin Chest Med 2000;21:139–46.
17. Goldstein MG, DePue J, Kazura A, Niaura R. Models for provider-patient interaction: applications to health behavior change. In: Shumaker SA, Schron E, Ockene J, eds. Handbook of health behavior change. New York: Springer 1998:85–113.
18. Simon JA, Solkowitz SN, Carmody TP, Browner WS. Smoking cessation after surgery: a randomized trial. Arch Intern Med 1997;157:1371–6.
19. Campanile G, Hautmann G, Lotti T. Cigarette smoking, wound healing, and face-lift. Clin Dermatol 1998;16:575–8.
20. Wing KJ, Fisher CG, O'Connell JX, Wing PC. Stopping nicotine exposure before surgery: the effect on spinal fusion in a rabbit model. Spine 2000;25:30–4.
21. Fulcher SM, Koman LA, Smith BP, et al. The effect of transdermal nicotine on digital perfusion in reformed habitual smokers. J Hand Surg 1998;23:792–9.
22. Nelson DE, Giovino GA, Emont SL, et al. Trends in cigarette smoking among US physicians and nurses. JAMA 1994;271:1273–5.
23. Ohida T, Sakurai H, Mochizuki Y, et al. Smoking prevalence and attitudes toward smoking among Japanese physicians. JAMA 2001;285:2643–8.
24. Kellerman SE, Herold J. Physician response to surveys: a review of the literature. Am J Prev Med 2001;20:61–7.
© 2004 International Anesthesia Research Society
25. Nuttall GA, Stehling LC, Beighley CM, et al. Current transfusion practices of members of the American Society of Anesthesiologists: a survey. Anesthesiology 2003;99:1433–43.