Motivations for choosing the practice of medicine vary widely among individuals, but in my experience the common denominator is a desire to improve health. Physicians who want to have maximal long-term impact on their patients’ health need look no further than the most common cause of preventable death and mortality in developed countries: cigarette smoking.1 The efficacy of interventions to help patients quit is beyond dispute, as are the benefits to both individual patients and society.2 As anesthesiologists, we are expanding our scope of practice into many facets of perioperative and postoperative care through models such as the perioperative surgical home.3 Our postoperative horizon cannot be limited to when the patient is initially “out of the woods” from the surgical intervention; we must ensure that every health issue we identify is addressed. It is our duty as physicians, and the responsibility we are advocating as part of our professional scope, to do whatever we can to improve long-term patient outcomes. None of us went into medicine to become operating room technicians. We are physicians. As such, it is our professional responsibility to address our patients’ smoking.
But can we really make a difference? In a current4 and a companion article previously published,5 Lee and colleagues show us that the answer is yes. A relatively straightforward intervention that could be easily implemented in most preoperative settings was efficacious in helping cigarette smokers scheduled for elective surgery to quit, both preoperatively and long-term (at 1 year postoperatively).
There is a voluminous evidence base, well encapsulated in clinical practice guidelines,2 that tobacco use interventions work, that efficacy increases when pharmacotherapy (e.g., nicotine patches) is a part of treatment and when interventions are more intensive (e.g., more contacts with the patient). So how intensive does a perioperative tobacco use intervention need to be? The literature is actually fairly limited. The most recent systematic review examining more and less intensive interventions was based on only 4 studies, all of them relatively small. The authors concluded that there was insufficient evidence that brief perioperative interventions were efficacious and that multiple in-person contacts initiated at least 4 to 8 weeks before surgery are necessary.6 However, in the busy perioperative period, this may not be feasible. The result of Lee et al. is exciting because it suggests that perhaps the “teachable moments” effect of surgery7 augments the efficacy of interventions that are not very intensive.
Lee and colleagues randomized elective surgical patients to receive either standard care (in essence, nothing) or a tobacco use intervention initiated in a preoperative clinic at least 3 weeks before surgery. The intervention included several elements: (1) brief (approximately 15 minutes) counseling by a nurse who had only minimal training in tobacco control (a 1-hour training session), (2) a stop-smoking brochure, (3) a free 6-week supply of nicotine patches, and (4) referral to a free “quitline,” which provided telephone counseling services. This intervention produced a significant increase in abstinence from cigarettes on the morning of surgery (from 4% to 14%). This itself is interesting, but the extraordinary finding is that the abstinence rates at 30 days after surgery were approximately doubled in both groups (11% in the control group and 29% in the intervention group), proportions that were very nearly stable over the first year postoperatively. One year after surgery, 8% of the control group and 25% of the intervention group remained abstinent. This increase almost certainly reflects the power of the teachable moment presented by surgery, changes in behavior triggered by the surgical experience itself that are now well-documented.7 Other studies using relatively intensive interventions have shown similar abstinence rates 1 year after surgery (in the range of 23%–43%),8–10 which rival the best results obtained by dedicated tobacco treatment programs serving the general population.2
What is not clear from the study of Lee et al. is which elements of the intervention may have contributed to efficacy. For example, although about half of patients in the intervention group were contacted by the quitline, only 25% of patients received any counseling from them, and information is not provided regarding quit rates in those who did and did not use the quitline. Similarly, no information is provided regarding utilization of nicotine patches. We know that patch therapy itself can delay relapse to smoking in postoperative surgical patients, even in the absence of any behavioral intervention,11 and that providing free patches increases both utilization of counseling services and quit rates.12 It would have been helpful if both quitline and patch utilization would have been analyzed as potential mediators of treatment effect, which would be of practical importance when considering what it takes to implement the intervention.
However, it may not even matter “which part worked” when the performance of the whole package was so good. After all, none of the intervention elements is particularly difficult to implement. Telephone quitlines are available free of charge to many citizens of countries in the developed world (including all United States residents—1-800-QUITNOW).13 Nicotine patches are inexpensive (with an acquisition cost of approximately $1.50 USD each in my hospital, a 6-week supply is approximately $63, less than rounding error in a typical surgical bill). Stop-smoking brochures specific to surgery are currently available free of charge from the American Society of Anesthesiology. In a “train the trainer” approach, an individual from a practice could undergo a 1-week training as a tobacco treatment specialist,14 then teach others in his or her practice how to deliver brief tobacco interventions such as used by Lee et al.; other training approaches are also possible.
Think about how tobacco interventions in surgical patients could impact overall health. Of the potential study participants assessed, found to be eligible and approached, 43% consented. Similar to previous studies,15 this suggests that many preoperative smokers are quite interested in quitting and amenable to interventions. As a thought experiment (illustrated in Fig. 1), take 1000 smokers scheduled for surgery. Assuming that the results of Lee et al. apply, 430 would be willing to make a quit attempt. Of the 570 not willing and who refuse interventions, assume conservatively that 4% (or 23) would be abstinent at 1 year postoperatively, the approximate overall annual spontaneous quit rate in the population.2 If we did not intervene in the 430 who were willing (the current state in most practices), 8% (or 34) would be abstinent at 1 year. However, if we intervened, 25% (or 108) would be abstinent. Overall, of the 1000 patients, 57 would be abstinent at 1 year if we did not intervene compared with 131 if we did. Thus, our intervention has netted us 74 additional quitters of 1000 smokers scheduled for surgery. With approximately 10 million smokers undergoing surgical procedures in the United States annually,1,16 this rate would translate to 740,000 additional annual quitters. This would represent an enormous contribution of anesthesiologists to the health of the nation.
I would argue that the long-term impact of sustained abstinence demonstrated by this and other studies itself justifies the application of consistent tobacco use interventions in surgical patients. However, there is an additional bonus; perioperative abstinence can reduce perioperative complications.6,17,18 The duration of preoperative abstinence necessary for benefit is not well-defined and likely depends on which complication is examined, although there is some evidence that even just maintaining postoperative abstinence may be of benefit.19 Although Lee et al.5 did show a decrease in postanesthesia care unit stay in patients receiving the intervention, neither their study nor many of the other randomized trials of perioperative tobacco use interventions were powered to examine the effect of interventions on acute perioperative complications that are plausibly related to smoking. Indeed, because the absolute incidence of serious smoking-related complications is fortunately low in elective surgical patients,20 and observational studies show relative risk values in the range of 0.7 to 0.8 for these complications with cessation,17 definitive studies on the efficacy of a given intervention to reduce the acute complications will require large numbers of patients. It is likely that the longer the duration of abstinence, the better. However, even if we cannot initiate tobacco use intervention weeks or months before surgery, this should not prevent us from intervening whenever we can. In the study by Lee et al., the median number of preoperative days without a cigarette in the intervention group was 1.
Systems of perioperative care are heterogeneous. Every anesthesia practice will need to determine how best to embed routine tobacco use interventions into its routine care. We need to move beyond small efficacy studies of tobacco use interventions to widespread implementation and adoption studies to guide clinicians about how best to incorporate such interventions into their practices. However, there is no longer any excuse for not consistently intervening if we truly are perioperative physicians and if we truly care about the long-term health of our patients. The longer we delay, the more our patients will die of tobacco-related diseases.
If concerns about the health of our patients were not enough, there are also new incentives to intervene. The Center for Medicare and Medicaid Services provides separate reimbursement for tobacco use interventions. The Affordable Care Act requires that private insurers cover efficacious preventive services, including tobacco use interventions.21 The American Society of Anesthesiologists House of Delegates has endorsed perioperative smoking abstinence as a metric that is intended to become a Physician Quality Reporting Measure for anesthesiologists. The American Society of Anesthesiologists provides several resources to help those who want to learn more at www.asahq.org/stopsmoking.
Thanks to the work of Lee et al., we now know that a relatively simple, eminently feasible tobacco use intervention works to help surgical patients quit smoking. It is time for all surgical patients entering the perioperative surgical home to receive such interventions as a routine part of their care. All we need are anesthesiologists willing to open the door. Our patients deserve nothing less.
Name: David O. Warner, MD.
Contribution: This author is the sole contributor to this work.
Attestation: David O. Warner approved the final manuscript.
Conflicts of Interest: David O. Warner has received a research grant from Pfizer to develop an online educational module to teach anesthesiology and surgery residents how to help their patients quit smoking.
This manuscript was handled by: Steven L. Shafer, MD.
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