Is There an Optimal Timing for Smoking Cessation?

INTRODUCTION

Cigarette smoking is the number-one cause of avoidable death within the United States. Thirty-four million Americans smoke cigarettes and half of them will die of this, contributing 480,000 deaths annually. Medical costs attributable to smoking in the United States are estimated at $170 billion per year. Passive smoking is also harmful and begins in utero with the premature birth of small babies, which can affect development later in life. Children whose relatives smoke have more respiratory symptoms and disease, including in the perioperative period. Finally, adult passive smoking exacerbates many diseases, including heart disease, and is estimated to cause around 50,000 deaths annually in the United States.

In recent years, many smokers have migrated from tobacco to e-cigarettes. These electrically powered devices vaporize liquid for inhalation and normally contain nicotine. Referred to as vaping, the habit is believed to be safer than smoking and may have a role in facilitating smoking cessation. A 2020 Cochrane review found that more people achieve smoking cessation using nicotine-containing e-cigarettes than using other forms of nicotine replacement therapy (NRT). Patients were followed up for 2 years during which there was no clear evidence of harm, but the long-term safety profile of vaping remains uncertain.

At present there is little information regarding the perioperative use of e-cigarettes. It is unknown if vaping reduces perioperative complications compared with traditional cigarettes. The risks of vaping depend on the chemical composition of the vapor, which may include irritants and carcinogens. Given that the overall risks associated with vaping are believed to be less than smoking, it would be expected to cause less perioperative morbidity, but there is a paucity of evidence for this. There is also limited evidence regarding the efficacy of e-cigarettes for preoperative use, with a pilot trial demonstrating comparable quit rates between NRT and e-cigarettes.

RELATIONSHIP BETWEEN SMOKING AND PERIOPERATIVE COMPLICATIONS

The first observational study of postoperative pulmonary complications (PPCs) and smoking was published in 1944 and reported that in patients having abdominal surgery, smokers were six times more likely to develop a PPC, a significant effect considering that in this cohort 88% of men but only 14% of women were smokers. Since then, statistical evidence of worse perioperative outcomes has continued to accumulate. A meta-analysis involving 533,602 patients found preoperative smoking to be associated with an increased risk for complications, including general morbidity, wound complications, infections, PPCs, neurologic complications, and admission to intensive care. Several other complications were not found to be associated, including mortality and cardiovascular complications.

Intraoperative complications are frequent in smokers. In one study, events such as laryngospasm, bronchospasm, hypoventilation, and reintubation occurred in 5.5% of smokers compared with 3.1% of nonsmokers. Smoking was also identified as an independent predictor of bronchospasm in a randomized trial of anesthetic agents.