Smoking in Sweden

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Stopping Smoking Improves Recovery
Anil Gupta Department of Anesthesiology Örebro
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Smoking Deaths
About 20 of all deaths are attributable to
Tobacco
Peto et al. Lancet 1992
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Smoking in Sweden

• Percentage of daily smokers among adults
• (Age 16-84)

2004 USA 23 smokers
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Types of Smokers
Non-smokers
Current smokers/Passive smokers
Ex-smokers
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Tobacco smoke

• gt 3000 chemicals
• gaseous - 80 90 (Nitrogen, O2, CO2)
• particulate - nicotine
• Harmful substances
• Nicotine
• CO
• Oxidant gases
• Polycyclic hydrocarbons

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Risks of Smoking

• Smoking is a known Risk factor for
• Lung cancer
• Bladder cancer
• Chronic obstructive pulmonary disease
• Emphysema
• Hypertension
• Coronary artery disease
• Peripheral vascular disease
• Ulcers
• Asthma

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Pre-existing medical conditions as predictors of
adverse events in day surgery

• 17 638 patients studied, 14 were smokers
• Smoking was associated with a higher risk of
  respiratory complications (OR 3.84)
• Excessive pain was found in 7.4 of smokers
• Cardiovascular complications were found in 2.4
  smokers

Chung et al. BJA 1999
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Smoking and the Cardiovascular system

Effects of Nicotine

• Increase in BP
• Increase in HR
• Increase in SVR

Due to the release of catecholamines from adrenal
meddula 30 min after smoking
Also increases coronary artery vascular
resistance
Myocardial oxygen supply-demand imbalance
Myocardial ischemia
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Smoking and the Cardiovascular system
Effcts of Carbon monoxide (CO)

• Increase in COHb levels lead to a decrease in
  oxygen content
• Shift of the oxygen dissociation curve to the
  left
• Weak, direct negative ionotropic effect on the
  heart

Myocardial oxygen supply-demand imbalance
Myocardial ischemia
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Harmful effects of Recent smoking

• Cardiovascular Complications
• Increased myocardial work
• Decreased oxygen supply
• Coronary vasocontriction
• Increased catecholamine release

Increased concentrations of CO has been
correlated to frequency of ST-depression during
general anaesthesia
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Effect of 12 h smoking fast on COHb

• CO half life of 4-6 h at rest
• (depends on ventilation)
• 12 h smoking fast removes about 87 of CO

COHb Carboxyhemoglobin CO Carbon monoxide
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Pulse oximetry and smoking
Egan and Wong JCA 1992
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Smoking and the Respiratory system

• Irritants in smoke lead to
• Increase in mucous secretion (2 - 6 weeks)
• Increase in viscosity of mucous
• Decrease in ciliary activity (4 - 6 days)
• Small airway narrowing (4 weeks 6 months)
• Decrease in surfactant

Return to normal
Impaired tracheobronchial clearence of secretions
(3 months)
Chronic bronchitis
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Smoking and the Hemostatic system

• Smoking
• Increases Hb
• Increases Red blood cells
• Increases White blood cells
• Increases Platelets and their reactivity

Increased hematocrit and blood viscocity
Increased risk of thrombotic diseases
(NOT deep vein thrombosis)
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Smoking and Perioperative Complications

• Chest complications
• Atelectases
• Pneumonia
• Wound complications
• Delayed healing
• Cardiovascular complications
• Myocardial ischemia

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Perioperative Problems

• Drug metabolism
• Smoking causes induction of liver enzymes
• Benozidiazepine requirements may be greater
• Not a pharmacokinetic effect
• Neuromuscular drugs
• Smoking (nicotine) stimulates ACh receptors
• Effects of N-M blockers vary depending on the
  drug
• Pain and analgesic drugs
• Decreased tolerance to pain more analgesics
• Fentanyl is metabolized quickly not paracetamol

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What is the Evidence that Smoking causes harm?
1. Wound healing
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Compared to Non-smokers A higher risk for wound
infection (OR 16.3)
Myles et al. Anesthesiology 2002
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Conclusion extreme discretion should be
exercised when offering abdominoplasty procedures
to smokers ..
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Wound Healing and Infection

• Reasons
• Nicotine
• Causes cutaneous vasoconstriction, decreasing
  blood supply to tissues
• Decreases proliferation of red blood cells,
• fibroblasts and macrophages
• Increase in platelet aggregation
• Carbon monoxide (CO)
• Decrease in oxygen delivery to tissues
• Shift of O2 dissociation curve to the left
• Inhibition of enzyme system by hydrogen cyanide

Silverstein P. Am J Med 1992
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What is the Evidence that Smoking causes harm?
2. Respiratory complications
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Compared to Non-smokers A higher risk for
coughing, laryngospasm and all respiratory
complications
Myles et al. Anesthesiology 2002
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Respiratory Complications and smoking

• Reasons
• Increase in mucous production, which is thick
• Ciliary dysfunction with difficulty in removal of
  mucous
• Increase in pulmonary epithelial permeability
  leading to increased reactivity
• Small airway narrowing

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Smoking and Respiratory Complications - Children

• Passive smoking

Cotinine is a major metabolite of nicotine and
can be detected in the urine (even during passive
smoking, as in children) Nicotine and cotinine
levels in the urine are consistently higher in
children exposed to environmental smoke
Conclusion
Children exposed to passive smoking had a higher
incidence of respiratory events in the recovery
room
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What is the Evidence that Smoking causes harm?
3. Other complications
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Methods 649 patients underwent hernia repair
(open suture or open mesh) 544 evaluated for
recurrence after 2 yrs Results Smoking
associated significantly and independently with
recurrence compared to non-smoking (OR
2.2). Open sutured repair compared to mesh
repair was the most significant predictor for
recurrence (OR 7.23). Local anesthesia was
associated with a higher recurrence
rate compared to general anesthesia!
Conclusion
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Conclusion A higher incidence of nausea (but not
vomiting) was found in non-smokers compared to
smokers.
Anaesthesia 2000
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What is the Evidence that Smoking causes harm?

• Conclusions
• Smoking increases the risk for
• Wound complications
• Respiratory complications
• Probably ischemia
• Smoking decreases the risk for
• Nausea (but not vomiting)

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Does stopping smoking preoperatively reduce
perioperative complications?
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(Orthopedic surgery)

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Retrospective study !
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4 h after induction of anesthesia Decrease in
antimicrobial function of alveolar macrophages
were 1.5 - 3 times greater in current and former
smokers Increase in expression of cytokines was
2-5 times less in smokers and former smokers
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Anesthesia related Complications

• Increase in secretions (1-2 weeks)
• Laryngospasm
• False SpO2 readings on pulse oximeter (COHb)
• Tachycardia/Hypertension/ST-T
• changes (recent smoking)

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Does stopping smokingpreoperatively reduce
perioperative complications?

• Conclusions
• Reduction in wound-related complications
• Reduction in respiratory complications
• Reduction in anesthesia-related complications
• Reduction in recurrence of hernias

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Consequences of stopping smoking
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• Problems
• Increased cough and sputum production
• Never reported to increase chest complications
• Can be managed by drugs perioperatively
• Nictonine withdrawl results in increased stress
• No increase in psychological stress reported in
  smokers vs. non-smokers (Warner, Anesthesiology
  2004)
• Effects of nicotine withdrawl are not consistent
• If they occur, they can be managed using NRT

Warner DO, AA 2005
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Advise on Stopping Smoking

• 66 physicians do not advise their patients to
  stop smoking
• 56 patients report that they have never been
  told to stop smoking by a physician
• 80 of units in UK had written advise to patients
  to stop smoking before surgery
• 25 advised stopping smoking 12 h before
• 25 advised stopping smoking 1 week before
• 50 advised stop smoking 1-6 weeks before

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Helping patients quit smoking is Teamwork (it is
never someone elses problem!)
Anesth Analg. 2005 Aug101(2)481-7,
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Proven Methods to help Smokers Quit

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• Anesthesiologists
• Ask about tobacco use
• Advise to quit
• Assess willingness to quit
• Assist in quitting
• Arrange follow-up

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Written instructions to Quit Smoking
Warner 2005
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When should one stop smoking?
Conclusions
Miller RD, Anesthesia 2005
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Can these recommendations be followed (in
practice)?

• For elective surgery
• Stop smoking 6-8 weeks before planned surgery by
  surgeons, nurses and councellors
• Stop smoking 12 h before planned surgery by
  Anaesthesiologists
• For cancer surgery (semi-acute)
• Advise to stop smoking as soon as Surgeon plans
  the operation (depends on waiting times)
• Certainly, in all patients, the no smoking rule
  should apply for 12 h before anaesthesia

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Final Conclusions

• Smoking increases the risk for
• Wound infections
• Respiratory events
• Stopping smoking improves outcome
• Reduction in wound-related complications
• Reduction in respiratory complications

Optimal time to stop smoking is gt 6 8 weeks
before planned surgery
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Final Conclusions

• Physicians should play an active role in
  informing patients to stop smoking
• Information of the risks and consequences of
  smoking should be incorporated into the
  preoperative nursing work-up
• Councelling through professionals should be an
  integral part of the operating facility

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Stopping Smoking Improves Outcome
Thank you!