Smoking is the leading cause of preventable death worldwide.1 Cigarette smoking is responsible for more than 480,000 deaths per year in the United States, including more than 41,000 deaths from secondhand smoke exposure.1 People who smoke cigarettes are also at higher risk for developing heart disease, stroke and lung cancer than nonsmokers, and smoking causes worse overall health, increased absenteeism from work and higher need for health care.2 Because an estimated 34.2 million adults in the United States smoke cigarettes,3 health care providers should be prepared to care for patients who smoke. Anesthesia providers in particular should consider the smoking status of their patients, as cigarette use increases the risk of perioperative morbidity and mortality.4 Anesthesiology professionals can take steps before, during and after a procedure to prevent complications in patients who smoke cigarettes.
Preoperative preparation for surgery is extremely important in patients who smoke, and it begins at least eight weeks before a procedure.5 A variety of substances in cigarette smoke incur harm to the cardiovascular, respiratory and gastrointestinal systems.4 Thus, anesthesia providers should always ask their patients about smoking and advise smokers to quit at every visit.6 It is also vital to screen patients who may be involuntarily ingesting tobacco through second-hand or third-hand smoke, as these patients may be subject to similar health issues.5,7,8 A study by Zaballos et al. found that though 75 percent of anesthesiologist participants stated they frequently or almost always advised patients about the health risks of smoking, patients said only 31 percent advised about the health risks of smoking and 23 percent advised patients to quit.9 Evidently, there may be gaps in smoking cessation education before surgery. As quitting smoking is crucial for patients to safely undergo anesthesia, the anesthesia provider is well-positioned to improve short-term surgical outcomes as well as long-term health outcomes.10 The anesthesiology professional should be in contact with the patient for several months before surgery and implement a brief smoking cessation intervention.6 If possible, this preoperative cessation should be accompanied by intensive counseling, pharmacotherapy and follow-ups to increase the likelihood that the patient does not return to smoking.6 For patients who have recently quit smoking, anxiolytic premedication with deep anesthesia should reduce any withdrawal-related problems.5 Overall, preoperative smoking cessation and premedication with anxiolytics are key to providing quality care to patients who smoke.
During a procedure, the anesthesia provider must consider the physiological effects of regular cigarette smoking. According to a paper by Rodrigo, there is evidence that some substances in cigarette smoke interfere with drug metabolism, particularly for muscle relaxants.5 Some studies have also investigated the potentially altered effects of neuromuscular blocks in patients who smoke, with mixed results.4 However, there is no doubt that smokers are at higher risk for cardiovascular disease, as cigarettes have adverse effects on lipid profiles, endothelial injury and atherosclerotic plaque development.4 Woehlck et al. found that patients who smoked up until the time of surgery showed heart rate abnormalities during the procedure.11 Smokers also show respiratory issues, with an increased incidence of cough, breath holding and laryngospasm during surgery.12 According to a study by Schwilk et al., smokers had a much higher risk than nonsmokers of intraoperative events such as re-intubation, laryngospasm, bronchospasm, aspiration, hypoventilation/hypoxemia and others.13 Because smokers have hypersensitive airways, anesthesia providers may need to alter their ventilation practices.4 Indeed, Schwilk et al. also showed that problems with intubation and airway management were common in smokers.13 These respiratory issues extend to children who are exposed to environmental smoke, according to a study by Chiswell and Akram.14 Furthermore, smoking causes an increased incidence of gastrointestinal reflux, which may affect a patient’s risk of aspiration during surgery.4 Clearly, cigarette smoking can put patients at higher risk for intraoperative anesthesia-related complications.
After a procedure, the anesthesia provider should be aware of potential complications that may arise in a patient who smokes. Smokers will need more oxygen therapy and more analgesic drugs,5 such as opioids.4 Though they have a reduced rate of postoperative nausea and vomiting compared to nonsmokers,4 patients who smoke are at higher risk for postoperative pneumonia, cardiac arrest, myocardial infarction and stroke.15 Additionally, several studies show that cigarette smokers have delayed wound and bone healing and higher risk of infection,10,15 which can be somewhat alleviated by preoperative smoking cessation.6 The anesthesia provider’s role includes preventing these postoperative complications and monitoring them if they arise.
Cigarette smoking is a leading cause of morbidity and mortality across the world. It can cause numerous surgery- and anesthesia-related complications in cardiovascular, respiratory and other body systems. The anesthesia provider is well-positioned to help a patient quit smoking before surgery. Anesthesiology professionals will also need to monitor a patient who smokes during and after surgery to prevent health problems or death. Future research should examine the anesthesia provider’s role in helping patients quit smoking permanently.
1. Office on Smoking and Health. Fast Facts. Smoking & Tobacco Use November 15, 2019; https://www.cdc.gov/tobacco/data_statistics/fact_sheets/fast_facts/index.htm.
2. Office on Smoking and Health. Health Effects of Cigarette Smoking. Smoking & Tobacco Use January 17, 2018; https://www.cdc.gov/tobacco/data_statistics/fact_sheets/health_effects/effects_cig_smoking/index.htm.
3. Office on Smoking and Health. Current Cigarette Smoking Among Adults in the United States. Smoking & Tobacco Use November 18, 2019; https://www.cdc.gov/tobacco/data_statistics/fact_sheets/adult_data/cig_smoking/index.htm.
4. Carrick MA, Robson JM, Thomas C. Smoking and anaesthesia. BJA Education. 2019;19(1):1–6.
5. Rodrigo C. The effects of cigarette smoking on anesthesia. Anesthesia Progress. 2000;47(4):143–150.
6. Yousefzadeh A, Chung F, Wong DT, Warner DO, Wong J. Smoking Cessation: The Role of the Anesthesiologist. Anesthesia & Analgesia. 2016;122(5):1311–1320.
7. Tønnesen H, M.D., D.M.Sc. Surgery and Smoking at First and Second Hand: Time to Act. Anesthesiology: The Journal of the American Society of Anesthesiologists. 2011;115(1):1–3.
8. Saha U. Tobacco interventions and anaesthesia: A review. Indian Journal of Anaesthesia. 2009;53(5):618–627.
9. Zaballos M, Canal MI, Martínez R, et al. Preoperative smoking cessation counseling activities of anesthesiologists: A cross-sectional study. BMC Anesthesiology. 2015;15(1):60.
10. Katznelson R, M.D., Beattie WS, M.D., Ph.D., F.R.C.P.C. Perioperative Smoking Risk. Anesthesiology: The Journal of the American Society of Anesthesiologists. 2011;114(4):734–736.
11. Woehlck HJ, Connolly LA, Cinquegrani MP, Dunning MB, 3rd, Hoffmann RG. Acute smoking increases ST depression in humans during general anesthesia. Anesthesia & Analgesia. 1999;89(4):856–860.
12. Grønkjær M, Eliasen M, Skov-Ettrup LS, et al. Preoperative Smoking Status and Postoperative Complications: A Systematic Review and Meta-analysis. Annals of Surgery. 2014;259(1):52–71.
13. Schwilk B, Bothner U, Schraag S, Georgieff M. Perioperative respiratory events in smokers and nonsmokers undergoing general anaesthesia. Acta Anaesthesiologica Scandinavica. 1997;41(3):348–355.
14. Chiswell C, Akram Y. Impact of environmental tobacco smoke exposure on anaesthetic and surgical outcomes in children: A systematic review and meta-analysis. Archives of Disease in Childhood. 2017;102(2):123–130.
15. Turan A, Mascha EJ, Roberman D, et al. Smoking and perioperative outcomes. Anesthesiology. 2011;114(4):837–846.