Fig. 1 Cigarette smoke contains more than 60 carcinogens, toxins, and poisons in addition to nicotine.
Courtesy of Nam Vo, PhD


Published 3/1/2012
Frank B. Kelly, MD

Ask, Advise, Refer to Improve Surgical Outcomes

Perioperative Smoking Cessation Forum reviews the evidence

It’s becoming increasingly clear that orthopaedic patients who smoke have worse outcomes than those who don’t. The clinical effects of smoking on bone and wound healing include longer times to union, higher rates of nonunion, and higher rates of infection and wound complications.

At the AAOS Now–sponsored Perioperative Smoking Cessation Forum, held in San Francisco just prior to the start of the 2012 AAOS Annual Meeting, experts in the field reviewed the evidence and the steps orthopaedic surgeons can take to reduce smoking among their patients and improve their outcomes.

5,000 chemicals
According to Nam Vo, PhD, assistant professor at the University of Pennsylvania, cigarette smoke contains about 5,000 chemical agents and more than 60 carcinogens, toxins, and poisons such as arsenic, ammonia, methane, butane, and cadmium—in addition to nicotine (
Fig. 1). It is, he said, “the most addictive substance known to man.”

Animal studies mirror the results of smoking seen in humans: delayed healing, reductions in trabecular bone, decreased collagen synthesis, and increased proinflammatory cytokines. Whether these conditions are due to the presence of nicotine or to one or more of the other lethal substances in cigarettes, however, has yet to be determined.

Clinical effects well known
The dangers of smoking on the cardiovascular and pulmonary systems are well known—even among patients. But smokers may not realize the adverse impact of smoking in orthopaedic procedures. Alan Hilibrand, MD, professor of orthopaedic surgery at Jefferson Medical College/Rothman Institute, reviewed several studies that highlighted the effects of smoking on fracture healing, reconstructive procedures, and wound healing.

“Smoking is the only significant predictor of nonunion in open tibial fractures,” said Dr. Hilibrand. “Spinal fusion studies have found higher nonunion rates among smokers, compared to nonsmokers. Patients who quit smoking experience a trend to benefits, but more studies are needed to determine the optimal timing for stopping smoking before surgery and the most effective smoking cessation programs.”

A pediatric problem?
“The first uptick in smoking is at age 12,” said Glenn Rechtine, MD, associate chief of staff and adjunct professor at the University of South Florida, “and may involve cigars or cigarellos. That makes this a concern, that pediatric orthopaedic surgeons should address.”

Dr. Rechtine also noted that women are more vulnerable to nicotine addiction, experience greater negative effects from smoking, and find it more difficult to quit than men. Although genetic factors make some individuals more susceptible to smoking than others, the following may also be contributing factors: multiple military deployments, menthol cigarettes, nocturnal body rhythms, and peer pressure.

A spine surgeon, Dr. Rechtine has refused to perform surgery in patients who smoke. “I tell them that they are not candidates for surgery; it won’t help them,” he explained. Based on a study of more than 5,000 patients, smokers had more pain and showed the least improvement, regardless of the treatment (surgical or nonsurgical).

Patients who quit smoking during treatment not only experienced a greater decrease in pain than those who continued to smoke, but also trended to better results. “I’ve got a 40 percent quit rate among my patients,” said Dr. Rechtine. Simply by asking whether a patient smokes, he notes, an orthopaedic surgeon can increase the chances of that person’s quitting.

The Swedish experience
In Sweden, orthopaedic surgeons have taken a strong stand against smoking. “It’s a matter of patient safety,” said Olle Svensonn, MD, of the Swedish Orthopaedic Association, who led the effort to establish “En RÖkfri Operation,” or “No Smoking Operation.”

Olle Svensonn, MD

“Patients are motivated to quit,” said Dr. Svensonn. “About 80 percent want support from the hospital to change poor lifestyle habits—such as tobacco use, overeating, or excessive drinking—prior to surgery. But to have an effect, the message must be clear and must come from all levels, from the intake person to the nurse to the doctor. Identify smokers immediately and put them on a track to help them stop.”

Fig. 1 Cigarette smoke contains more than 60 carcinogens, toxins, and poisons in addition to nicotine.
Courtesy of Nam Vo, PhD
Swedish hospitals have adopted a program to help surgery patients stop smoking—and have seen their incidence of postoperative complications drop. Prior to surgery, patients who smoke are given individual or group counseling, access to an open “hotline,” and free nicotine replacement therapy (NRT). The goal is for the patient to be smoke-free for a minimum of 6 weeks.

A teachable moment
According to Nancy Rigotti, MD, director of the tobacco research and treatment center at Massachusetts General Hospital, hospitalization presents a “window of opportunity” for smoking cessation. Although quit rates depend on the reason for hospitalization, about one in four patients hospitalized for surgery (other than cardiac surgery) give up cigarettes for at least a year afterward. (Among cardiac patients, the quit rate is 50 percent for up to 5 years after surgery.)

“Hospitalized smokers are accessible for treatment,” said Dr. Rigotti, “and interventions started in the hospital help smokers stay off cigarettes after discharge.” A meta-analysis of various intervention strategies found that bedside counseling followed by telephone support for at least a month after discharge increases the odds of smoking cessation by 65 percent—regardless of the reason for hospital admission. Adding NRT to counseling may improve these rates.

Outpatient care
“Nicotine dependence is in the brain,” said Richard D. Hurt, MD, professor of medicine and director of the Nicotine Dependence Center at Mayo Clinic, Rochester, Minn. The arc of plasma nicotine after just one cigarette, he showed, is steeper than the arc of plasma cocaine after six 50-mg doses of cocaine. As a result, treatment for tobacco dependence must include supportive counseling plus pharmacotherapy.

Dr. Hurt outlined a three-step process to help patients stop smoking.

“First, ask about tobacco use. Have your receptionist ask, your nurse ask, your physician’s assistant ask, and you ask—even if you already know the answer. Asking shows the patient that smoking is a serious problem that must be addressed.

“Then, advise the patient to stop smoking. Don’t just say ‘you know, you ought to consider stopping someday.’ Tell the patient, ‘you need to stop smoking.’

“Finally, because smokers are going to push back, offer help. Refer them for counseling and pharmacotherapy,” he said.

Dr. Hurt noted that each state has a free Quitline (1-800-QUIT-NOW). This free, private, convenient service provides telephone counseling by appointment. Counselors are trained professionals, and using a Quitline can double or even triple an individual’s chances of successfully quitting smoking.

“Tobacco dependence is a serious medical problem,” concluded Dr. Hurt, “and needs to be treated as such. Treatment should involve supportive counseling and pharmacotherapy and should be of sufficient duration to be effective. Longer is better … this is not a strep throat or a urinary tract infection.”

A model for the AAOS?
Finally, David O. Warner, MD, director of the Anesthesia Clinical Research Unit at Mayo Clinic, presented a possible model for the AAOS, based on actions taken by the American Society of Anesthesiologists (ASA). The vision of the ASA Smoking Cessation Initiative is that “every smoker cared for by an anesthesiologist will receive assistance in quitting as an integral part of care.”

“This is a win-win opportunity,” he noted. “Smoking cessation can improve perioperative outcomes, demonstrate to the public that we care about our patients, and increase the lifespans of our patients.”

The initial task force pilot program identified 14 anesthesia practices nationally, with a champion in each practice to promote the Ask-Advise-Refer strategy. The result was an increase in self-reported respondent behavior (Ask-Advise), and increased use of the Quitline by surgical patients (Refer). Subsequent activities included patient and provider websites (, continuing medical education offerings, and a listserv for those interested in perioperative tobacco control.

“Smoking is the most costly and most preventable risk factor in postoperative complications,” he concluded. “Surgery is a teachable moment—one we need to capitalize on.”

Frank B. Kelly, MD, is a member of the AAOS Now editorial board and cochaired the AAOS Now–sponsored Perioperative Smoking Cessation Forum with S. Terry Canale, MD, editor-in-chief of AAOS Now.