Published 8/1/2019
Terry Stanton

Study Probes Durability of Smoking Cessation for Elective Surgery

Almost half of patients who quit smoking remained nonsmokers after one year

A study appearing in the August 15 issue of the Journal of the AAOS found that among patients who complied with a requirement to quit smoking before elective lower-extremity orthopaedic surgery, 48 percent maintained smoking cessation for at least one year postoperatively.

Of the patients who relapsed, 55 percent stated that they did not resume smoking until at least three months postoperatively, suggesting that the period after surgery may be an important time for intensified smoking cessation counseling.

The study authors noted that smoking tobacco is a risk factor for a variety of complications and adverse outcomes. Smoking cessation before surgery has shown a 40 percent relative risk reduction in total perioperative complications.

“It is well known that smoking is a major risk factor for many diseases, including cardiovascular disease and pulmonary illnesses,” said senior author Jeremy T. Smith, MD, of Brigham and Women’s Hospital. “With respect to orthopaedics, we know that smoking is related to impaired wound healing, infection, nonunion and delayed fracture healing, and prolonged hospitalization. We also know that even short periods of smoking abstinence, as short as three to four weeks in some studies, can reduce operative complication rates.”

In the foot and ankle division at his institution, Dr. Smith said, patients are required to quit smoking prior to elective surgery, and patients are confirmed to be nicotine-free by serum evaluation of nicotine and cotinine. Experience and observation of patients who comply with the requirement have demonstrated that “the anticipation of a successful surgical outcome and relief of the lower-extremity condition seems to serve as a unique motivator to quit smoking,” Dr. Smith said. “On multiple occasions, patients have proudly informed me that they have not returned to smoking since their surgery. In most instances, these individuals had attempted to quit unsuccessfully many times previously. We thus undertook this study to evaluate the impact of required smoking cessation on long-term smoking habits.”


The researchers performed the retrospective cohort study by querying the hospital database to identify all patients who had a normal nicotine/cotinine serum level and subsequently underwent elective lower-extremity orthopaedic surgery between January 2009 and October 2017. Medical records were reviewed to confirm that all patients were smokers who were required to quit by the orthopaedic surgeon before the procedure. The minimum follow-up from time of surgery was one year.

All patients were referred to either a general practitioner or the hospital’s smoking cessation services for assistance with quitting. No specific smoking cessation method was recommended. A period of at least one month was required after cessation before confirmation by a negative serum nicotine/cotinine level (< 3.0 ng/mL), at which point a patient became eligible for surgery.

Attempts were made to contact all patients to inquire about current smoking status and techniques for smoking cessation. The survey consisted of 25 questions (supplemental digital content available at http://links.lww.com/JAAOS/A342), including demographic and medical questions, as well as questions pertaining to smoking history, smoking cessation process, and current smoking status. Descriptive analyses were used to interpret the data.

Of the 36 patients who quit smoking before elective surgery, 23 (eight men and 15 women) completed the survey. (Dr. Smith noted that the small sample size was partly attributed to the low rate of smoking in the Boston region—16 percent by one estimate—where the study was conducted.) The mean time from surgery to completion of the survey was 55 months (range, 12–88 months.) Of the 13 who did not participate in the study, two consented to the study but did not complete the survey, four refused to participate, four could not be contacted, and three were excluded because of death or were currently receiving treatment at another institution.

Table 1 Responses to smoking cessation questions
Reproduced from Smith DA, Mctague MF, Weaver MJ, Smith JT: Durability Of Smoking Cessation For Elective Lower Extremity Orthopaedic Surgery. J AM ACAD ORTHOP SURG 2019. [epub ahead of print]

The median age of the 23 patients was 59 years (range, 29–67 years). Most patients were women (65 percent) and white (87 percent). Of the 23 patients who stopped smoking for surgery, 17 (74 percent) refrained from tobacco use for three months following surgery, and 11 identified as current nonsmokers (48 percent) at the time of follow-up. Of those 11 patients, the median number of quit attempts before success was three (range, 1–20). Eighty-two percent of patients said they were very likely to continue to refrain from smoking. Of the 12 patients who identified as current smokers at the time of follow-up, the median number of quit attempts was four (range, 1–100).

Of the 12 current smokers, the length of time postoperatively before a patient began smoking again was less than a week in one patient, up to three months in six patients, up to six months in two patients, up to a year in one patient, and longer than a year in one patient; one patient did not answer the question regarding timing of relapse. When asked why they started smoking again, 45 percent cited “stress,” 37 percent cited “falling back into the habit,” and 18 percent cited “friends who smoke.” Of the 12 patients who relapsed, 11 (92 percent) had reduced the number of cigarettes they smoked regularly. When asked how likely they were to continue smoking, 64 percent answered likely, 18 percent answered unlikely, and 18 percent answered very unlikely. Of patients who began smoking again, the number of cigarettes smoked preoperatively, sex, age, race, ethnicity, education level, and income level did not influence relapse.

Regarding interaction with the surgeon about smoking, 41 percent of the cohort believed that it did change his or her outlook on smoking (Table 1). All patients were able to recall the doctor advising them to quit smoking, and 61 percent felt that they were given the tools they needed to quit smoking before surgery. Of the nine patients who felt that they were not given the tools needed to quit smoking, three wished they had received more support from the surgeon, two wished they had been told about prescription medication, three did not believe there is a good method to quit, and one did not answer.

Dr. Smith said that he and his coauthors were surprised by the relatively high percentage of patients who did not relapse and start smoking again. “Smoking cessation is enormously difficult, and thus we suspected that most patients would begin smoking again after they healed from their lower-extremity surgery,” he said. “Yet our findings suggest that many patients can maintain smoking abstinence after surgery.”

Multiple benefits

Dr. Smith said that although the study did not specifically evaluate clinical outcomes, “It is likely that smoking cessation will have positive health impacts on surgical outcomes and general health.” Furthermore, “In some ways, inspiring patients to quit smoking may be more impactful on their overall health than our orthopaedic intervention. As physicians, we strive to optimize our patients’ health, and motivating patients to quit smoking, from a personal and public health perspective, can only be a good thing.”

The findings suggest several avenues of additional exploration, Dr. Smith said. “Understanding who relapses, and why, may further inform us about how best to counsel and support patients during postoperative recovery.”

He added, “It would also be informative to evaluate the impact of required smoking cessation on smoking behavior among patients with different orthopaedic conditions and in patients who live in different regions of the country or world. It is possible that smoking pressures—including physiologic and psychosocial pressures—may vary from place to place, and thus strategies for cessation may not be generalizable.”

Dr. Smith’s coauthors of “Durability of Smoking Cessation for Elective Lower Extremity Orthopaedic Surgery” are Danica H. Smith, BA; Michael F. McTague, MPH; and Michael J. Weaver, MD.

Terry Stanton is the senior science writer for AAOS Now. He can be reached at tstanton@aaos.org.