General Surgery Rotation

General Surgery: Tobacco use/dependence

One in five American adults, or about 45.3 million people living in the U.S., smoke cigarettes.

  • After 50 years of steady decline in smoking prevalence, progress has stalled.

Approximately 30 percent of all patients undergoing elective general surgery procedures smoke, which means that an estimated 10 million operations are performed on smokers annually.

  • Smoking within one year of surgery has been associated with increased postoperative complications, increased hospital costs, and higher resource use.
  • Deleterious effects on wound healing also occur and are thought to be related to the nicotine content of conventional tobacco products as well as tobacco substitutes containing nicotine.

Optimally, patients who smoke should stop smoking at least 8 weeks before scheduled surgery.

  • The highest rate of pulmonary complications in 200 patients undergoing CABG was in those who had stopped smoking 1-8 weeks preoperatively.
  • Recent cessation of cigarette smoking may pose a greater risk of pulmonary complication because of the commonly observed increase in cough and sputum production.
  • Patients should abstain from smoking for as long as possible both before and after surgery.
  • Using nicotine gum around the time of surgery is not encouraged.

Smoking cessation before surgery is associated with demonstrable benefits.

  • Short-term cessation results in a measurable reduction in vasoconstriction and irregular heart activity due to an immediate decrease in nicotine.
  • The lack of oxygen to surgical wound sites and increased risk of blood clots are also reversed with short-term smoking cessation.
  • Smoking-related impairment in wound healing and pulmonary function improve within four to eight weeks of smoking cessation.
  • There is no evidence that short-term cessation is harmful perioperatively.

Helping patients quit: 

The best methods for using pharmacotherapy for the surgical patient remain to be determined. If patients are willing to make a quit attempt at least weeks before surgery, bupropion can be used because drug therapy needs to begin 1 to 2 weeks before the quit date.

Perioperative nicotine replacement is controversial

  • Any of several delivery methods for nicotine replacement NRT would be appropriate.
  • If patients are willing to abstain only temporarily or set a quit date coincident with the surgical date, products such as nicotine gum or lozenges may be useful even on the morning of surgery to assist in maintaining the preoperative fast from cigarettes.
  • Data suggest that use of NRT in hospitals is not routinely necessary to treat withdrawal symptoms, but this may be an excellent setting in which to initiate NRT under the guidance of health care providers.

Nicotine replacement therapy (NRT)

Long Acting Short-acting
Patch Gum (Nicorette) Lozenges
Starting on quit day:

  • If >10 cigarettes/d, use the highest dose (21 mg/d) × 6 wk, then 14 mg/d × 2 wk, then 7 mg/d × 2 wk
  • Apply new patch each morning to nonhairy skin site, remove and replace next morning
  • Rotate daily to avoid skin irritation
  • Remove at bedtime to avoid vivid dreams and insomnia, if experienced
  • 4 mg dose recommended for 25+ cigarette/d smokers
  • Chew the gum whenever an urge to smoke arises
  • One piece of gum every 1 ± 2 h × 6 wk, for 3 mo total duration
  • Avoid acidic beverages before and during use (coffee, carbonated beverages)—lowers oral pH causing nicotine to ionize and reducing nicotine absorption
  • Side effects related to vigorous chewing (excess nicotine release)
  • Resembles a “tic-tac,” dissolves rapidly and delivers nicotine more rapidly
  • 4 mg dose for smokers who smoke within 30 min of waking up; 2 mg for all other smokers
  • Similar dosing schedule to gum, maximum 5 lozenges every 6 h or 20/d
  • Place in mouth and dissolves over 30 min, no chewing necessary

Chantix and Bupropion

Chantix (Varenicline)  Bupropion (Zyban SR, Wellbutrin SR)
Partial agonist at α4β2 subunit of the nicotinic acetylcholine receptor

  • Binds to and produces partial stimulation of the α4β2 nicotinic receptor, reducing symptoms of withdrawal
  • Binds to α4β2 subunit with high affinity, blocking nicotine in tobacco smoke from binding to the receptor, reducing the reward aspects of cigarette smoking

Administration:

  • Quit smoking 1 wk after starting medication (stable blood levels achieved)
  • 0.5 mg daily × 3 d, then 0.5 mg BID × 4 d, then 1 mg BID up to 12 Wks
  • Risk of nausea minimized by taking with food and a full glass of water, or by increasing dose
  • Abnormal dreams can be reduced by taking the evening dose of Chantix earlier in the day, lowering the dose or skipping evening dose
Enhances central nervous system noradrenergic and dopaminergic release

  • Safe for use in patients with stable CVD or COPD
  • Good choice for patients concerned about post-cessation weight gain or with comorbid depression
  • Approved for use in pregnancy (first or second line)
  • Safe for adolescents (not first line, limited data)

Administration:

  • Takes 5-7 d to reach steady-state blood levels
  • Start one week prior to quit-date
  • 150 mg/d × 3 d, 150 mg BID thereafter at least 12 wks
Question 1
Patients should quit smoking before surgery for at least which one of the following periods to maximally decrease the risk of postoperative pulmonary complications?
A
1 day
B
1 week
C
2 months
D
6 months
E
1 year
Question 1 Explanation: 
Optimally, patients who smoke should stop smoking at least 8 weeks before scheduled surgery.
Question 2
Smoking does not increase risk for which one of the following postoperative complications?
A
Pneumonia
B
Myocardial ischemia
C
Nausea and vomiting
D
Wound infection
E
Nonunion of fractured bones
Question 2 Explanation: 
Smoking does not increase the risk of postoperative nausea and vomiting but does increase the risk of pneumonia, myocardial ischemia, wound infection and nonunion of fractured bones.
Question 3
Which one of the following messages should not be communicated to smokers scheduled for surgery?
A
They cannot smoke in the surgical facility
Hint:
Patients should not smoke in the surgical facility
B
They should try not to use NRT
C
Most people are free from cigarette cravings immediately after surgery
Hint:
Despite what people think most patients do not have cigarette cravings immediately after surgery
D
Around the time of surgery is a good time to quit smoking permanently
Hint:
This is very true
E
Quitting smoking will help prevent complications after surgery
Hint:
Quitting smoking will definitely help prevent complications after surgery
Question 3 Explanation: 
There is a lot of debate about NRT both preoperatively and postoperatively but the data has demonstrated the benefits of NRT outweigh the risk if replacement therapy helps the patient avoid cigarettes and patients on NRT still show demonstrable benefit in risk reduction.
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