Download PDF( 43 kB)

The Australian and New Zealand College of Anaesthetists recognises that tobacco smoking is addictive and can damage both the health of smokers and those passively exposed to tobacco smoke. The College supports all measures to decrease tobacco consumption and involuntary exposure to tobacco smoke (i.e. passive smoking).

Some adverse effects of smoking are considerably lessened following cessation of smoking.⁽¹⁾ These benefits are particularly relevant in the perioperative period.

1.   Smoking increases the blood concentration of carboxyhaemoglobin. This has an average elimination half-life of four hours ⁽²⁾ and therefore abstinence of only 12 hours will greatly reduce carboxyhaemoglobin concentrations, improve oxygen content and availability, and reverse negative inotropic and arrhythmic effects on the heart. Smokers’ polycythaemia, increased blood viscosity, increased fibrinogen and hypercoaguable state take a few days to two weeks to reverse.⁽⁴⁾

2.   Nicotine increases heart rate, myocardial contractility, blood pressure and peripheral vasoconstriction.^(3-5) These adverse effects generally improve following 12 - 24 hours of abstinence.⁽⁶⁾

3.   In the respiratory system, smoking causes hypersecretion of mucus, impairment of tracheobronchial clearance and small airways narrowing, and smokers have an increased incidence of postoperative respiratory problems⁽⁷⁾. Smokers have a greater tendency to develop hypoxia in the postoperative recovery period.⁽⁸⁾ If smoking is stopped, sputum production initially increases for 1-2 weeks and then declines over the next month. Compared to nonsmoking patients, production of purulent sputum in the postoperative period is 50% higher in patients who stopped smoking < 8 weeks prior to surgery, 25% higher in those who ceased to smoke > 8 weeks prior to surgery, and no different to nonsmokers if cessation of smoking occurred > 6 months prior to surgery.^(9,10) Small airways function improves after one month, with further improvements up to six months.⁽¹¹⁾ The three times higher incidence of chest infection and other pulmonary complications in smokers following coronary artery surgery is reduced to nonsmoking levels if smoking is stopped two months preoperatively, but increased to five times higher incidence if smoking is only ceased for less than eight weeks preoperatively.^(9,12) There is also evidence of increased respiratory complications during and after general anaesthesia in children exposed to environmental tobacco smoke.⁽¹³⁾

4.   Smoking may adversely affect immune mechanisms.^(14,15) Decreased levels of immunoglobulins and cells involved in the immune response in smokers apparently return to normal following a six month period of abstinence.

5.   Perioperative analgesic requirements are increased in smokers.^(16,17) This may be due to withdrawal of endogenous opioid stimulation, or increased enzyme induction which improves 6 - 8 weeks after cessation of smoking⁽¹⁸⁾.

6.   Surgical wound complication rates are higher in smokers⁽¹⁹⁾, particularly following plastic and reconstructive surgery,^(20,21) bone surgery^(22,23), bowel surgery⁽²⁴⁾ and microsurgery⁽²⁵⁾. Smoking has adverse effects on the microcirculation⁽²⁶⁾ that may impair wound healing.⁽²⁷⁾

CONCLUSION

Tobacco smoking is an identifiable major risk factor relating to surgery and the perioperative period.

Patients who smoke should be encouraged to stop smoking at least six to eight weeks before surgery. In the short term, smoking should not be permitted 12 hours before surgery.

The College supports all reasonable measures to reduce tobacco use in the community.

REFERENCES

1.   Warner D.O.
Helping surgical patients quit smoking: why, when and how.
Anaesthesia and Analgesia 2005; 101: 481-487

2.   Lawther P.J. and Commins B.T.
Cigarette smoking and exposure to carbon monoxide.
Annals of the New York Academy of Science 1970; 174: 135-147

3.   Benowitz N.L. and Gourlay S.G.
Cardiovascular toxicity of nicotine: implications for nicotinic replacement therapy.
Journal of the American College of Cardiology 1997; 29: 1422-1431

4.   Feher M.D., Rampling M.W., Brown J., Robinson R., Richmond W., Cholerton S., Bain B.J. and Sever P.S.
Acute changes in atherogenic and thrombogenic factors with cessation of smoking.
Journal of the Royal Society of Medicine 1990; 83: 146-148

5.   Roth G.M. and Shick R.M.
The cardiovascular effects of smoking with special reference to hypertension.
Annals of the New York Academy of Science 1970; 90: 308-316

6.   Rode A. and Shephard R.J.
The influence of cigarette smoking upon the oxygen cost of breathing in near-maximal exercise.
Medicine and Science in Sports and Exercise 1971; 3: 51-55

7.   Bluman L.G., Mosca L., Newman N. and Simon D.G.
Preoperative smoking habits and postoperative pulmonary complications.
Chest 1998; 113: 883-889

8.   Tait A.R., Kyff J.V., Crider B., Santibhavank V., Learned D. and FinchJ.S.
Changes in arterial oxygen saturation in cigarette smokers following general anaesthesia.
Canadian Journal Anaesthesia 1990; 37(4 Pt 1): 423-428

9.   Warner M.A., Offord K.P., Lennon R.L., Conover M.A. and Jansson‑Schumacher, U.
Role of preoperative cessation of smoking and other factors in postoperative pulmonary complications: a blinded prospective study of coronary artery bypass patients.
Mayo Clinic Proc. 1989; 64: 609-616

10.   Mitchell C., Garrahy P. and Peake P.
Postoperative respiratory morbidity: identification of risk factors.
Australian and New Zealand Journal of Surgery 1982; 52: 203-209

11.   Buist A.S., Sexton G.J., Nagy J.M. and Ross B.B.
The effect of smoking cessation and modification on lung function.
American Review of Respiratory Disease 1976; 114: 115-122

12.   Moller J.T., Wittrup M. and Johansen S.H.
Hypoxemia in the postanesthesia care unit: an observer study.
Anesthesiology 1990; 73: 890-895

13.   Skolnick, E.T, Vomvolakis, M.A., Buck, K.A. and Mannino, S.F.
Exposure to environmental tobacco smoke and the risk of adverse respiratory events in children receiving general anesthesia
Anesthesiology 1998; 88: 1144-53

14.   Sopori M.L., Goud N.S. and Kaplan A.M.
Effect of tobacco smoke on the immune system.
In Dean J.H., Luster A.E., Kimer M. editors of Immunotoxicology and Immunopharmacology.
Raven Press: New York 1994: 413-432

15.   Sopori M.L., Kozak W., Savage S.M., Geng Y., Sosxynski D., Kluger M.J. Perryman E.K. and Snow G.E.
Effect of nicotine on the immune system: possible regulation of immune responses by central and peripheral mechanisms.
Psychoneuroendocrinology 1998; 23: 189-204

16.   Woodside J.R.
Female smokers have increased postoperative narcotic requirements.
Journal of Addiction Disease 2000; 19: 1-10

17.   Creekmore F.M., Lugo R.A. and Weiland J.
Postoperative opiate analgesia requirements of smokers and nonsmokers.
Annals of Pharmacotherapy 2004; 38: 949-953

18.   Hart P., Farrell G.C., Cooksley W.G.E. and Powell L.W.
Enhanced drug metabolism in cigarette smokers.
British Medical Journal 1976; 2: 147-149

19.   Silverstein P.
Smoking and wound healing.
American Journal of Medicine 1992; 93 (Suppl 1A): 225-245

20.   Netscher D.T., Wigoda P., Thornby J., Yip B. and Rappaport N.
The Hemodynamic and Hematologic Effects of Cigarette Smoking versus a Nicotine Patch
Plastic and Reconstructive Surgery 1995 September; 96: 681-688

21.   Selber J.C., Kurichi J.E., Vega S.J., Sonnad S.S. and Serletti J.M.
Risk factors and complications in free TRAM flap breast reconstruction.
Annals of Plastic Surgery 2006; 56: 492-497

22.   Furr A.M., Schweinfurth J.M. and May W.L.
Factors associated with long-term complications after repair of mandibular fractures.
Laryngoscope 2006; 116: 427-430

23.   Haverstock B.D. and Mandracchia V.J.
Cigarette smoking and bone healing: implications in foot and ankle surgery.
Journal of Foot and Ankle Surgery 1998; 37: 69-74

24.   Sorensen L.T., Jorgensen T., Kirkeby L.T. Skovdal J., Vennits B. and Wille-Jorgensen P.
Smoking and alcohol abuse are major risk factors for anastomotic leakage in colorectal surgery.
British Journal of Surgery 1999; 86: 927-931

25.   Reus W.F., Colen L.B. and Straker D.J.
Tobacco smoking and complications in elective microsurgery.
Plastic and Reconstructive Surgery 1992; 89: 490-494

26.   van Adrichem L.N.A., Hovius S.E.R., and van der Meulem J.C.
Acute effects of cigarette smoking on microcirculation of the thumb.
British Journal of Plastic Surgery 1992; 45: 9-11

27.   Jones J.K. and Triplett R.G.
The relationship of cigarette smoking to impaired wound healing: A review of evidence and implications for patients care.
Journal Oral and Maxillofacial Surgery 1992; 50: 237-240

COLLEGE PROFESSIONAL DOCUMENTS

College Professional Documents are progressively being coded as follows:

TE Training and Educational

EX Examinations

PS Professional Standards

T Technical

POLICY - defined as 'a course of action adopted and pursued by the College'. These are matters coming within the authority and control of the College.

RECOMMENDATIONS - defined as 'advisable courses of action'.

GUIDELINES - defined as 'a document offering advice'. These may be clinical (in which case they will eventually be evidence-based), or non-clinical.

STATEMENTS - defined as 'a communication setting out information'.

This document is intended to apply wherever anaesthesia is administered.

This document has been prepared having regard to general circumstances, and it is the responsibility of the practitioner to have express regard to the particular circumstances of each case, and the application of this document in each case.

Professional documents are reviewed from time to time, and it is the responsibility of the practitioner to ensure that the practitioner has obtained the current version. Professional documents have been prepared having regard to the information available at the time of their preparation, and the practitioner should therefore have regard to any information, research or material which may have been published or become available subsequently.

Whilst the College endeavours to ensure that professional documents are as current as possible at the time of their preparation, it takes no responsibility for matters arising from changed circumstances or information or material which may have become available subsequently.

Promulgated: 1986

Reviewed: 1991, 1996, 2001

Date of current document: Feb 2007

© This document is copyright and cannot be reproduced in whole or in part without prior permission.

College Website: http://www.anzca.edu.au/