Abstract
Objective
Methods
Results
Conclusion
Keywords
- •Smoking cessation before any type of surgery reduced risks of complications, including wound healing and pulmonary complications.
- •Longer periods of smoking cessation before surgery demonstrated a significantly larger reduction in complications.
- •Meta-analysis of randomized trials showed a relative risk reduction of 41% (95% confidence interval, 15-59, P = .01) for prevention of postoperative complications. This was supported with observational data examining total complications, wound healing, and pulmonary complications.
Materials and Methods
Eligibility Criteria
Study End Points
Search Strategy
Study Selection
Data Collection
Data Analysis
Results
Results of the Literature Search

Characteristics of Included Studies
Methodological Quality of Included Studies
First Author, Year | Report Method of Sequence Generation | Report Efforts to Conceal Allocation | Report Blinding Status of Groups or Researchers | Refusal Rate of Eligible Participants | Intent-to-Treat Analysis | Free of Selective Reporting | Lost to Follow-Up > 20% | Study Funding Source(s) |
---|---|---|---|---|---|---|---|---|
Lindstrom 2008 | + | + | + | 39% | + | + | − | Public, industry provided drug |
Moller 2002 | + | − | − | 28% | + | + | − | Public, industry provided drug |
Myles 2004 | + | + | + | − | + | + | + | Hospital, industry provided drug |
Sorensen 2003 | − | + | + | 25% | + | + | − | Public, industry provided drug |
Sorensen 2007 | − | + | + | 9% | + | + | − | Public, industry |
Warner 2005 | + | _ | + | 4% | + | + | − | Public, industry provided drug |
First Author, Year | Adequate Case/Control/Group Definition? | Potential for Bias in Case/Group Representation | Presence of Controls/Comparison Group? | Comparability among Groups | Ascertainment of Exposure | Cessation Validation Method | Non-Response Rates | Assessment of Outcome | Sufficient Follow-Up for Outcome Occurrence? | Adequacy of Follow-Up (Rates) |
---|---|---|---|---|---|---|---|---|---|---|
Barrera 2005 | Yes | Yes | Yes | PQ were significantly older than NS. | Self-report | Self-report via questionnaire | Not applicable | Independent | Yes | >80% |
Bluman 1998 | Yes | Yes | Yes | CS were significantly younger than PS or NS. | Self-report | Self-report via questionnaire | Not applicable | Independent (medical records) | Yes | >80% |
Chang 2000 | Yes | Yes | Yes | No significant difference among groups. | Not specified | Medical records | Not applicable | Independent (medical records) | Unclear | >80% |
Goodwin 2005 | Yes | Yes | Yes | No major significant demographic differences except for the higher proportion of NS with stage 0 disease. | Self-report | Self-report | Not applicable | Independent (medical records) | Yes | >80% |
Kuri 2005 | Yes | Yes | Yes | NS were more likely to be female, and LQ were significantly younger than EQ. | Self-report | Comparison of 3 self-reports | Not applicable | Independent (medical records), self-reports | Unclear | Unclear |
Levin 2004 | Yes | Yes | Yes; groups were undefined by their percentages relative to sample size | No significant difference among groups in terms of age and gender. | Medical records | Medical records | Not applicable | Independent (medical records) | Yes | >80% |
Mason 2009 | Yes | Yes | Yes | NS were more likely to be female. | Medical records | Medical records | Not applicable | Independent (medical records) | Unclear | >80% |
Myles 2002 | Yes | Yes | Yes | CS were younger than PS or NS. | Self-report | Exhaled air CO | Not applicable | Independent (medical records), self-reports | No | >80% |
Nakagawa 2001 | Yes | Yes | Yes | Similar demographics among groups. | Self-report | Medical records, Self-report | Not applicable | Independent (medical records), self-report | Unclear | >80% |
Padubidri 2001 | Yes | Yes | Yes | TRAM flap surgery was used more in NS, and tissue expander method was used more often in smokers. | Medical records | Medical records | Not applicable | Independent (medical records) | Unclear | >80% |
Sorensen 2005 | Yes | Yes | Yes | Baseline demographics among groups were unreported. | Self-report | Medical records, validated by a second self-report during follow-up | Not applicable | Independent (medical records) | Yes | >80% |
Taber 2009 | Yes | Yes | Yes | CS had 1 y less of education and more alcohol use than other groups. | Self-report | Self-report | Not applicable | Independent (medical records) | Unclear | >80% |
Vaporciyan 2002 | Yes | Yes | Yes | Groups differed significantly in age, sex, and disease type. | Medical records | Medical records | Not applicable | Independent (medical records) | Yes | >80% |
Warner 1984 | Yes | Yes | Yes | Baseline demographics among groups were unreported. | Self-reports, medical records | Medical records | Not applicable | Independent (medical records) | Yes | >80% |
Warner 1989 | Yes | Yes | Yes | Baseline demographics among groups were unreported. | Self-report, medical records | Urinary cotinine analysis | Not applicable | Independent (medical records) | Yes | >80% |
Yamashita 2004 | Yes | Yes | Yes | CS were younger than PS or NS. | Self-report | Self-report | Not applicable | Independent | Yes | >80% |
Meta-analysis of Effectiveness
First Author, Year | Type of Study | Types of Surgery | Intervention and Control Interventions | Sample Size | Male (%) | Mean Age (y) | Cessation Period Defined Clearly? | Cessation Validation Method | Pre-surgery Smoking Cessation Period | Cessation Intervention (and Period Pre-surgery) | Follow-up Period Postsurgery |
---|---|---|---|---|---|---|---|---|---|---|---|
Lindstrom 2008 | RCT | Hernia repair, laparoscopic cholecystectomy, hip/knee prosthesis | IG = 47%; smokers who received an intervention to keep them smoke-free from 4 wk preoperatively to 4 wk postoperatively CG = 53%; smokers who did not receive any such intervention for smoking cessation pre-surgery In per protocol analysis, smokers were grouped as: 1. Smokers who quit ≥ 3 wk preoperatively and 4 wk postoperatively 2. Smokers who quit 1-2 wk preoperatively and 4 wk postoperatively 3. Smokers who continued smoking or only reduced smoking | 102 | 53 | 55 | Yes | Self-report and CO | IG: smoke-free from 4 wk preoperatively to 4 wk postoperatively In per-protocol analysis groups: group 1, ≥3 wk preoperatively and 4 wk postoperatively; group 2, 1-2 wk preoperatively and 4 wk postoperatively; group 3, cessation period undefined | Yes; individual counseling, telephone hotline, and free nicotine substitution (nicotine replacement therapy) for 4 wk pre-surgery | 30 d |
Moller 2002 | RCT | Hip or knee replacement | IG = 52%; defined as smokers who received an intervention to keep them smoke-free or help reduce smoking by 50% from 6-8 wk preoperatively CG = 48%; defined as smokers who did not receive any such intervention for smoking cessation pre-surgery | 108 | 42.6 | 65 | Yes | Exhaled air CO | 6-8 wk pre-surgery and 10 d postsurgery | Yes; information and weekly counseling for 6-8 wk pre-surgery | 4 wk |
Sorensen 2003 | RCT | Colorectal surgery | IG: 47%; defined as smokers who received an intervention to keep them smoke-free or reduce their smoking 2-3 wk pre-surgery and until sutures were removed CG: 53%; defined as smokers who did not receive any such intervention and were asked to maintain their daily smoking habits | 57 | 65 | 65.5 (median) | Yes | Self-report, exhaled air CO; salivary cotinine | IG: advised to be smoke-free or reduced smoking from 2-3 wk pre-surgery | Yes; counseling and nicotine replacement therapy | 30 d |
Sorensen 2007 | RCT | Elective open incisional or inguinal herniotomy | IG: 70%; defined as smokers who received an intervention by means of an advice and reminder to stop smoking at least 1 mo pre-surgery and until sutures were removed CG: 30%; defined as smokers who did not receive any such intervention | 213 | 84.5 | 54.6 (median) | Yes | Self-report, exhaled air CO; salivary cotinine | IG: advised to stop smoking at least 1 mo pre-surgery | Yes; 3 levels: advice only, advice and telephone reminder, advice and reminder and outpatient nicotine substitution demonstration | 3 mo |
Myles 2004 | RCT | General, orthopedic, urologic, ear, nose, throat, faciomaxillary | IG: Bupropion 7 wk before expected surgery (150 mg bid) + 1 telephone counseling. CG: placebo + 1 telephone counseling | 47 | 66 | 45 | Yes | Exhaled air CO | Both groups 7 wk pre-surgery | Bupropion (150 mg bid) | 6 mo |
Warner 2005 | RCT | Orthopaedic, intra-abdominal, spinal, genitourinary, otorhinolaryngologic, gynecologic, other | IG: nicotine patch applied on day of surgery CG: placebo patch | 121 | 48 | 47 | Yes | Exhaled air CO | Both groups, day of surgery | Nicotine patch applied on day of surgery | 1 mo |
First Author, Year | Intensity of Preoperative Smoking Intervention | Definition of Perioperative Complication | Relative Risk (95% CI) for Perioperative Complications |
---|---|---|---|
Lindstrom 2008 | Intensive | Events causing additional medical or surgical treatment or investigation, prolonged hospital stay, unscheduled postoperative checkups within 30 d Any wound complication |
|
Moller 2002 | Intensive | Death or postoperative morbidity requiring treatment within 30 d Wound healing complications |
|
Myles 2004 | Less intensive | Postoperative wound infections | 0.82 (0.06-11.33) |
Sorensen 2003 | Intensive | Adverse events within 30 d requiring medical or surgical intervention | 0.94 (0.51-1.73) |
Sorensen 2007 | Less intense | Postoperative wound infection with swollen or infected wound or medical intervention required at suture removal | 0.71 (0.21-2.41) |
Warner 2005 | Less intensive | Serious postoperative adverse events | 0.86 (0.24-3.03) |


Observational Studies
Risk of Total Postoperative Complications
First Author | Type of Study | Primary Surgery Type | Studied Group According to Smoking Status | Sample Size | Male (%) | Mean Age (y) | Cessation Period Defined Clearly? | Cessation Validation Method | Pre-surgery Smoking Cessation Period | Cessation Intervention (and Period Pre-surgery) | Follow-up Period Postsurgery |
---|---|---|---|---|---|---|---|---|---|---|---|
Barrera 2005 | Cohort | Lung tumor resection/thoracotomy | NS = 21% PS = EQ: defined as those who quit smoking > 2 mo pre-surgery = 62% LQ: defined as those who quit smoking ≤ 2 mo, but > 1 wk pre-surgery = 13% CS = 4% | 300 | 48 | 64 ± 12 | Yes | Self-report via questionnaire | EQ quit smoking for > 2 mo pre-surgery LQ quit smoking for ≤ 2 mo, but > 1 wk pre-surgery | No | 30 d |
Bluman 1998 | Cohort | General, orthopedic, urologic or cardiovascular elective surgery | NS = 20% PS = 46%; defined as those who smoked > 2 wk pre-surgery CS = 34%; defined as those who smoked ≤ 2 wk pre-surgery | 410 | 97 | 59.5 | Yes | Self-report via questionnaire | PS: >2 wk pre-surgery CS: ≤2 wk pre-surgery | No | NR |
Chang 2000 | Cohort | Breast reconstruction with TRAM flaps | NS: 67% PS: defined as those who quit smoking at least 4 wk pre-surgery = 21% CS = 13% | 718 | NR | Not specified | Yes | Medical records | PS: quit smoking at least 4 wk pre-surgery | No | NR |
Goodwin 2005 | Cohort | Tissue expander/implant breast reconstruction | NS = 74% PS = 15%; defined as those who quit smoking > 4 wk pre-surgery CS = 11%; defined as having continued or stopped smoking < 4 wk pre-surgery | 515 | 0 | 47 | Yes | Self-report | PS = stopped smoking > 4 wk pre-surgery CS = continued or stopped smoking < 4 wk pre-surgery | No | 20 mo |
Kuri 2005 | Cohort | Reconstructive head and neck surgery | NS = 21% PS = LQ = 18%; defined as smoking within 8-21 d pre-surgery IQ = 11%; defined as smoking within 22-42 d pre-surgery EQ = 35%; defined as smoking within ≥ 43 d pre-surgery CS = 15%; defined as smoking within 7 d pre-surgery | 188 | 79.8 | 59 | Yes | Comparison of 3 self-reports | LQ: smoking within 8-21 d pre-surgery IQ: smoking within 22-42 d pre-surgery EQ: smoking within 43 d or longer pre-surgery CS = smoking within 7 d pre-surgery | No | NR |
Levin 2004 | Cohort | Onlay bone graft, sinus lift | PS: patients who quit smoking for ≥ 6 mo pre-surgery MS: CS smoking < 10 cigarettes/d and smoking history < 10 y HS: CS smoking > 10 cigarettes/d and smoking history > 10 y Groups were undefined by their percentages relative to sample size | 128 | 33.6 | NR | Yes | Medical records | PS: quit smoking for ≥ 6 mo pre-surgery | No | ≥6 mo postsurgery |
Mason 2009 | Cohort | Lung resections | NS = 21%; defined as never smokers or those who smoked < 100 cigarettes in their lifetime PS: LQ = 5.1%; defined as those who quit smoking for > 14 d to 1 mo pre-surgery IQ = 12%; defined as those who quit 1-12 mo pre-surgery EQ = 50%; defined as those who quit smoking > 12 mo pre-surgery CS = 20%; defined as smoking within 14 d pre-surgery | 7990 | 48.3 | 66 | Yes | Medical records | PS = LQ: quit smoking for > 14 d to 1 mo pre-surgery IQ: quit smoking 1-12 mo pre-surgery EQ: quit smoking > 12 mo pre-surgery CS = smoking within 14 d pre-surgery | No | NR |
Myles 2002 | Cohort | Ambulatory surgery | NS = 35%; defined as never smokers with a COexp of ≤ 10 ppm PS = 24%; defined as those who quit smoking for > 28 d pre-surgery CS = 41%; defined as CS or with COexp of > 10 ppm | 489 | 38 | 39 | Yes | Self-report and CO analysis | PS = quit smoking for > 28 d pre-surgery | No | 7 d |
Nakagawa 2001 | Cohort | Pulmonary surgery | NS = 41% PS = RS = 5%; defined as those who quit smoking 2-4 wk pre-surgery ES = 42%; defined as those who quit smoking for > 4 wk pre-surgery CS = 13%; defined as those who smoked within 2 wk pre-surgery | 288 | 58 | 61.5 | Yes | Medical records, self-report | PS = RS = 2-4 wk pre-surgery ES = >4 wk pre-surgery CS = within 2 wk pre-surgery | No | NR |
Padubidri 2001 | Cohort | Postmastectomy breast reconstruction | NS = 69%; defined as those who had never smoked PS = 10%; defined as previous smokers who quit smoking ≥ 3 wk pre-surgery CS = 21%; defined as those who were still smoking at the time of surgery | 748 | 0 | 49.2 | Yes | Medical records | PS: quit smoking ≥ 3 wk pre-surgery | Yes; quitting smoking was advised during enrolment at clinic | NR |
Sorensen 2005 | Cohort | Elective and emergency laparotomies | NS = 29% PS = 29%; defined as those who previously smoked but quit sometime pre-surgery CS = 42%; defined as those who smoked at time of surgery and at follow-up | 310 | 45.5 | 64.6 (median) | No | Medical records, validated by a second self-report during follow-up | Not specified | No | 33-57 mo |
Taber 2009 | Cohort | Laparoscopic donor nephrectomy | NS = 63%; defined as never smokers PS = 18%; defined as those who previously smoked but quit at least 2 wk pre-surgery CS = 19%; defined as those who smoked up to the surgery day | 221 | 45 | 39 | Yes | Self-report | PS: quit at least 2 wk pre-surgery | No | NR |
Vaporciyan 2002 | Cohort | Pneumonectomy | NS = 13% S = LQ = 23%; defined as persons who quit smoking < 1 mo pre-surgery EQ = 63%; defined as those who quit smoking ≥ 1 mo pre-surgery | 257 | 69.6 | 60 ± 10 (median) | Yes | Medical records | LQ: quit < 1 mo pre-surgery EQ: quit ≥ 1 mo pre-surgery | No | 30 d |
Warner 1984 | Cohort | Coronary artery bypass grafting | NS = 9% CS = 25%; defined as those who never stopped smoking pre-surgery Stopped smoking < 2 wk pre-surgery = 17% Stopped smoking 2-4 wk pre-surgery = 9% Stopped smoking 4-8 wk pre-surgery = 6% Stopped smoking > 8 wk pre-surgery = 35% | 500 | 77 | 58.2 | Yes | Medical records | Group 1: smokers who stopped < 2 wk pre-surgery Group 2: smokers who stopped 2-4 wk pre-surgery Group 3: smokers who stopped 4-8 wk pre-surgery Group 4: smokers who stopped > 8 wk pre-surgery | No | 30 d |
Warner 1989 | Cohort | Coronary artery bypass grafting | NS = 22%; defined as those who had never smoked and assigned a smoke-free day of 150 PS = 69%; defined as previous smokers who quit smoking sometime in the past, and this group includes LQ = 11%, defined as those who quit ≤ 8 wk pre-surgery, EQ = 58%, defined as those who quit > 8 wk pre-surgery, and CS = 9%, defined as those with cotinine levels > 0.5 μg/mL and assigned a smoke-free day of −1 | 192 | 83 | 64 | Yes | Urinary cotinine analysis | Among PS, LQ: quit ≤ 8 wk pre-surgery EQ: quit > 8 wk pre-surgery | No | 1 y (via correspondence) |
Yamashita 2004 | Cohort | Elective minor surgeries | NS = 48%; defined as those who had never smoked PS = 37%; defined as smokers who quit smoking < 2 d pre-surgery CS = 16%; defined as smokers who smoked until 1 d pre-surgery | 1008 | 52.6 | 53 | Yes | Self-report via interview | PS: quit smoking < 2 d pre-surgery CS: quit smoking > 1 d pre-surgery | No | 30 d or until discharge |
First Author | Studied Group According to Smoking Status | Sample Size | Male (%) | Complication Risk/Percentage Risk/Relative Risk/Odds Ratio | Important Findings |
---|---|---|---|---|---|
Barrera 2005 | NS = 21% PS = EQ: defined as those who quit smoking > 2 mo pre-surgery = 62% LQ: defined as those who quit smoking ≤ 2 mo but > 1 wk pre-surgery = 13% CS = 4% | 300 | 48 | % Overall complications and 95% CI NS = 8% (1.24-14.38) PS = 19% (14.1-24.46) CS = 23% (0.18-45.98) % Pneumonia and 95% CI NS = 3% (−1.14 to 7.4) PS = 11% (6.69-14.83) CS = 23% (0.18-45.98) % Atelectasis and 95% CI NS = 0% PS = 5% (2.09-7.77) CS = 0% Mean hospital length of stay (d) NS = 6 PS = 8 CS = 9 | Overall pulmonary complications and pneumonia incidence were higher among CS compared with PS and NS. CS had longer hospital stays than PS and NS. PQ (>2 mo quit time) had fewer complications compared with recent quitters (≤2 mo, >1 wk quit time). |
Bluman 1998 | NS = 20% PS = 46%; defined as smoking > 2 wk pre-surgery CS = 34%; defined as smoking ≤ 2 wk pre-surgery | 410 | 97 | % Any complications and 95% CI NS = 5% (0.22-9.54) PS = 13% (8.04-17.62) CS = 22% (15.15-28.83) % Pulmonary infections and 95% CI NS = 0% PS = 1% (−0.4 to 2.54) CS = 3% (0.1-5.58) % Atelectasis and 95% CI NS = 4% (−0.4 to 7.72) PS = 7% (3.72-11.26) CS = 8% (3.37-12.23) % Hospital readmission for pneumonia and 95% CI NS = 1% (−1.16 to 3.6) PS = 0 CS = 1% (−0.68 to 2.1) % Mortality due to pulmonary disease and 95% CI NS = 0 PS = 1% CS = 1% (−0.51 to 1.57) | Postsurgical pulmonary complication risk was 6× higher in CS compared with NS (OR 5.5, CI, 1.9-16.2). CS who reduced smoking pre-surgery were 7× more likely to develop postsurgical pulmonary complications compared with those who did not reduce smoking. Among those reducing cigarette smoking ≤ 1 mo pre-surgery, those who reduced closest to surgery were at greatest risk of developing complications. |
Chang 2000 | NS: 67% PS: defined as persons who quit smoking at least 4 wk pre-surgery = 21% CS = 13% | 718 | NR | % Overall flap necrosis and 95% CI NS: 22.6% (18.8-26.3) PS: 25.3% (18.4-32.3) CS: 31.1% (21.6-40.7) % Mastectomy skin flap necrosis and 95% CI NS: 9% (6.4-11.6) PS: 10% (5.2-14.8) CS: 18.9% (10.8-27.0) % Flap fat necrosis and 95% CI NS: 6.5% (4.3-8.7) PS: 8.7% (4.2-13.2) CS: 7.8% (2.3-13.3) | PS who quit smoking at least 4 wk pre-surgery have reduced postsurgical complications compared with CS. Smokers with a smoking history of > 10 pack-y were at an increased risk of perioperative complications compared with those with < 10 pack-y. CS were at a higher risk of mastectomy skin flap necrosis than NS. |
Goodwin 2005 | NS = 74% PS = 15%; defined as having stopped smoking > 4 wk pre-surgery CS = 11%; defined as having continued or stopped smoking < 4 wk pre-surgery | 515 | 0 | Comparison is between NS and smokers (CS + PS) % Total complications and 95% CI NS = 15.1% (11.6-18.7) CS = 37.9% (29.6-46.16) % Reconstructive failure and 95% CI NS = 1.6% (0.34-2.86) CS = 5.3% (1.48-9.12) % Skin flap necrosis and 95% CI NS = 6.5% (4.03-8.97) CS = 16.7% (10.31-23.03) % Infection and 95% CI NS = 2.9% (1.22-4.58) CS = 9.1% (4.19-14.01) | Because there was no difference in the overall complication rates in PS and CS (39.7% vs 36.5%), PS were therefore considered as part of CS in the comparisons. In comparison with NS, smokers were 3× more likely to experience a complication postsurgery. A positive relationship was observed between cigarette ppd and overall complications (OR 1.80; 95% CI, 1.00-3.34). A similar relationship also was seen between duration of smoking history and overall complications. |
Kuri 2005 | NS = 21% PS = LQ = 18%; defined as smoking within 8-21 d pre-surgery IQ = 11%; defined as smoking within 22-42 d pre-surgery EQ = 35%; defined as smoking within ≥ 43 d pre-surgery CS = 15%; defined as smoking within 7 d pre-surgery | 188 | 79.8 | % Incidence of impaired wound healing and 95% CI NS: 47.5% (32-63) PS: LQ = 67.6% (52-83) IQ = 55.0% (33-77) EQ = 59.1% (47-71) CS: 85.7% (73-97) Risk of impaired wound healing development (OR and 95% CI) among study groups NS: 0.11 (0.03-0.51) PS: LQ = 0.31 (0.08-1.24) IQ = 0.17 (0.04-0.75) EQ = 0.17 (0.05-0.60) | This study suggests that a 3-wk smoke-free period pre-surgery can reduce the incidence of impaired wound healing among patients undergoing reconstructive head and neck surgery. The data suggest that smoking cessation for ≥ 3 wk before reconstructive head and neck surgery can provide benefits for smokers, regardless of the level of cigarette consumption. |
Levin 2004 | PS: patients who quit smoking for ≥ 6 mo pre-surgery MS: CS smoking < 10 cigarettes/d and smoking history < 10 y HS: CS smoking > 10 cigarettes/d and smoking history > 10 y Groups were undefined by their percentages relative to sample size | 128 | 33.6 | % Total complications and 95% CI (patients with onlay graft) PS: 23.1% (11.63-34.53) CS: 50% (21.71-78.29) % Total complications and 95% CI (patients with sinus lift) PS: 63.3% (49.77-76.77) CS: 66.7% (49.8-83.54) | Compared with PS who had quit smoking for > 6 mo, CS were more likely to experience postoperative complications after onlay graft surgeries. Smoking cessation for > 6 mo can reduce complication risk to similar levels as those of NS. |
Mason 2009 | NS = 21%; defined as never smokers or smoked < 100 cigarettes in their lifetime PS = LQ = 5.1%; defined as persons who quit smoking for > 14 d to 1 mo pre-surgery IQ = 12%; defined as persons who quit 1-12 mo pre-surgery EQ = 50%; defined as persons who quit smoking > 12 mo pre-surgery CS = 20%; defined as smoking within 14 d pre-surgery | 7990 | 48.3 | Hospital mortality rate (OR and 95% CI) NS: 0.39% PS: LQ = 1.7% (4.6 [1.2-18]) IQ = 1.3% (2.6 [0.65-11]) EQ = 1.5% (2.5 [0.82-7.6]) CS: 1.5% (3.5 [1.1-11]) Pulmonary complications (OR and 95% CI) NS: 2.6 PS: LQ = 6.2 (1.6 [0.85-3.1]) IQ = 6.4 (1.5 [0.81-2.8]) EQ = 5.8 (1.3 [0.77-2.2]) CS = 6.9 (1.8 [1.05-3.1]) | Any smoking, past or current, was clearly associated with increased hospital mortality and pulmonary complications. Therefore, surgeons should counsel smokers that risk remains elevated regardless of timing of cessation, but that quitting holds a benefit that improves over time. Smoking seemed to have less of an effect on pulmonary complications compared with mortality. The longer the cessation period, the greater the risk reduction in pulmonary complications. During this study, the authors were unable to identify an optimal interval of smoking cessation. |
Myles 2002 | NS = 35%; defined as never smokers and with a COexp of ≤ 10 ppm PS = 24%; defined as patients who quit smoking for > 28 d pre-surgery CS = 41%; defined as CS or with COexp of > 10 ppm | 489 | 38 | % Any respiratory complication and 95% CI NS: 25.9% (19.47-32.55) PS: 34.5% (25.83-43.13) CS: 33.5% (26.96-40.04) CS vs NS: (adjusted OR 1.71, 95% CI, 1.03-2.84) % wound infections and 95% CI NS: 0.6% (−0.55 to 1.71) PS: 2.6% (−0.3 to 5.48) CS: 3.7% (1.08-6.32) CS vs NS: (adjusted OR: 16.3, 95% CI, 1.58-1.75) | Smokers (PS + CS) had a significantly increased risk of respiratory complication compared with NS. Adjusted OR 1.66 (95% CI, 1.07-2.57) |
Nakagawa 2001 | NS = 41% PS = RS = 5%; defined as patients who quit smoking 2-4 wk pre-surgery ES = 42%; defined as patients who quit smoking for > 4 wk pre-surgery CS = 13%; defined as patients who smoked within 2 wk pre-surgery | 288 | 58 | % Overall incidence of postoperative pulmonary complications and 95% CI NS: 23.9% (16.2-31.66) PS: RS = 53.8% (26.75-80.95) ES = 34.7% (26.23-43.19) CS: 43.2% (27.28-59.2) Adjusted OR and 95% CI CS vs NS: 2.09 (0.83-5.25) RS vs NS: 2.44 (0.67-8.89) ES vs NS: 1.03 (0.47-2.26) | For patients undergoing pulmonary surgery, smoking cessation of at least 4 wk pre-surgery can lower the risk of postoperative pulmonary complications. |
Padubidri 2001 | NS = 69%; defined as persons who had never smoked PS = 10%; defined as previous smokers who quit smoking ≥ 3 wk pre-surgery CS = 21%; defined as those who were still smoking at the time of surgery | 748 | 0 | % Overall complication and 95% CI NS: 25.9% (22.14-29.7) PS: 25% (15.26-34.74) CS: 39.4% (31.66-47.04) % Mastectomy flap necrosis and 95% CI NS: 1.5% (0.49-2.61) PS: 2.6% (−0.97 to 6.23) CS: 7.7% (3.53-11.95) | Patients who are scheduled to undergo breast reconstructions should quit smoking for at least 3 wk pre-surgery. Quitting in this time frame or earlier can lower the complications rate to that observed among NS. |
Sorenson 2005 | NS = 29% PS = 29%; defined as those who previously smoked but quit sometime pre-surgery CS = 42%; defined as those who smoked at time of surgery and at follow-up | 310 | 45.5 | Association of smoking status with incisional hernia (adjusted OR and 95% CI) NS: 1 PS: 1.57 (0.81-3.64) CS: 3.93 (1.82-8.49) | CS are 4× at greater risk of incisional hernia than NS. |
Taber 2009 | NS = 63%; defined as never smokers PS = 18%; defined as those who previously smoked but quit at least 2 wk pre-surgery CS = 19%; defined as those who smoked up to the surgery day | 221 | 45 | Mean hospital length of stay (days ±SD) NS: 2 ± 1 PS: 2 ± 1 CS: 2 ± 1 % Postoperative infection and 95% CI NS: 3% (0.1-5.62) PS: 8% (−0.67-16.05) CS: 5% (−1.68-11.2) | Among patients receiving laparoscopic donor nephrectomies, postoperative outcomes were similar among CS, PS who quit at least 2 wk pre-surgery, and NS. |
Vaporciyan 2002 | NS = 13% S = LQ = 23%; defined as persons who quit smoking < 1 mo pre-surgery EQ = 63%; defined as persons who quit smoking ≥ 1 mo pre-surgery | 257 | 69.6 | % Incidence of major pulmonary events and 95% CI LQ: 21.7% (11.25-32.09) EQ: 9.2% (4.76-13.64) Risk of developing major pulmonary events (OR and 95% CI) LQ vs EQ = 2.70 (1.18-6.17) | Timing of smoking cessation was a predictor of developing major pulmonary events. Smoking within 1 mo of pneumonectomy was strongly associated with the development of major pulmonary events. Patients who quit smoking late (ie, smoked within 1 mo pre-surgery) were 2.7× more likely to develop major pulmonary events compared with those who quit smoking for periods ≥ 1 mo. |
Warner 1984 | NS = 9% CS = 25%; defined as persons who never stopped smoking pre-surgery Stopped smoking < 2 wk pre-surgery = 17% Stopped smoking 2-4 wk pre-surgery = 9% Stopped smoking 4-8 wk pre-surgery = 6% Stopped smoking > 8 wk pre-surgery = 35% | 500 | 77 | % Overall pulmonary problems (NS vs smokers) and 95% CI NS = 11.4% (1.98-20.74) Smokers: 39% (34.56-43.52) % Estimate of incidence of pulmonary complications and 95% CI NS = 11.4% (1.98-20.74) Stopped > 8 wk pre-surgery = 17% (11.45-22.55) Stopped 4-8 wk pre-surgery = 46% (27.54-64.46) Stopped 2-4 wk pre-surgery = 62% (47.66-76.34) Stopped < 2 wk pre-surgery = 57% (46.56-67.72) CS = 48.4% (39.59-57.19) | Among patients undergoing coronary artery bypass grafting, clinical benefit due to smoking cessation was observed only in patients who quit smoking for > 8 wk pre-surgery. Smoking cessation in this period can lower the incidence of postoperative complications to levels comparable to those of NS. Preoperative smoking cessation for < 8 wk does not lower postoperative pulmonary complications. |
Warner 1989 | NS = 22%; defined as persons who never smoked and assigned a smoke-free day of 150 PS = 69%; defined as previous smokers who quit smoking sometime in the past, and this group includes: LQ = 11%; defined as persons who quit smoking ≤ 8 wk pre-surgery EQ = 58%; defined as persons who quit smoking > 8 wk pre-surgery CS = 9%; defined as persons with cotinine levels > 0.5 μg/mL and assigned a smoke-free day of −1 | 192 | 83 | % Incidence of postoperative pulmonary complications and 95% CI NS: 11.9% (2.11-21.69) >6 mo: 11.1% EQ (>8 wk): 14.5% (7.88-20.94) LQ (≤8 wk): 57.1% (35.97-78.31) CS: 33% (11.55-55.11) | Among patients undergoing coronary artery bypass grafting, smoking cessation < 2 mo pre-surgery does not seem to reduce the incidence of postoperative pulmonary complications below that observed in CS. Patients who quit smoking ≤ 2 mo pre-surgery were ∼4× more at risk of developing postoperative pulmonary complications (57.1% vs 14.5%). Smokers who quit > 6 mo pre-surgery had comparable complication rates as NS (11.1% vs 11.9%). |
Yamashita 2004 | NS = 48%; defined as persons who had never smoked PS = 37%; defined as smokers who quit smoking < 2 d pre-surgery CS = 16%; defined as smokers who smoked until 1 d pre-surgery | 1008 | 52.6 | % Intraoperative sputum volume increase and 95% CI NS: 9.4% (6.77-11.99) PS: 17.9% (13.98-21.8) CS: 18.2% (12.24-24.24) Smoke-free period and risk of intraoperative sputum volume increase (RR and 95% CI) Quit < 2 mo pre-surgery PS/CS vs NS: 2.0 (0.9-4.3) Quit < 2 wk pre-surgery PS/CS vs NS: 2.4 (1.2-4.8) % Total postoperative pulmonary complications and 95% CI NS: 1.7% (0.52-2.82) PS: 1.4% (0.18-2.54) CS: 1.9% (−0.23 to 4.01) | In minor surgical patients undergoing general anesthesia, PS and CS were ∼2× more likely to have an increased intraoperative sputum volume than NS. Smoking cessation ≥ 2 mo pre-surgery can lower the risk of intraoperative sputum volume increase. |
Risk of Pulmonary Complications
Risk of Wound-Healing Complications
Length of Hospital Stay
Mortality
Duration of Cessation Period
Discussion
The Health Consequences of Smoking: A Report of the Surgeon General. [Atlanta, Ga.]: Dept. of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; Washington, DC: For sale by the Supt. of Docs., U.S. G.P.O.; 2004.
Conclusions
References
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Article info
Footnotes
Funding: Development of this manuscript was sponsored by Pfizer Ltd, Walton Oaks, Walton-On-The-Hill, Surrey, KT20 7NS, United Kingdom. Edward Mills, Oghenowede Eyawo, and Ping Wu were paid consultants to Pfizer in connection with the development of this manuscript. Jon Ebbert received no compensation. Edward Mills is supported by a Canada Research Chair.
Conflicts of Interest: Edward Mills has consulted to Pfizer Ltd and Merck Shire Dohme in the past. Ping Wu has consulted to Pfizer Ltd in the past. Ian Lockhart and Steven Kelly are employees of Pfizer Ltd. Oghenowede has consulted to Pfizer Ltd in the past. Jon Ebbert has no conflicts of interest.
Authorship: All authors had access to the data and played a role in writing this manuscript.