Faculty Peer Reviewed
Mr. T is a 53-year-old man, with history significant for cholelithiasis. He decides to have an elective cholecystectomy after years of biliary colic. Mr. T is an active smoker and wanted to know if he should stop smoking prior to surgery?
Smoking is associated with adverse outcomes in surgery, however debate continues regarding the safety of perioperative smoking cessation. The current understanding of perioperative smoking cessation follows that smokers who stop smoking close to surgery have a higher risk of pulmonary and overall perioperative surgical complications. Warner et al first described the phenomenon in 1989 when he demonstrated that patients who stopped smoking less than two months prior to surgery had four times as many pulmonary complications compared to patients who stopped smoking for greater than two months. They surmised that the increased complication rate was likely from decreased cough and increased sputum production. [1,3] This prevailing wisdom continued with Smetana who suggested in 1999, ten years later, that smoking cessation must be initiated and continued eight weeks prior to surgery to prevent increased pulmonary complications.  If patients have an increased risk of adverse outcomes as described by Warner et al, would it be prudent to continue smoking if surgery is less than 4 to 8 weeks away? Most physicians would say absolutely not. There is a growing body of literature that is beginning to show that 4 to 8 weeks of smoking abstinence does not increase pulmonary or overall perioperative complication rates in surgical patients. [5,6]
Moller chipped away at the status quo in 2002 and analyzed data from 120 patients who were assigned to a smoking intervention program 6 to 8 weeks prior to surgery or to standard care. The study addressed the question of an ideal time to stop smoking: would 6 weeks be sufficient to show decreased complications? Moller found that smoking cessation 6 to 8 weeks before surgery actually reduced the overall complication rate (52% vs. 18% control). The study also found that pulmonary complications occurred at the same rate for the intervention group compared to the control group (2% vs. 2% control).  Moller also showed a decreased relative risk for any complication (RR 0.34; 95%, CI 0.17-0.58). Subsequently, Sorensen and Jorgensen examined 60 patients who were randomly assigned to either abstinence or continued smoking 2 to 3 weeks prior to surgery. They also found that with even a few weeks of smoking cessation there was no difference between those who stopped smoking and those who continued smoking in pulmonary or overall complication rate. Interestingly, their study group demonstrated 11% pulmonary complications in the intervention group and 16% in the control group.  When the researchers compared both groups for overall surgical complications the intervention group had no significant improvement when compared to the control group (intervention 41% vs. control 43%).  Both of these articles showed that varying lengths of smoking cessation had no difference in pulmonary complications and decreased a risk for overall complications.
Barrera et al in 2005 prospectively studied pulmonary complications in lung cancer patients who underwent thoracotomies. They examined 300 lung cancer patients who were non-smokers, past quitters (>2months prior to surgery), recent quitters (< 2 months prior to surgery), and continuous smokers. The researchers found that the pulmonary complication rate was 19% between recent quitters and 23% in on-going smokers.  When comparing those who stopped smoking 8 weeks before surgery and those who continued to smoke until time of surgery no paradoxical increase in pulmonary complications was found in this study.  Furthermore, they found that independent risk factors for developing pulmonary complications were patients who had lower predicted DLCO (OR 1.42; 95% CI 1.17-1.70), smoking more than 60 pack years (OR 2.54; 95% CI 1.28-5.04), and primary lung cancer (OR 3.94; 95% CI 1.34-11.59).  Barrera provided further evidence that smoking cessation demonstrated no increased risk when comparing patients who continued to smoke and those who stopped smoking less than 8 weeks prior to surgery. Unfortunately, the patients who were recent smokers had high variation in the length of smoking cessation in the study.
More recently, Lindstrom et al published a small, multi-center, randomized control trial showing that smoking cessation prior to surgery reduces any postoperative complications. The researchers examined outcomes of 117 general and orthopedic surgical patients in a 4 week pre-operative period. The intervention group received intensive smoking cessation with the goal of abstinence, while the control group received the standard of care including neutral and general information about the harms of smoking. The researchers’ main outcome was any postoperative complication within 30 days. They demonstrated a relative risk reduction of 0.51 (95%, CI 0.27-0.97) of any postoperative complication with only 4 weeks of smoking cessation. They recorded no pulmonary complications in the intervention group and only one pulmonary complication in the control group. Furthermore, they established a number needed to treat (NNT) of 5 (95%; CI 3-40).  In 2010, Moller studied breast cancer patients who required surgery in less than 4 weeks. Researchers examined 130 patients were assigned to either brief intervention or standard care. Patients in the brief intervention arm had 2 days preoperative to 10 days postoperative of smoking abstinence. The researchers showed that postoperative complications between those patients who stopped smoking and those patients who continued were similar with a relative risk of 1.00 (95%; CI 0.75-1.33). They concluded that brief cessations are not of clinical relevance.  Again, conclusions were based upon a short follow up period and different types of surgery.
The Cochrane Review subsequently examined a series of eight clinical trials for the effect of smoking cessation programs upon pulmonary and overall complications.  They found that several studies showed no difference or even possibly reduced rates of pulmonary complications. [6,7,9,11] The authors of the review concluded that perioperative intervention 4 to 8 weeks prior to surgery with nicotine replacement therapy (NRT) is supported by evidence and likely to reduce any complication (RR 0.70; 95% CI 0.56-0.88). 
Another recent systematic review and meta-analysis in the Archives of Internal Medicine examined nine studies that compared surgical patients who recently quit smoking and those who continued smoking. The meta-analysis showed no difference between quitting within 8 weeks before surgery compared to continued smoking for any perioperative complication (RR 0.78; 95% CI 0.57-1.07).  The researchers did further analysis with studies that validated self-abstinence from smoking and showed that the trend favored recent quitters, however, no significant difference was seen between those patients who continued to smoke and recent quitters (RR 0.57; 95% CI, 0.16-2.01).  Interestingly, when researchers looked at four studies that examined pulmonary complications they saw a trend that favored higher risk in recent quitters, but the relative risk crossed 1 (1.18; 95% CI 0.95-1.46).  This trend can be explained by the increased weight placed on Warner’s research (80.76%) compared to other studies that showed no difference between quitters and smokers.  The authors also suggest that certain surgeries or patient populations could be at higher risk for pulmonary complications. However, in aggregate, the evidence shows no difference between those who stopped smoking compared to those who continued to smoke. A limitation noted by the authors was that the category of recent quitters consisted of significant heterogeneity, in that the category included patients who stopped smoking anywhere from 2 days to 8 weeks prior to surgery. They also noted that only three studies validated abstinence with urinary cotinine testing or exhaled carbon monoxide reading, lending higher quality to these studies.  And the meta-analysis found that two studies showed increased cough reflex in those who stopped smoking and two studies showed decreased cough reflex in those who stopped smoking. In other words, there is no satisfactory conclusion for the assumption that decreased cough reflex causes pulmonary complications. 
Conclusions reached by both observational studies, randomized control trials, and meta-analyses suggest that smoking cessation does not increase pulmonary or perioperative complications, and it may reduce complications four weeks prior to surgery. Moreover, a short period of cessation prior to surgery showed no significant changes in clinical outcomes.  Ideally, patients should stop smoking 8 weeks prior to surgery, but if not possible, cessation of smoking 4-8 weeks prior to surgery will not adversely affect pulmonary and perioperative complications contrary to conclusions established by Warner. [2,10]Certain prospective and randomized controlled trials suggest that even 4 weeks of smoking cessation may decrease pulmonary and any perioperative complications. [7,9,11] The limitations of many of these studies include small sample sizes, limitation to single centers or if multi-centered regionally isolated to Europe, limited follow-up, as well as the significant heterogeneity in amount of smoking, time to surgery, and type of surgery across studies. Broader studies will need to be performed to examine the ideal time to stop smoking, with standardized complications and types of surgeries. Multi-center and multi-national studies must be performed to increase the generalizability of conclusions.
Mr. T stops smoking 4 weeks prior to surgery and aside from issues with post-surgical pain control does very well. The patient decides to continue with his smoking abstinence and is smoke-free to this day.
1. Smoking cessation 4 to 8 weeks prior to surgery carries no significant difference compared to the continuation of smoking until surgery, with respect to pulmonary or any post-operative complications. Emerging evidence suggests that smoking cessation may actually reduce postoperative complications. [7,8]
2. Pulmonary Function Tests and amount of smoking may better predict pulmonary complications in smokers. 
3. Further research should be completed to determine the ideal time to stop smoking prior to surgery, but even brief episodes of smoking cessation may be beneficial for the patient. [10,11]
Dr. Benjamin Wu is a 2nd year resident at NYU Langone Medical Center
Peer Reviewed by Nishay Chitkara, MD, Medicine (Pulmonary) at NYU Langone Medical Center
Image courtesy of Wikimedia Commons
1. Warner MA, Offord KP, Warner ME, Lennon RL, Conover MA, 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 Clin Proc. 1989 Jun;64(6):609-16. http://www.ncbi.nlm.nih.gov/pubmed/2787456
2. Smetana GW. “Preoperative pulmonary evaluation.” N Engl J Med. 1999 Mar 25;340(12):937-44. http://www.ncbi.nlm.nih.gov/pubmed/10089188
3. Myers K, Hajek P, Hinds C, McRobbie H. Stopping Smoking Shortly Before Surgery and Postoperative Complications: A Systematic Review and Meta-analysis. Arch Intern Med. 2011 Mar 14. [Epub ahead of print, cited 2011, March 22]
4. Warner DO.Perioperative abstinence from cigarettes: physiologic and clinical consequences. Anesthesiology. 2006 Feb;104(2):356-67. http://www.ncbi.nlm.nih.gov/pubmed/16436857
5. Johnson RG, Arozullah AM, Neumayer L, Henderson WG, Hosokawa P, Khuri SF. “Multivariable predictors of postoperative respiratory failure after general and vascular surgery: results from the patient safety in surgery study.” J Am Coll Surg. 2007 Jun;204(6):1188-98. http://www.ncbi.nlm.nih.gov/pubmed/17544077
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7. Sørensen LT, Jørgensen T. “Short-term pre-operative smoking cessation intervention does not affect postoperative complications in colorectal surgery: a randomized clinical trial.” Colorectal Dis. 2003 Jul;5(4):347-52. http://www.ncbi.nlm.nih.gov/pubmed/12814414
8. Barrera R, Shi W, Amar D, Thaler HT, Gabovich N, Bains MS, White DA. Smoking and timing of cessation: impact on pulmonary complications after thoracotomy. Chest. 2005 Jun;127(6):1977-83. http://www.ncbi.nlm.nih.gov/pubmed/15947310
9. Lindström D et al. “Effects of a perioperative smoking cessation intervention on postoperative complications: a randomized trial.” Ann Surg. 2008 Nov;248(5):739-45. http://www.ncbi.nlm.nih.gov/pubmed/18948800
10. Thomsen T, Tønnesen H, Okholm M, Kroman N, Maibom A, Sauerberg ML, Møller AM. “Brief smoking cessation intervention in relation to breast cancer surgery: a randomized controlled trial.” Nicotine Tob Res. 2010 Nov;12(11):1118-24. http://www.ncbi.nlm.nih.gov/pubmed/20855414
11. Thomsen T, Villebro N, Møller AM.Interventions for preoperative smoking cessation.Cochrane Database Syst Rev. 2010 Jul 7;(7):CD002294. http://www.ncbi.nlm.nih.gov/pubmed/20614429