Smoking Cessation Initiatives in Total Joint Arthroplasty, An Evidence-Based Review
There are many adverse physiological changes that can result from smoking, changes that can contribute to complications after joint replacement.
Smoking is a well-established risk factor for postoperative complications such as delayed wound healing, infections, and early revision following total joint arthroplasty. Such complications can be costly to treat, with hospital costs for TJA being about $5,000 higher for smokers compared with nonsmokers. Currently, smoking cessation programs are the only intervention demonstrated to reproducibly improve outcomes for smokers undergoing TJA. Several randomized controlled trials have shown that perioperative smoking cessation programs confer short-term quit rates between 40% and 89%.
These authors conducted a review of the literature regarding smoking cessation and its effects of total joint arthroplasty outcomes. Their bullet point conclusions are:
» As smoking increases the risk of adverse events and leads to increased hospital costs following total joint arthroplasty (TJA), many institutions have introduced perioperative smoking cessation initiatives. Although such programs have been demonstrated to improve outcomes for smokers undergoing TJA, the optimal approach, duration, and timing of smoking cessation models have not been well-defined.
» Overall, initiating a smoking cessation program 4 weeks preoperatively is likely adequate to provide clinically meaningful reductions in postoperative complications for smokers following TJA, although longer periods of cessation should be encouraged if feasible.
» Patients brought in for emergency surgical treatment who cannot participate in a preoperative intervention may still benefit from an intervention instituted in the immediate postoperative period.
» Cotinine testing may provide some benefit for encouraging successful smoking cessation and validating self-reported smoking status, although its utility is limited by its short half-life. Further study is needed to determine the value of other measures of cessation such as carbon monoxide breath testing.
» Smoking cessation programs instituted prior to TJA have been demonstrated to be cost-effective over both the short and long term.
Here are a few other questions they considered:
(1)How long a period of abstinence is needed? The evidence is that 2 to 6 weeks of abstinence would be necessary to reduce the incidence of infection, 3 to 4 weeks to reduce wound-related complications, and 6 to 8 weeks to reduce pulmonary complications. Longer periods of smoking cessation decreased the rate of postoperative complications further, with each week of cessation increasing the magnitude of the effect.
(2) How can a surgeon know if the patient has ceased smoking? Smoking status is typically measured by patient self-reporting, cotinine tests, or CO breath testing. One study found that self-reporting was accurate 97% of the time while others found that 20% falsely reported abstinence. Cotinine is the major metabolite of nicotine and may be measured in the urine or saliva using immunoassay-based test strips. It has a half-life of 7 to 14 hours. CO breath tests measure the concentration of CO in expired air. Breath CO is a good indicator of recent smoking, but it has a half-life of only 2 to 3 hours and usually becomes undetectable around 24 hours after smoking cessation.
(3) What are the other benefits of smoking cessation? Smoking adds approximately $100 billion in annual direct health-care costs annually. Thus smoking cessation programs can provide even further potential value if abstinence from smoking is maintained. Additionally, it has been observed that smoking cessation programs encourage other positive lifestyle changes such as improved exercise, eating, and drinking habits, which can further contribute to improved patient health and decreased costs.
(4) What if smoking cessation cannot be achieved before surgery (e.g. in trauma cases)? If a preoperative intervention cannot be implemented (as in the case of emergency surgery), smokers should still be offered a smoking cessation intervention during postoperative hospitalization, as a reduction in postoperative complications may still be attainable.
Comment: This is an informative article that makes a good case for smoking cessation in individuals considering joint replacement.
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