Smoking has been portrayed as being glamorous or macho, leading young people to take it up. Its habit-forming tendency prompts older individuals to continue.
Why should surgeons care? There are many adverse physiological changes that can result from smoking, changes that can contribute to complications after joint replacement as detailed in this review: Smoking Cessation Initiatives in Total Joint Arthroplasty, An Evidence-Based Review
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. Smoking cessation programs instituted prior to TJA have been demonstrated to be cost-effective over both the short and long term. 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.
Several randomized controlled trials have shown that perioperative smoking cessation programs confer short-term quit rates between 40% and 89%.
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.
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.
How can surgeons help?
A recent review gives some guidelines: Addressing Smoking in Musculoskeletal Specialty Care
Physicians who simply advise patients to quit substantially improve cessation rates.
The national Quitline (1-800-QUIT-NOW) connects patients in the United States to free Quitline counseling (coaching, educational resources, and referrals) in all 50 states and has proven efficacy.
Government and private insurance plans in the United States are required to cover the cost of 2 quitting attempts per year, including counseling referrals and medications.
Most patients require multiple quitting attempts to be successful. Counseling and medications can each double or triple the chances of success.
Several biopsychosocial factors that affect orthopaedic outcomes (weight, anxiety, depression, etc.) are also relevant to smoking cessation; management of these factors is thus potentially aggregately advantageous.
Here is a three step approach
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