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.
There are many adverse physiological changes that can result from smoking, changes that can contribute to complications after joint replacement.
The authors of The impact of tobacco use on clinical outcomes and long-term survivorship after anatomic total shoulder arthroplasty explored the effect of smoking status on the outcomes of anatomic shoulder arthroplasty.
Patients were stratified into three cohorts based on their smoking status on the date of their operation: 1) non-smokers (n=78) 2) former smokers (n=49) 3) current smokers (n=16). Nonsmokers were defined as individuals who had never smoked tobacco. Former smokers were defined as individuals who quit smoking tobacco at least one year prior to their index procedure; these individuals had previously smoked at least 0.25 packs per day. Current smokers were defined as individuals who started smoking at least one year prior to surgery and continued to smoke within one year of their surgery (consumption of at least 0.25 packs per day for one year).
Interestingly and importantly at the time of surgery, smokers were younger (51.5 years) than both non-smokers (64.9 years) and former smokers (65.1 years; .
Visual Analog Scale, American Shoulder and Elbow, and Simple Shoulder Test scores were lower for smokers comparatively; these differences did not reach significance with the numbers of patients in this study.
Revision rates were lower in the non-smoking cohort (7.7%) compared to both former (20.4%) and current smokers (37.5%).
Survival curves showed that non-smoker implants lasted longer than those of current smokers.
Some important questions present themselves:
(1) In that current smokers were over a decade younger than former or non-smokers, to what degree is the poorer survivorship for smokers due to patient age or to smoking status (recalling that patients <60 years of age do less well after shoulder arthroplasty)?
(2) To what degree does smoking contribute to the earlier development of arthritis?
(3) Aside from its adverse effect on health, does smoking reveal a tendency to take risks that may jeopardize the longevity of the arthroplasty? See Smokers’ Decision Making: More than Mere Risk Taking: "The fact that smoking is bad for people’s health has become common knowledge, yet a substantial amount of people still smoke. Previous studies that sought to better understand this phenomenon have found that smoking is associated with the tendency to take risk in other areas of life as well. The current paper explores factors that may underlie this tendency. An experimental analysis shows that smokers are more easily tempted by immediate high rewards compared to nonsmokers. Thus the salience of risky alternatives that produce large rewards most of the time can direct smokers to make bad choices even in an abstract situation such as the Iowa Gambling Task (see this link). These findings suggest that the risk taking behavior associated with smoking is not related to the mere pursuit of rewards but rather reflects a tendency to yield to immediate temptation."
A recent systematic review, Smoking cessation prior to total shoulder arthroplasty: A systematic review of outcomes and complications found 24 studies on this topic. The authors concluded that patients who quit smoking at least 1 month preoperatively had improved outcomes compared to current smokers. Current smokers had statistically significant higher pain scores or opioid use. Five studies found increased rates of revision surgery in smokers. Smokers were significantly more likely to have increased rates of surgical, wound, superficial, and deep surgical site complications. The authors recommend a period of four weeks or more of preoperative smoking cessation.
You can support cutting edge shoulder research that is leading to better care for patients with shoulder problems, click on this link.
Follow on twitter: https://twitter.com/shoulderarth
Follow on facebook: click on this link
Follow on facebook: https://www.facebook.com/frederick.matsen
Follow on LinkedIn: https://www.linkedin.com/in/rick-matsen-88b1a8133/
Here are some videos that are of shoulder interest
Shoulder arthritis - what you need to know (see this link).
How to x-ray the shoulder (see this link).
The ream and run procedure (see this link).
The total shoulder arthroplasty (see this link).
The cuff tear arthropathy arthroplasty (see this link).
The reverse total shoulder arthroplasty (see this link).
The smooth and move procedure for irreparable rotator cuff tears (see this link).
Shoulder rehabilitation exercises (see this link).
(1) In that current smokers were over a decade younger than former or non-smokers, to what degree is the poorer survivorship for smokers due to patient age or to smoking status (recalling that patients <60 years of age do less well after shoulder arthroplasty)?
(2) To what degree does smoking contribute to the earlier development of arthritis?
(3) Aside from its adverse effect on health, does smoking reveal a tendency to take risks that may jeopardize the longevity of the arthroplasty? See Smokers’ Decision Making: More than Mere Risk Taking: "The fact that smoking is bad for people’s health has become common knowledge, yet a substantial amount of people still smoke. Previous studies that sought to better understand this phenomenon have found that smoking is associated with the tendency to take risk in other areas of life as well. The current paper explores factors that may underlie this tendency. An experimental analysis shows that smokers are more easily tempted by immediate high rewards compared to nonsmokers. Thus the salience of risky alternatives that produce large rewards most of the time can direct smokers to make bad choices even in an abstract situation such as the Iowa Gambling Task (see this link). These findings suggest that the risk taking behavior associated with smoking is not related to the mere pursuit of rewards but rather reflects a tendency to yield to immediate temptation."
(4) To what degree does smoking cessation reduce the risk? See Smoking Cessation Initiatives in Total Joint Arthroplasty, An Evidence-Based Review. Points from this article follow:
Hospital costs for total joint arthroplasty (TJA) are 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%.
Initiating a smoking cessation program 4 weeks preoperatively is likely adequate to provide clinically meaningful reductions in postoperative complications for smokers following TJA. 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.
How can a surgeon know if the patient has ceased smoking? Smoking status is typically measured by patient self-reporting, Cotinine testing, 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.
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.
Hospital costs for total joint arthroplasty (TJA) are 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%.
Initiating a smoking cessation program 4 weeks preoperatively is likely adequate to provide clinically meaningful reductions in postoperative complications for smokers following TJA. 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.
How can a surgeon know if the patient has ceased smoking? Smoking status is typically measured by patient self-reporting, Cotinine testing, 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.
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.
You can support cutting edge shoulder research that is leading to better care for patients with shoulder problems, click on this link.
Follow on twitter: https://twitter.com/shoulderarth
Follow on facebook: click on this link
Follow on facebook: https://www.facebook.com/frederick.matsen
Follow on LinkedIn: https://www.linkedin.com/in/rick-matsen-88b1a8133/
Here are some videos that are of shoulder interest
Shoulder arthritis - what you need to know (see this link).
How to x-ray the shoulder (see this link).
The ream and run procedure (see this link).
The total shoulder arthroplasty (see this link).
The cuff tear arthropathy arthroplasty (see this link).
The reverse total shoulder arthroplasty (see this link).
The smooth and move procedure for irreparable rotator cuff tears (see this link).
Shoulder rehabilitation exercises (see this link).
