Surgical complications are much more likely in smokers

By Dr. Liji Thomas, MDJan 21 2020

A new study shows that smoking tobacco puts you at a greatly increased risk for complications after surgery. This includes heart and lung damage, poor wound healing and a higher chance of complications. However, quitting smoking, even as late as 4 weeks before the surgery, improves the chances of having a good post-operative result and fewer complications.

Anesthesia is also likely to be less complicated in smokers who have quit compared to those who are still smoking. In fact, even children who breathe in second-hand smoke have a higher frequency of lung complications after anesthesia.

Image Credit: Sruilk / Shutterstock

The relevance

Not less than 1.1 billion people in the world smoke at present, with about 370 people using smokeless tobacco in addition to the above figure. However, for decades smoking tobacco has been known to create health problems involving the heart, the blood vessels, and the lungs. In fact, smoking alone caused almost 12% of all deaths in 2015.

Surgical treatment is required by about 190 million to 280 million people every year, for injuries, illnesses or infections. Surgical complications such as wound infections, lung complications and cardiac events are known to occur at a far higher rate than in non-smokers. These events occur at a rate of 4% to 16% of surgical procedures. Death and disability following surgery occur in 1% of cases in developed countries, but in up to 10% of cases in developing countries.

The post-surgical period is one in which the body is both recovering from injury and is stressed. Inflammation occurs to resist infection and to promote healing. During this process, both oxygen and nutrients are required at a higher rate. Many things, including active smoking, hinder this process.

Toxic effects of smoking

Cigarette smoke contains nicotine and carbon monoxide which are both known to be toxins and to reduce oxygen levels in blood and to make the blood more viscous. Nicotine also inhibits normal platelet function and constricts blood vessels. This effect increases the risk significantly that heart complications will arise following surgery.

Lung damage also occurs with smoking, which reduces the airflow through the lungs and interferes with normal ciliary function, and this in turn makes it more likely that pulmonary complications will occur.

Thirdly, smoking disrupts proper immune function, making it harder for the body to heal normally, and also increasing the chances of infection. Oxygen levels in the peripheral tissues are reduced, healing responses are slowed and anti-inflammatory cytokines are produced at lower levels. In fact, it is proved that smoking a single cigarette significantly reduces the body’s ability to heal itself after surgery by hindering the supply of required nutrients.

Smoking can also slow down bone healing, causing non-union of broken bones, by reducing oxygen supply, blood flow and collagen synthesis.

In fact, the study reports an almost 20% improvement in health outcomes with each week a smoker is off tobacco because of the resulting improvement in the circulation, allowing better perfusion of all tissues and especially of vital organs. Overall, analysis of the effects of smoking cessation show a 40% reduction in complications, and specifically a 43% reduction in poor wound healing

The rate of complications after surgery in smokers

Many reviews have shown that all postsurgical complications increase in smokers, as follows:

• 75% increase in total complications
• 150% increase in wound healing complications, especially slow healing and wound dehiscence, infections at the wound site and non-union of bones
• 100% more infections
• 150% more lung infections and other lung complications
• 70% higher neurological complications
• 60% more chance of an ICU admission following surgery.

Obviously, the occurrence of complications makes things much harder for both the patient and the health care team involved. Not only does the patient undergo more suffering and have to undergo prolonged hospitalization and additional medication, but the families, caregivers and patient care staff have to spend more on the procedure than was originally planned.

To counter this, the surgical team should assess the patient for a history of past and current smoking and introduce smoking quitting programs before the surgery is planned. Thus, investing in helping the patient quit smoking, whatever the stage of healthcare, is an important bit of support, and is doubly essential before a surgical procedure is planned.

In addition, training surgeons and anesthetists to participate in initiating and helping maintain smoking cessation is a potentially powerful tool to help more smokers to quit, taking advantage of the need for surgery.

The WHO is promoting the quitting of smoking through specific programs as well as educational campaigns, so that smokers become aware of the damage they are causing themselves during and after surgery by smoking.

Researcher Vinayak Prasad, who heads the No Tobacco Unit of the World Health Organization (WHO) sums up: “The report provides evidence that there are advantages to postponing minor or non-emergency surgery to give patients the opportunity to quit smoking, resulting in a better health outcome.”

Supporting smokers who want to quit

Smokers can quit but in most cases, they need a lot of support to maintain their initial motivation level. Such support can come from family, friends and from professionals. Some programs designed to help quitting smokers include high intensity behavioral interventions such as contact with support staff on a weekly basis, using nicotine or other medicated patches to reduce nicotine cravings, and a hotline for telephone support.

The research finds that when such interventions are arranged at least 4 weeks before a planned surgery, the post-operative course is smoother. Moreover, such interventions produce tangible impact within a week. Routine care for surgery should involve referral of smokers who have quit or want to quit to quitting programs for follow-up and support, to help such patients achieve the best outcomes after surgery.