Smoking or vaping: Perioperative management

Authors:: David O Warner, MD; Paul Preston, MD; Rajeev Iyer, MD, MS
Section Editors:: Natalie F Holt, MD, MPH; Hasmeena Kathuria, MD
Deputy Editors:: Nancy A Nussmeier, MD, FAHA; Paul Dieffenbach, MD

Literature review current through: Jan 2024.

This topic last updated: Nov 03, 2022.

INTRODUCTION — Cigarette smoking is a risk factor for perioperative pulmonary, cardiovascular, bleeding, and wound healing complications. Limited evidence suggests that risks are also associated with "vaping" (ie, use of electronic cigarettes [e-cigarettes]) as a method for consumption of nicotine (or other substances such as cannabis).

This topic will discuss adverse effects of smoking or vaping on perioperative outcomes, and the role of anesthesia care providers together with other health care professionals in managing these risks.

Detailed discussions of risks and management of patients who smoke are available in other topics. (See "Strategies to reduce postoperative pulmonary complications in adults", section on 'Smoking cessation' and "Cardiovascular risk of smoking and benefits of smoking cessation" and "Risk factors for impaired wound healing and wound complications", section on 'Smoking and nicotine replacement therapy'.)

Further information regarding the risks of vaping and management of patients who consume nicotine or other substances using e-cigarettes is available in separate topics. (See "Vaping and e-cigarettes" and "E-cigarette or vaping product use-associated lung injury (EVALI)" and "Management of smoking and vaping cessation in adolescents".)

PERIOPERATIVE RISKS OF SMOKING

Cigarette smoking — Cigarette smoking has known deleterious effects on surgical patients. Perioperative pulmonary, wound healing, cardiovascular, and other complications are more likely in patients who have continued smoking up until the time of surgery [1-4]. A 2014 meta-analysis of available studies found increased risk of pulmonary complications (relative risk [RR] 1.73, 95% CI 1.35-2.23) and wound-related complications (RR 2.15, 95% CI 1.87-2.49) for smokers compared with non-smokers [5]. A subsequently published observational study of cigarette smokers undergoing elective surgery also noted an association between surgical site infection and smoking (odds ratio [OR] 1.51, 95% CI 1.20-1.90), particularly if smoking occurred on the day of surgery (OR 1.96, 95% CI 1.23-3.13) [6]. Also, cardiovascular complications are more frequent in patients who smoke [1,2]. Furthermore, using data from the nearly 5.5 million cases in the American College of Surgeons National Surgical Quality Improvement Program database, a higher risk for transfusion of blood products (odds ratio [OR] 1.06, 95% CI 1.05-1.07) and need for reoperation (OR 1.28, 95% CI 1.27-1.31) was noted for some types of surgery in the 19 percent of patients who smoked compared with nonsmokers, [7].

Further discussions of adverse effects of smoking are available in other topics:

●(See "Strategies to reduce postoperative pulmonary complications in adults", section on 'Smoking cessation'.)

●(See "Risk factors for impaired wound healing and wound complications", section on 'Smoking and nicotine replacement therapy'.)

●(See "Cardiovascular risk of smoking and benefits of smoking cessation".)

Exposure to secondhand smoke in nonsmoking patients has also been associated with adverse effects. In children exposed to secondhand smoke, the risk of airway complications such as laryngospasm is more than doubled [8]. In one study of 60 nonsmoking adults undergoing one lung ventilation for lobectomy, those exposed to secondhand smoke had lower partial pressure of arterial oxygen and higher partial pressure of carbon dioxide compared to those not exposed [9]. In this study, exposure to secondhand smoke was also associated with higher postoperative morphine consumption, and similar observations have been reported by others [9-11].

Cannabis smoking — There are potential adverse effects of smoking synthetic tetrahydrocannabinol (THC) products or cannabis (marijuana), which may theoretically affect anesthetic risk.

These include [12,13]:

●Pulmonary effects, such as airway irritation and exacerbation of underlying respiratory diseases including asthma, chronic obstructive pulmonary disease (COPD), and pneumonia [13-19]. Also, smoking cannabis increases levels of carboxyhemoglobin, thereby reducing oxygen-carrying capacity, similar to smoking conventional cigarettes [20].

●Cardiovascular and cerebrovascular effects, such as sympathetic activation and increased circulating catecholamines, with increased heart rate and blood pressure (with either acute or chronic use) [13,21-23]. Cannabis use also impairs vascular endothelial function [24] and increases risk of myocardial infarction (MI), ischemic stroke, or transient ischemic attack [13,20,25-28]. In a retrospective study that included more than 27,000 patients, the incidence of postoperative MI was 0.7 percent in patients who reported active cannabis use compared with 0.3 percent in those without (adjusted OR 1.88, 95% CI 1.31-2.69) [28]. At high doses, enhanced parasympathetic tone with dose-dependent bradycardia and hypotension may occur [13].

●Neuropsychiatric effects, such as impaired cognitive performance [29,30]. Acute administration or acute withdrawal in chronic users may cause anxiety and/or psychotic symptoms in some patients [30-33].

●Cannabis use may be associated with higher requirements for anesthetic agents [34-36], and increased postoperative pain and opioid use after surgical procedures [37-40], although patient responses may vary [13].

●Gastrointestinal effects in some patients, such as delayed gastric emptying, recurrent nausea and vomiting, or abdominal pain [13,41,42].

PERIOPERATIVE RISKS OF VAPING

Vaping nicotine — Electronic cigarette (e-cigarette) vapor may have deleterious effects on surgical patients, although data are scant. Nicotine is the active ingredient in e-cigarettes, but the vaporization process also produces other pharmacologically active compounds. Constituents of commonly vaporized liquids include a variety of preservatives, solubilizing agents, and flavors. Likely harmful compounds include propylene glycol, formaldehyde, acrolein, vegetable glycerin, aldehydes, carcinogenic nitrosamines, polycyclic aromatic, hydrocarbons, and heavy metals such as lead [43,44]. However, the identity and potential effects of each of these additives have not been thoroughly studied. (See "Vaping and e-cigarettes".)

A new type of device uses a different technology to heat-not-burn (HNB) tobacco leaf to produce a nicotine-containing vapor. These newer devices expose users and bystanders to many of the same chemicals as tobacco smoke, but at substantially lower levels than conventional cigarettes [45]. HNB products are described in detail separately. (See "Patterns of tobacco use", section on 'Heat-not-burn tobacco products'.)

Potential adverse perioperative effects of vaping nicotine and the various additive agents in e-cigarettes include:

●Pulmonary effects, including direct cytotoxic effects of electronic cigarette fluids, aerosols and solvents on lung cells [46], exacerbations of asthma, and increased lung inflammation [43].

●Cardiovascular effects, such as sympathetic activation and increased circulating catecholamines, vascular oxidative stress, inflammation, and thrombogenesis [21,47-49].

●Theoretical concern regarding wound healing. In two studies in rats, rates of necrosis of skin flaps were higher in those exposed to cigarette vapor or conventional cigarette smoke, compared with unexposed rats [50,51]. However, it unknown whether the increased rates observed in the vapor-exposed rats were caused by nicotine or other vapor constituents, and there is no evidence in humans suggesting that nicotine can increase risk of wound infections [52,53].

Vaping other substances — Other products consumed via vaping include synthetic tetrahydrocannabinol (THC) products or cannabis (marijuana), together with additive substances, such as the solvent vitamin E acetate [12,54-58]. There is little evidence regarding specific perioperative effects of vaping THC with added substances.

However, the potential for adverse effects has been highlighted by the onset of acute e-cigarette or vaping product use-associated lung injury (EVALI) in some patients in the United States [48,49,59-62].2 Severity of symptoms and physiologic derangements can range from mild (not requiring hospitalization) to severe (requiring noninvasive ventilation, endotracheal intubation with mechanical ventilation, or extracorporeal membrane oxygenation [ECMO]) [60,63,64]. Although the cause is not completely understood, most cases are associated with vaping THC together with the additive vitamin E acetate. (See "E-cigarette or vaping product use-associated lung injury (EVALI)".)

Conversely, there may be some beneficial effects associated with perioperative use of cannabis and cannabinoid products [33]. For example, these agents can be an effective treatment for nausea and vomiting after chemotherapy [65], although efficacy for postoperative nausea and vomiting (PONV) has not been demonstrated. Also, cannabinoids may have anticonvulsant properties [66,67].

HELPING PERIOPERATIVE PATIENTS QUIT SMOKING OR VAPING — All surgical patients should receive the core elements of perianesthesia tobacco treatment, including (1) ascertainment and documentation of tobacco use status; (2) advice to quit; (3) pharmacotherapy such as nicotine replacement therapy (NRT); and (4) access to counseling and other resources (eg, BecomeAnEx.org) [68].

Smoking cessation

Rationale for smoking cessation — We agree with the recommendations of the Society of Perioperative Assessment and Quality Improvement (SPAQI) regarding the benefits of smoking cessation [3] (see 'Perioperative risks of smoking' above). Patients who abstain for at least some periods of time are in various stages of recovery from the effects of smoking, with benefits in terms of reduced risks for several perioperative complications [1,69]. A 2014 meta-analysis of randomized trials of perioperative interventions such as counseling and NRT noted reduction in the incidence of any postoperative complication (relative risk [RR] 0.42, 95% CI 0.27-0.65), as well as the incidence of wound-related complications (RR 0.31, 95% CI 0.16-0.62), compared with no intervention [70]. The duration of abstinence necessary to achieve perioperative benefit is not known. However, a 2011 meta-analysis of observational studies noted that the longer the period of abstinence, the greater the reduction in risk for complications [71].

Although patients should quit for as long as possible before the date of surgery, limited data suggest that even brief preoperative abstinence (such as not smoking the morning of surgery) may have benefits [3]. For example, in one study in patients undergoing vascular surgery, abstinence shortly before surgery resulted in lower levels of exhaled carbon monoxide and fewer episodes of cardiac ischemia related to increased heart rate and blood pressure compared with those who did smoke on the morning of surgery [72]. In a large observational study of cigarette smokers undergoing elective surgery, the odds ratio (OR) for the association between smoking on the day of surgery (versus not smoking the morning of surgery) and surgical site infection was 1.96 (95% CI, 1.23 to 3.13) [6]. In other words, smoking on the morning of surgery was associated with a near doubling of surgical site infection risk. Furthermore, there is no evidence to support the discredited notion that quitting shortly before surgery increases the risk of pulmonary complications [73]. Thus, there is no barrier for all patients who smoke to be advised to quit prior to surgery, even those seen for a brief period shortly before surgery.

Assessment and referral for smoking cessation — Pharmacotherapy and counseling should be offered to all smokers early in the preoperative period and continued postoperatively [3,68]. Even in the absence of perioperative interventions for smoking cessation (eg, formal counseling sessions or use of NRT), patients are more likely to succeed if they attempt to quit smoking in the perioperative period before and/or after a surgical procedure [74]. (See "Evaluation of perioperative pulmonary risk" and "Strategies to reduce postoperative pulmonary complications in adults".)

Counseling to help patients manage perioperative tobacco use has the potential to mitigate perioperative risks, and also provides an opportunity to help patients quit using tobacco permanently, which can have lasting health benefits [68,69,75]. (See "Behavioral approaches to smoking cessation".)

Guideline-concordant pharmacotherapy includes US Food and Drug Administration (FDA)-approved medication for smoking cessation such as NRT (typically combination nicotine patches with gum or lozenges) and/or the partial nicotinic agonist varenicline (see "Pharmacotherapy for smoking cessation in adults"):

●The likelihood that surgical patients can abstain from smoking is increased by use of NRT initiated or continued in the perioperative period [76]. Notably, evidence does not support an older concern that NRT could theoretically impair wound healing due to vasoconstriction. Surgical patients using NRT to maintain abstinence from tobacco do not have increased risk for wound-related or other perioperative complications [52,53,77].

●Varenicline reduces the symptoms of nicotine withdrawal by binding with high affinity and acting as a partial agonist at the alpha-4 beta-2 nicotinic receptor. It blocks nicotine from binding to the receptor, interrupting the reinforcing effects of nicotine that lead to nicotine dependence."

Typically, strategies that combine counseling and pharmacotherapy are employed. In one study, a perioperative smoking cessation intervention that included varenicline, one counseling session, and provider referral to a quit-line increased abstinence by 62 percent compared with brief counseling and self-referral to a quit-line [78]. In another study, a preoperative intervention consisting of a brief (less than five minutes) counseling session by a trained preadmission nurse, stop-smoking brochures, referral to a telephone counseling service, and a free six week supply of nicotine patches increased both short-term (30 day) abstinence (risk ratio 4.0, 95% CI 1.2-13.7) and long-term (one year) abstinence (risk ratio 3.0, 95% CI 1.2-7.8) [79,80].

One recommended approach to encourage smoking cessation in surgical patients can be summarized as "Ask, Advise, and Refer" (see "Overview of smoking cessation management in adults") [3,81,82]:

●All surgical patients should be asked whether they smoke (or use electronic cigarettes [e-cigarettes]), even if their tobacco status has already been documented in the health record [83]. Asking this question confirms the accuracy of previously recorded information and reinforces the message that tobacco use incurs some risk during and after surgery.

●All patients should be strongly advised to quit smoking for as long as possible before and after a surgical procedure to achieve the best possible outcome [68]. Patients who do not want to quit in the long term can be advised to at least "quit for a bit" (ie, abstain from smoking from at least the morning of surgery until one week after surgery) [84]. Patients who are unwilling to "quit for a bit" should be advised to avoid smoking on the morning of surgery. This advice is particularly effective when delivered in person by the surgeon, anesthesiologist, or primary care provider.

●All patients should be referred to resources that can aid with abstinence, which may include [3,68]:

•Online resources (eg, BecomeAnEx.org) [85].

•In-person tobacco treatment services, typically with both counseling by trained tobacco treatment specialists and FDA-approved pharmacotherapy such as NRT (typically combination nicotine patches and gum) and/or the nicotinic partial agonist varenicline. (See "Behavioral approaches to smoking cessation" and "Overview of smoking cessation management in adults" and "Pharmacotherapy for smoking cessation in adults".)

•Telephone counseling ("quit-lines") that provide ongoing support [86].

Use of e-cigarettes to quit smoking — The use of e-cigarettes as a form of NRT is being explored to help smokers quit. However, given the concerns regarding the potential effects of e-cigarette vapor in the perioperative period and the proven efficacy and safety of alternative tobacco treatment interventions, we do not recommend e-cigarettes as a form of NRT in the perioperative period. (See 'Perioperative risks of vaping' above and "Overview of smoking cessation management in adults".)

Limited evidence suggests that it is feasible to encourage patients to use e-cigarettes to reduce or eliminate exposure to tobacco smoking in the perioperative period [87-91]. However, it is unknown whether use of e-cigarettes can reduce perioperative complications.

Institutional strategies — The main challenge in helping surgical patients quit smoking is not a lack of effective interventions, but rather the practical difficulties of consistently applying these interventions in busy perioperative practices. Principles of implementation science have been used to guide efforts to incorporate smoking cessation as a routine part of surgical care, although widespread implementation of such efforts is challenging [92]. Examples of institutional pilot efforts to provide integrated systematic approaches to perioperative smoking cessation include [3,68,93,94]:

●Harnessing current screening workflows and documentation of surgical patients' smoking status that may already be in place in primary care settings, by extending these into preoperative clinic settings [3].

●Creating robust prompts for clinicians regarding smoking status before preoperative clinic visits.

●Educating surgeons and anesthesiologists that even just brief advice to quit smoking from clinicians is effective.

●Designing and implementing an easy referral process for patients who are receptive to smoking cessation.

●Measuring results of smoking cessation programs by collecting electronic data in preoperative clinics with outcome measures that include:

•Clinic screening rates

•Referral rates to smoking cessation programs

•Prescriptions or dispensation of aids for smoking cessation

•Records of actual quit rates reported on the day of surgery, or by measuring carbon monoxide levels via breath testing

●Changes in preoperative workflows have been implemented in many institutions during the novel coronavirus disease 2019 (COVID-19) pandemic. In-person presurgical and preanesthetic visits have been replaced with remote, telephonic, or video-based visits. Proposed steps to foster smoking cessation do not depend on in-person preoperative clinic visits; in fact, electronic medical records may allow more robust referral to resources that can aid with abstinence, and measurement of the efficacy of interventions. Some data suggest that remote coaching and prescribing are as effective as in-person counseling regarding smoking cessation [94].

These available options can be customized to the needs of an institution or a surgical practice (termed “multimodal perianesthesia tobacco treatment”). Effectiveness increases as individual treatment elements such as ascertainment and documentation of tobacco use, advice to quit, access to NRT, and referral to counseling are combined [68].

Vaping cessation — Similar to asking all surgical patients whether they smoke tobacco, all should also be asked whether they use e-cigarettes (ie, "vaping") [95]. Even though nicotine-containing e-cigarettes are classified as tobacco products, many patients do not realize this. Although there are many different terms used to describe these devices, most patients of all ages will recognize the terms "electronic cigarettes" or "vape." It is particularly important to also ask adolescent surgical patients about their use of these devices since 20 percent of high school students report use of e-cigarettes [96]. (See "Vaping and e-cigarettes" and "Management of smoking and vaping cessation in adolescents".)

Those who indicate that they use e-cigarettes or vape should be asked specifically what substances they vape, with the question best phrased as "nicotine or something else" [97]. It is important to make this distinction because those inhaling substances other than nicotine (eg, delta-9 tetrahydrocannabinol [THC] products) may be at greater risk for development of perioperative lung injury [60]. Notably, there is an ever-changing variety of products that can be vaped, and systems are used by individuals to "mix their own" vaping liquid.

Although specific perioperative effects of various types of e-cigarette vapor are largely unknown, we use the following approach for patients who vape:

●Counseling with the explanation that although the effects of vaping on perioperative complications are unclear, there are reasons for concern regarding short-term and long-term effects [12,88,98-101]. Thus, we advise patients to abstain from vaping for as long as possible before and after surgery, similar to abstaining from conventional cigarette smoking. This recommendation is particularly strong for those who vape substances other than nicotine.

●Similar to patients who smoke, patients who vape should be referred to resources that can aid with abstinence. (See 'Smoking cessation' above and "Management of smoking and vaping cessation in adolescents".)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Smoking cessation, e-cigarettes, and tobacco control".)

SUMMARY AND RECOMMENDATIONS

●Perioperative risks of smoking

•Cigarette smoking – Cigarette smoking increases the risk of perioperative pulmonary, cardiovascular, wound healing (eg, surgical site infection), and bleeding complications (See 'Cigarette smoking' above.)

•Cannabis smoking – Potential adverse perioperative effects of smoking synthetic tetrahydrocannabinol (THC) products or cannabis (marijuana] include pulmonary, cardiovascular neuropsychiatric, and gastrointestinal effects. (See 'Cannabis smoking' above.)

●Perioperative risks of vaping – Although not yet well defined, there are potential adverse pulmonary, cardiovascular, and wound-related effects of vaping nicotine and the various additive agents in electronic cigarettes (e-cigarettes). Other products consumed via vaping include THC (or cannabis) together with substances such as the solvent vitamin E acetate. Vaping may cause acute e-cigarette or vaping product use-associated lung injury (EVALI), with severity ranging from mild (not requiring hospitalization) to severe (requiring noninvasive ventilation or endotracheal intubation with mechanical ventilation). (See 'Vaping nicotine' above and 'Vaping other substances' above.)

●Perioperative cessation of smoking or vaping

•Rationale – Quitting smoking reduce perioperative risk. Although patients should quit for as long as possible before the date of surgery (ideally more than four weeks preoperatively), even brief preoperative abstinence (such as not smoking the morning of surgery) may have benefits. (See 'Rationale for smoking cessation' above.)

•Assessment and strategies for smoking cessation

-All surgical patients should receive the core elements of perianesthesia tobacco treatment including 1) ascertainment and documentation of tobacco use status; 2) advice to quit; 3) pharmacotherapy such as nicotine replacement therapy (NRT); and 4) access to counseling, ideally with referral to resources promoting abstinence. Surgery provides an opportunity to help patients quit using tobacco permanently, as even without help patients are more likely to succeed if they attempt to quit smoking in the perioperative period compared with other times. (See 'Assessment and referral for smoking cessation' above.)

-Consistent implementation of tobacco treatment in routine clinical care is essential but has proven to be challenging. An integrated systems approach (termed multimodal perioperative tobacco treatment) that is adapted to the particular needs of individual practices and institutions is most effective and sustainable. (See 'Institutional strategies' above.)

•Assessment and strategies for vaping cessation – All patients should also be asked whether they use e-cigarettes (ie, "vaping") during routine queries about tobacco use. Those who answer "yes" are asked what specific substances they vape, with the question best phrased as "nicotine or something else.” Similar to smoking conventional cigarettes, we advise patients to quit vaping nicotine and other substances for as long as possible before and after a surgical procedure. Ideally, counseling and referral to resources promoting abstinence are offered. (See 'Vaping cessation' above and 'Use of e-cigarettes to quit smoking' above.)

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Topic 127216 Version 9.0

خرید پکیج

Smoking or vaping: Perioperative management

References