Rizcion Dagani, DPM, MBA Podiatry Resident, PGY-3
Madigan Army Medical Center
Tobacco Use in the United states
Implications in the Surgical Patient
Effects on Bone Healing
Effects on Wound Healing
Implications for Anesthesia
Smoking Cessation
5.1% of all adults (36.5 million people) smoke cigarettes1
Use of smokeless tobacco increasing in many areas as is combination use of cigarettes and smokeless tobacco2
Image Sources: Huffington Post, Centers for Disease Control and Prevention
4000+ chemicals in cigarette smoke2 Two phases of cigarette smoke3
Volatile Phase Particulate Phase
Systems most affected4 Pulmonary Cardiovascular Immune System Wound Healing
Image Source: Centers for Disease Control and Prevention
Several studies reveal an increased prevalence of overall post-operative complications in smokers vs. non-smokers Peri-operative complications include:
Non-union or delayed union of surgical and non-surgical/traumatic fractures Delayed wound healing Pulmonary complications Increased rate of infection Increased risk of thrombus
Image Source: American Podiatric Medical Association
Prolonged healing time
Increased rates of non-union
Decreased quality of bone repair
Impaired collagen production
Decreased bone density
Impaired cellular function and formation
Image Source: Nature Reviews Rheumatology 5
Decreased peripheral blood flow Decreased tissue oxygenation and aerobic metabolism6
Direct inhibition of cellular function
Increased risk of infection
Increased risk of pulmonary complications in OR or PACU
Impaired cellular function
Reduced pulmonary capacity
Increased carbon monoxide levels
Selection of anesthetic agents
Greater frequency of chronic pain
Increased requirements of postoperative analgesia
Increased risk of DVT/PE
Reduces pulmonary and wound-related complications 2
Overall relative risk reduction of 41% across multiple surgical subspecialties 11
Effects on bone at least partially reversible 3
Each additional week of cessation decreased effect of smoking by 19% 2
Short-term success Only 22% of patients remained tobacco-free at 1 year-post-op 2
1 in 5 Americans use tobacco
Effects of tobacco can be seen particularly in bone healing, wound healing, cardiovascular complications
Pre-operative smoking cessation is beneficial as effects of smoking/risk of post-op complications can be partially reversed
1. Centers for Disease Control and Prevention. Smoking and Tobacco Use. https://www.cdc.gov/tobacco/ 2. Stephens,BF, Murphy,A & Mihalko,WM. (2013). The effects of nutritional deficiencies, smoking, and systemic disease on
orthopaedic outcomes. The Journal of bone and joint surgery. American volume, 95(23), 2152-7. 3. Lee, John J, Patel, Rakesh, Biermann, J Sybil & Dougherty, Paul J. (2013). The Musculoskeletal Effects of Cigarette Smoking The
Journal of Bone and Joint Surgery-American Volume, 95(9), 850-859. doi:10.2106/JBJS.L.00375 4. Tonnesen, H., Nielsen, P. R., Lauritzen, J. B. & Moller, A. M.. (2009). Smoking and alcohol intervention before surgery: evidence for
best practice British Journal of Anaesthesia, 102(3), 297-306. doi:10.1093/bja/aen401 5. Einhorn, Thomas A. & Gerstenfeld, Louis C.. (2014). Fracture healing: mechanisms and interventions Nature Reviews Rheumatology,
11(1), 45-54. doi:10.1038/nrrheum.2014.164 6. Sørensen, Lars Tue. (2012). Wound Healing and Infection in Surgery - The Pathophysiological Impact of Smoking, Smoking Cessation,
and Nicotine Replacement Therapy Annals of Surgery, 255(6), 1069-1079. doi:10.1097/SLA.0b013e31824f632d 7. Myles, Paul S., Iacono, George A., Hunt, Jennifer O., Fletcher, Helen, Morris, John, McIlroy, David & Fritschi, Lin. (2002). Risk of
Respiratory Complications and Wound Infection in Patients Undergoing Ambulatory Surgery - Smokers versus Nonsmokers Anesthesiology, 97(4), 842-847. doi:10.1097/00000542-200210000-00015
8. Kotani,N, Kushikata,T, Hashimoto,H, Sessler,DI, Muraoka,M & Matsuki,A. (2001). Recovery of intraoperative microbicidal and inflammatory functions of alveolar immune cells after a tobacco smoke-free period. Anesthesiology, 94(6), 999-1006.
9. Rutgers Virtual Labs – Cardiobvascular & Respiratory Systems. http://bio.rutgers.edu/~gb102/lab_10/skip.html 10. Warner, David O. (2007). Tobacco dependence in surgical patients Current Opinion in Anaesthesiology, 20(3), 279-283.
doi:10.1097/ACO.0b013e3280c60c3b 11. Scolaro, John A, Schenker, Mara L, Yannascoli, Sarah, Baldwin, Keith, Mehta, Samir & Ahn, Jaimo. (2014). Cigarette Smoking
Increases Complications Following Fracture: A Systematic Review The Journal of Bone and Joint Surgery-American Volume, 96(8), 674-681. doi:10.2106/JBJS.M.00081
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18. Ring, J., Shoaib, A. & Shariff, R.. (2017). Smoking cessation advice in limb reconstruction: An opportunity not to be missed Injury, 48(2), 345-348. doi:10.1016/j.injury.2016.12.004
19. Santolini, Emmanuele, West, Robert & Giannoudis, Peter V.. (2015). Risk factors for long bone fracture non-union: a stratification approach based on the level of the existing scientific evidence Injury, 46, S8-S19. doi:10.1016/S0020-1383(15)30049-8
20. Sweetland, S., Parkin, L., Balkwill, A., Green, J., Reeves, G. & Beral, V.. (2013). Smoking, Surgery, and Venous Thromboembolism Risk in Women: United Kingdom Cohort Study Circulation, 127(12), 1276-1282. doi:10.1161/CIRCULATIONAHA.113.001428
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22. Wei Lei, Chad Lerner, Isaac K. Sundar & Irfan Rahman. (2017). Myofibroblast differentiation and its functional properties are inhibited by nicotine and e-cigarette via mitochondrial OXPHOS complex III Scientific Reports, 7, 43213. doi:10.1038/srep43213