How many people smoke cigarettes?
What are cigarettes?
Health Harms of Smoking
Higher Surgical Site Infection and Postoperative Wound Complications in Smokers
Higher Nonunion Rate in Smokers
Worse Outcomes of Orthopaedic Operations in Smokers
Can These Adverse Effects Of Smoking Be Reversed?
Can Quitting Smoking before Operation Help?
Quit Smoking Altogether
Cigarettes are smoked by over 1 billion people, which is nearly 20% of the world population. China consumes about 40% of the world’s cigarettes and nearly one-third of the world’s smokers are in China. The smoking prevalence was 28.1% in 2010 in China. Fortunately, there is a gradual decline in the smoking prevalence in Hong Kong, dropped from 23.3% in 1982 to 10.5% in 2015.
Over 7,000 known toxins (70 of which are carcinogenic) are released and inhaled during smoking. These include nicotine, carbon monoxide and hydrogen cyanide etc. Carbon monoxide reduces oxygen carrying capacity of red blood cells and formation of carboxymyoglobin reduces oxygen storage in muscles. Hydrogen cyanide impedes cellular oxidative metabolism. Nicotine has multiple adverse effects including inhibition of osteoblast formation and function (impaired bone healing and non-union), impairment of wound and tendon healing (wound complications), impairment of immune response (wound infection), vasoconstriction, increased platelet adhesiveness (tissue hypoxia) and addiction. Given these facts, smoking actually causes diseases in nearly every organ and has many adverse effects on musculoskeletal system, particularly on the outcomes after orthopaedic surgery.
Smoking is the single most important preventable risk factor for premature death and chronic diseases, including cancer and cardiovascular disease. Smokers die 13 years earlier than non-smokers. Smoking is responsible for 7,000 deaths a year in Hong Kong and nearly 6 million deaths a year worldwide.
Smoking causes lung cancer, liver cancer, colorectal cancer, bladder cancer and kidney cancers and other cancers. Smoking is a major cause of chronic obstructive pulmonary disease, cardiovascular diseases (hypertension, heart attack, stroke and peripheral arterial disease), diabetes, eye diseases (cataract and macular degeneration), low birth weight baby and sudden infant death syndrome.
The direct medical cost and indirect cost (loss of productivity from sick leaves and premature deaths) is up to 11.3 billion Hong Kong dollars a year. The direct medical cost of smoking accounts for 5.7% of global health expenditure and the indirect cost of smoking totaled to 1.8% of the world’s annual gross domestic product (GDP).
Most people are aware of health hazards of smoking, but the health hazards are often under-estimated, particularly the dangers of second hand smoking. Many patients do recognize smoking is a major cause of lung cancer, pulmonary diseases and cardiovascular diseases. However, they probably do not aware of serious detrimental effects of smoking on their outcomes after surgery. Smoking, whether current smoking or ever-smoking, exposes patients scheduled for surgery to risk increases of 20% in-hospital mortality and 40% in major complications including deep infection, pneumonia, sepsis, septic shock, pulmonary embolism, myocardial infarction, stroke, cardiac arrest.
For orthopaedic operations, smoking is associated with a significant increased risk of wound complications by 2.2 folds, general infection by 2.2 folds and bleeding by 3.1 folds. Smoking is a strong risk factor for surgical site infection after spine surgery and total joint arthroplasty. The increased risk of wound infection is 14 times for superficial infection and 1.5 times for deep infection after fractures, 6 times for deep wound infection after internal fixation of ankle fractures and 3.7 times for chronic osteomyelitis after fixation of open tibial fractures.
Smoking delays fracture healing and increases non-union rate following fractures. Smoking significantly increases the risk of non-union of all fractures by 2.3 folds for all fractures, by 2 folds for open fractures and by 2.2 folds for tibial fractures. Smokers have a lower success rate of treatment of acute fracture with bone loss and atrophic non-union with demineralized bone matrix. There is a significant risk of non-union after lumbar fusion and multilevel anterior cervical interbody fusion in smokers and the risk increases with the number of levels fused and the number of cigarettes consumed daily. Besides spinal fusion, smokers have higher failure in ankle fusion, open wedge tibial osteotomy, callotasis and ulnar shortening osteotomy. Smoking also adversely affects the bone grafting incorporation, with a higher failure rate after bone grafting for scaphoid nonunion.
There is less improvement in smokers after spine surgery. Smokers have higher dissatisfaction rate, less improvement of leg pain, higher risk of recurrent disc prolapse after discectomy for disc prolapse. Smokers are more likely to report dissatisfaction, continue use of analgesic after surgery and less improvement of back pain and walking ability after decompression of lumbar spinal stenosis. Smokers also have significantly less improvement after surgery for cervical myelopathy. After cervical spine surgery, smokers have more degenerative changes at adjacent segment requiring treatment or reoperation.
Smokers have worse outcome after total joint arthroplasty (hip, knee, shoulder, elbow and ankle) compared to non-smokers. Smoking is associated with an increased risk of overall postoperative complications, wound complication, wound infection and periprosthetic joint infection. Smoking also has negative impact on prosthesis survival of total hip arthroplasty, total knee arthroplasty and shoulder arthroplasty.
Smoking is associated with tendinopathy and impairs tendon healing. Smoking is detrimental to outcomes of arthroscopic rotator cuff repair, superior labrum anterior and posterior (SLAP) repair and needle aspiration of calcific deposits for calcific tendinitis of rotator cuff. Smoking is associated with significantly increased postoperative complication rate (infection and venous thromboembolism), an increased residual instability and worse clinical outcome scores after anterior cruciate ligament reconstruction.
Although smoking is not associated with a higher failure rate after microvascular flap surgery or digital replantation, a higher rate of cold intolerance, dysesthesia and chronic pain is observed in patients who continue to smoke after digital replantation.
Fortunately, the half-life of nicotine and carbon monoxide and side effects usually last less than 12 hours after abstinence. Carbon monoxide is eliminated in the body by 24 hours and nicotine is eliminated by 48 hours after stop smoking. By a few weeks to 3 months, the circulation improves and lung function increase by up to 30%. The minimal time required for recovery of organ dysfunction after smoking cessation for wound healing is 3 to 4 weeks, for bone healing is 4 weeks, for immune competence is 2 to 6 weeks and for pulmonary function is 6 to 8 weeks. For planned admissions, smoking cessation 8 weeks or more before admission is considered by National Health Service, United Kingdom as an optimum amount of time for the body to recover from the immediate effects of smoking.
The deleterious effects of smoking on the musculoskeletal system seem to be partially reversible and quitting smoking before operation mitigates the adverse effects of smoking on postoperative complications. There are high quality evidence showing the benefits of smoking cessation before surgery, specifically in total joint arthroplasty, fracture fixation and anterior cruciate ligament reconstruction.
Preoperative smoking cessation reduces postoperative complications by 41%, with a significant larger effect of at least 4 weeks of preoperative smoking cessation than a short duration. There are a significantly reduction in total postoperative complications, pulmonary complications and wound complications after preoperative smoking cessation.
The overall complications and wound-related complications in smokers who quit smoking before total hip and knee joint arthroplasty is only one-third of those who smokers who continue to smoke. Smokers who quit smoking before total ankle arthroplasty have similar perioperative complication rates and outcomes when compared to non-smokers. In anterior cruciate ligament reconstruction, those who stop smoking at least one month prior to operation have no significant difference in outcomes compared with patients who have never smoke.
Continuation of smoking cessation after operation is equally beneficial. Smoking cessation initiated during acute hospital stay and continued for 6 weeks postoperatively also benefits limb fracture surgery. The chance of having complication in the intervention group is only 40% of that of the control group. Patients undergoing spine fusion surgery is recommended to quit smoking at least 4 weeks before and 6 months after surgery.
Children may be victims of second hand smoking. Environmental tobacco smoke exposure increases respiratory adverse events by 1.8 times and laryngospasm by 3.5 times in the perioperative period in children. Reducing second hand smoke exposure of children before the elective surgery via parental smoking cessation or not smoking in home before the elective surgery is highly recommended.
For elective operations, smoking cessation 8 weeks or more before admission is considered as an optimum amount of time for the body to recover from the immediate effects of smoking. While waiting for an elective operation, quitting smoking is one of the most important things the patient can do to prevent perioperative complications. Each week of smoking cessation increase the magnitude of preventive effect on perioperative complication by 19%.
Smoking is not allowed in hospital and throughout the perioperative period. The no smoking hospital environment creates an external force to support abstinence. Take the chance to stop smoking earlier to prepare for the operation and take the chance to quit smoking to total abstinence. Within 2 weeks to 3 months of quitting, blood circulation improves and lung function increases by up to 30 percent. After 1 year of abstinence, the excessive risk of heart attack is reduced by half. After 1 year, there is an increased bone mineral density at hip in postmenopausal women. After 5 years, the risk of heart attack and stroke reduces to the same level of people who never smoke. After 10 years, the risk of hip fracture in women and the risk of developing rheumatoid arthritis reduce to that of a non-smoker. After 10 years of abstinence, the risk of lung cancer is half of that of continuing smokers, and continues to decline. After 10 to 15 years, the risk of dying almost returns to that of people who never smoke.
Everyone can quit smoking. To START quitting smoking, pay attention to:
S = set a quit date
T = tell family, friends that you quit smoking
A = anticipate and plan for challenges you will face
R = remove cigarettes and tobacco from your home, working place, car etc.
T = talk to your doctor about getting help to quit smoking
Ask the Integrated Smoking Cessation Hotline at 1833183. Nicotine replacement therapy can help in heavy smokers. More detail smoking cessation service providers may be found in the web site of Hong Kong Council of Smoking and Health (www.smokefree.hk).
Dr. Ho Sheung-Tung