To the Editor: 

We read with interest the work of Turan et al. ,1who used the American College of Surgeons National Surgical Quality Improvement Program Database and found that cigarette smoking increased risk for perioperative mortality and major morbidity in patients having noncardiac surgery. The accompanying editorial by Katznelson and Beattie2provides a valuable perspective on their work, and we applaud their call for anesthesiologists to take a leadership role in efforts to help surgical patients quit smoking. In addition to potential beneficial effects on the acute perioperative risk nicely documented by Turan et al. , surgery also represents a teachable moment for smoking cessation (e.g. , undergoing a surgical procedure increases the chances that smokers will successfully quit),3and the benefits of smoking cessation to long-term health are unquestioned. The issue of the optimal timing of preoperative smoking cessation is of practical importance, and the duration of preoperative abstinence necessary for maximum benefit is not defined (and may differ among various smoking-related complications). For example, recent data suggest that even prolonging postoperative abstinence in smokers who had smoked up to the time of their surgery may benefit patients who have undergone orthopedic surgery.4 

Unfortunately, in their excellent commentary Katznelson and Beattie perpetuate a concept that hinders perioperative tobacco control efforts: the fear that brief preoperative abstinence from smoking may actually have deleterious effects. They raise the concern that abstinence from smoking may exacerbate preoperative stress, citing a paper from our group that showed that although smokers report more stress than nonsmokers, stress was not increased by perioperative abstinence, and cravings for cigarettes were surprisingly low.5This finding actually favors attempts at smoking cessation during the immediate perioperative period, especially when considering the forced abstinence created by smoke-free healthcare facilities. They also state that several studies suggest that patients who experience sudden withdrawal from tobacco may be at increased risk for pulmonary complications, referencing two observational studies to support this assertion.6,7However, the study of Bluman et al.  did not analyze patients who quit smoking shortly before surgery, but rather those who “cut down” the number of cigarettes smoked by a relatively modest amount.6The study of Nakagawa et al.  did not find a significant difference in pulmonary complications between those patients who quit from 2–4 weeks before surgery and those who had smoked within 2 weeks before surgery.7 

It is beyond the scope of this letter to fully review this topic, but a recent meta-analysis of available studies, which as Katznelson and Beattie note are primarily observational and have significant limitations and potential biases, concluded that relatively brief preoperative abstinence from smoking (less than 8 weeks) does not increase pulmonary risk compared with continued smoking.8Indeed, we are not aware of any individual study that has found a statistically significant increase in pulmonary complications with brief preoperative abstinence, including the two initial studies by Warner et al . that were interpreted by some authors as raising concerns.9,10The conjectured mechanism responsible for increased risk is a transient increase in cough and sputum production after smoking cessation. However, there is no evidence that cough and sputum production actually increase after smoking cessation, either in an ambulatory population11or specifically in anesthetized patients.12It does seem clear that more prolonged abstinence from smoking is necessary to reduce the risk of pulmonary morbidity because it takes several weeks for the lungs to recover from the effects of smoking.13 

Thus, although more data would be welcome, we do not believe that there is any evidence to support the possibility that short-term smoking cessation increases pulmonary complications. It is very likely that the longer the duration of abstinence the better in terms of reducing risk of pulmonary and other complications. However, given the power of the teachable moment and the long-term benefits to health, anesthesiologists and others should seize any opportunity at any time to help their patients quit smoking, without fearing that brief preoperative abstinence could worsen outcome. The American Society of Anesthesiologists provides several tools to do so.*

†Mayo Clinic, Rochester, Minnesota.

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Katznelson R, Beattie WS: Perioperative smoking risk. ANESTHESIOLOGY 2011; 114:734–6
Shi Y, Warner DO: Surgery as a teachable moment for smoking cessation. ANESTHESIOLOGY 2010; 112:102–7
Nsell H, Adami J, Samnegrd E, Tnnesen H, Ponzer S: Effect of smoking cessation intervention on results of acute fracture surgery: A randomized controlled trial. J Bone Joint Surg Am 2010; 92:1335–42
Warner DO, Patten CA, Ames SC, Offord K, Schroeder D: Smoking behavior and perceived stress in cigarette smokers undergoing elective surgery. ANESTHESIOLOGY 2004; 100:1125–37
Bluman LG, Mosca L, Newman N, Simon DG: Preoperative smoking habits and postoperative pulmonary complications. Chest 1998; 113:883–9
Nakagawa M, Tanaka H, Tsukuma H, Kishi Y: Relationship between the duration of the preoperative smoke-free period and the incidence of postoperative pulmonary complications after pulmonary surgery. Chest 2001; 120:705–10
Myers K, Hajek P, Hinds C, McRobbie H: Stopping smoking shortly before surgery and postoperative complications: A systematic review and meta-analysis. Arch Intern Med 2011; 171:983–9
Warner MA, Divertie MB, Tinker JH: Preoperative cessation of smoking and pulmonary complications in coronary artery bypass patients. ANESTHESIOLOGY 1984; 60:380–3
Warner MA, Offord KP, Warner ME, Lennon RL, Conover MA, Jansson-Schumacher U: Role of preoperative cessation of smoking and other factors in postoperative pulmonary complications: A blinded prospective study of coronary artery bypass patients. Mayo Clin Proc 1989; 64:609–16
Warner DO, Colligan RC, Hurt RD, Croghan IT, Schroeder DR: Cough following initiation of smoking abstinence. Nicotine Tob Res 2007; 9:1207–12
Yamashita S, Yamaguchi H, Sakaguchi M, Yamamoto S, Aoki K, Shiga Y, Hisajima Y: Effect of smoking on intraoperative sputum and postoperative pulmonary complication in minor surgical patients. Respir Med 2004; 98:760–6
Warner DO: Perioperative abstinence from cigarettes: Physiologic and clinical consequences. ANESTHESIOLOGY 2006; 104:356–67