Surgery and smoking at first and second hand: time to act.

A N original study in this issue of ANESTHESIOLOGY shows that only 6.6% of smoking parents maintained abstinence during the period when their child underwent surgery. This cessation rate is disappointingly low, probably because the parents are not informed about the increased risk for their children in relation to the operation and not offered support to quit smoking. It is a fact that daily smoking is a heavy and independent risk factor at surgery. The threshold is so low that even secondhand smoke is a risk factor, and children with smoking parents develop more respiratory complications in relation to anesthesia. The association between smoking and surgery has been evaluated in more than 300 papers since 1944, when Dr. Morton first published the finding that smokers develop more pulmonary complications after operation. Every year still more articles confirm this association; however, the time has come to act instead of repeating the same observations over and over again. The question is therefore what to do to reduce the increased risk for smokers undergoing surgery. We could of course hope that the smoking patients or parents would stop smoking themselves, either coincidentally with the operation or because undergoing surgery is considered a teachable moment in life. However, Drs. Shi and Warner have now shown that parental smoking behavior is not affected by this hope. In addition, the spontaneous cessation rate in surgical patients is only a little higher than that of smokers not undergoing surgery. The perspectives are that far too many firstand secondhand smokers develop complications that are potentially preventable. This leaves us with a great deal of room for improvement in postoperative outcomes among smokers, including children exposed to secondhand smoke. During the last 10 yr, evidence has been gathered from randomized clinical trials (RCT) about the risk-reducing effect of perioperative smoking cessation intervention programs. The first RCT was published on elective orthopaedic surgery by Dr. Møller and colleagues in 2002. It demonstrated that the postoperative complication rate was halved in the group allocated to an intensive smoking cessation intervention of 6 – 8 weeks, the Gold Standard Programme (GSP) (table 1). Another study on elective general surgery was published in 2008 by Dr. Lindström and colleagues. They used the same program and found a similar effect, although they began the GSP only 4 weeks before surgery and continued for 4 weeks after it. Other RCTs have evaluated minor and briefer smoking cessation programs without showing any significant risk-reducing effects in the surgical pathway. It seems that only programs associated with high rates of smoking cessation, such as the GSP, influence the postoperative complication rate. From the clinical point of view (and for the benefit of the patients), we should use the interventions requiring the lowest number of patients needed to treat. Depending on the level of staff salary, the fully hospitalfunded GSP is followed by a moderate or substantial reduction of direct hospital costs. The extra resources spent on the mainly outpatient program that is free of charge for the paIllustration: J. P. Rathmell, A. Johnson.