Prevalence and Trends in Smoking Among Surgical Patients in Michigan, 2012-2019
Authors: Ryan Howard, Kushal Singh, Michael Englesbe
Journal: JAMA Network Open (2021)

Surgery is a teachable moment, and smoking cessation interventions that coincide with an episode of surgical care are especially effective. Implementing these interventions at a large scale requires understanding the prevalence and characteristics of smoking among surgical patients.To describe the prevalence of smoking in a population of patients undergoing common surgical procedures and to identify any clinical or demographic characteristics associated with smoking.This cross-sectional study included all adult patients (aged ≥18 years) in a statewide registry who underwent general and vascular surgical procedures from 2012 to 2019 at 70 hospitals in Michigan. Data analysis was conducted from August to October 2020.Undergoing a surgical procedure in any of the following categories: appendectomy, cholecystectomy, colon procedures, gastric or esophageal procedures, hepatopancreatobiliary procedures, hernia repair, small-bowel procedures, hysterectomy, vascular procedures, thyroidectomy, and other unspecific abdominal procedures.The prevalence of smoking prior to surgery, defined as cigarette use in the year prior to surgery, obtained from medical record review. Multivariable logistic regression was performed to analyze smoking prevalence based on insurance type and year of surgery while adjusting for demographic and clinical factors, including age, sex, race/ethnicity (determined from the medical record), insurance type, geographic region, comorbidities (ie, hypertension, diabetes, congestive heart failure, chronic obstructive pulmonary disease, chronic steroid use, and obstructive sleep apnea), American Society of Anesthesiologists classification, admission status, surgical priority, procedure type, and year of surgery.From 2012 to 2019, 328 578 patients underwent surgery and were included in analysis. Mean (SD) age was 54.0 (17.0) years, and 197 501 patients (60.1%) were women. The overall prevalence of smoking was 24.1% (79 152 patients). Prevalence varied regionally from 21.5% (95% CI, 21.0%-21.9%; 6686 of 31 172 patients) in southeast Michigan to 28.0% (95% CI, 27.1%-28.9%; 2696 of 9614 patients) in northeast Michigan. When adjusting for clinical and demographic factors, there were greater odds of smoking among patients with Medicaid (odds ratio [OR], 2.75; 95% CI, 2.69-2.82) and patients without insurance (OR, 2.21; 95% CI, 2.10-2.33) compared with patients with private insurance. Among procedure categories, patients undergoing vascular surgery had greater odds of smoking (OR, 3.24; 95% CI, 3.11-3.38) than those undergoing cholecystectomy. Compared with 2012, the adjusted odds of smoking decreased significantly each year (eg, 2019: OR, 0.78; 95% CI, 0.74-0.81). In 2019, the adjusted prevalence of smoking was 22.3% (95% CI, 22.0%-22.7%) among all patients, 43.0% (95% CI, 42.4%-43.6%) among patients with Medicaid, and 36.3% (95% CI, 35.2%-37.4%) among patients without insurance.In a statewide population of surgical patients, nearly one-quarter of patients smoked cigarettes, which is higher than the national average. The prevalence of smoking was especially high among patients without insurance and among those receiving Medicaid. Given the established association between undergoing a major surgical procedure and health behavior change, targeted smoking cessation interventions at the time of surgery may be an effective strategy to improve population health, especially among at-risk patient groups.