Should smokers be referred to a smoking-cessation clinic before undergoing elective surgery?

Trial: Møller AM, Villebro N, Pedersen T, Tønnesen H. Effect of preoperative smoking intervention on postoperative complications: a randomised clinical trial. Question Can smokers be assisted in giving up smoking before elective surgery and does this reduce complications? Trial details Design: Randomised controlled trial of preoperative smoking intervention in patients undergoing hip and knee replacement surgery. Setting: Three university-affiliated hospitals in Denmark. Patients: 62 women and 46 men aged 30–85 years, scheduled for surgery in 6–8 weeks. A further 12 patients were recruited to the trial, but were not included in the analysis because their operations had been postponed or cancelled. Median (range) of smoking exposure was 15 (3–30) cigarettes per day. Interventions: Weekly counselling with a project nurse and the option of nicotine replacement therapy. The first meeting included a questionnaire to measure nicotine dependence and a personalised nicotine substitution schedule was devised. The patients were strongly encouraged to stop smoking completely, or to at least reduce their tobacco consumption by at least 50%. At all subsequent meetings, tobacco consumption was recorded and patients were advised on how to manage immediate withdrawal symptoms and how to keep weight gain to a minimum. Main outcome measures: Frequency of postoperative complications. Main results: The overall complication rate was 18% in the intervention group and 52% in controls (P = 0.0003). These included wound-related complications (5% v 31%; P = 0.001), cardiovascular complications (0 v 10%; P = 0.08), and secondary surgery (4% v 15%; P = 0.07). The median length of stay was 11 days (range, 7–55 days) in the intervention group and 13 days (range, 8–65 days) in the control group (P = 0.41). Overall relative risk reduction was 65% and the number needed to treat (NNT) to avoid any complication was 3 (95% CI, 2–6). In addition, the NNT to avoid wound infection was 4 and the NNT to avoid secondary surgery was 9. Conclusion: A smoking intervention program before surgery can help smokers quit and is associated with a reduction in postoperative complications. Smoking increases the risk of complications in patients undergoing surgery, and it is usual practice to recommend stopping smoking for at least 6 weeks beforehand. 1-3 About 25% of all patients who undergo surgery are current smokers. Studies of the adverse effects of smoking in surgical patients have mostly focused on cardiopulmonary risk reduction, but recent studies identify an association with wound infection. Trial methods …