Smoking and Surgery: Making the Case for Preoperative Smoking Cessation

Abstract

Objectives: Cigarette smoking increases complications after surgery. Cessation may improve outcomes and associated costs, but the value of quitting in the weeks before surgery has yet to be demonstrated and there are concerns about a potential increase in complications. In these studies we aim to compare the outcomes of those who recently quit smoking to those who continued and create an economic evaluation framework to estimate the potential value of pre-operative smoking cessation programs for patients undergoing elective colorectal surgery. Methods: Patients undergoing elective colorectal, bariatric and spine operations in Washington State's Surgical Care and Outcomes Assessment Program (2011-2013) were included, characterized by smoking status. Postoperative complications were compared by smoking status, adjusting for demographic and clinical characteristics using multivariate logistic regression. A decision-analytic model was then developed from the payer perspective using a cohort of colorectal patients to integrate the costs and incidence of post-operative complications for a patient undergoing elective colorectal surgery after a smoking cessation program versus usual care. Results: Among 17,214 patients, current smokers were at higher risk for all complications compared to non-smokers (death: OR 2.27, 95% CI: 1.17, 4.40; respiratory complications: OR 2.26, 95% CI: 1.59, 3.20; reoperation: OR 1.42, 95% CI: 1.10, 1.83). Recent quitters had significantly lower risk of respiratory complications than current smokers (OR 0.55, 95% CI: 0.30, 0.99). For a cohort of patients undergoing a preoperative smoking cessation program, the base case estimates imply that the total direct medical costs of complications for patients who underwent a preoperative smoking cessation program were on average $296 lower per patient than those in the usual care group during the first 90 days after surgery. Conclusions: Recent quitters and never smokers had similar risks of death, reoperative intervention and respiratory complications, and quitters were projected to have lower postoperative costs than current smokers. Cigarette cessation, even in the weeks leading up to surgery should be encouraged and cessation programs that cost less than $296 per patient are expected to be cost saving.