Smoking and Alcohol Intervention before Surgery: Evidence for Best Practice

Research Abstract and Commentary

Smoking and hazardous drinking are common and important risk factors for an increased rate of complications after surgery. The underlying pathophysiological mechanisms include organic dysfunctions that can recover with abstinence. Abstinence starting 3–8 weeks before surgery will significantly reduce the incidence of several serious postoperative complications, such as wound and cardiopulmonary complications and infections. However, this intervention must be intensive to obtain sufficient effect on surgical complications. All patients presenting for surgery should be questioned regarding smoking and hazardous drinking, and interventions appropriate for the surgical setting applied.

Tonnesen, H., Nielsen, P. R., Lauritzen, J. B., & Moller, A. M. (2009). Smoking and alcohol intervention before surgery: Evidence for best practice. British Journal of Anaesthesia, 102, 297-306.

Commentary by Dana Rutledge, RN, PhD

In this article, Tonnesen and colleagues systematically reviewed literature on the effects of smoking on postoperative pulmonary and wound complications and the effect of hazardous drinking (2-3 drinks/day) on postoperative morbidity. Their review used a research or review method called meta-analysis, whereby reviewers analyze results from individual studies in order to integrate or synthesize results as a whole. Figure 1 below shows their findings regarding the complications found associated with smoking and alcohol for all types of surgeries, in all settings.

The authors then reviewed literature on the effects of preoperative interventions (smoking/alcohol cessation) to evaluate effects on postoperative outcomes. They found that smoking interventions are most likely to enhance wound healing and pulmonary complications, and that they could not state what the “optimal” length or duration of smoking cessation necessary to guarantee success. However, Tonnesen and colleagues found that even short-term interventions led to positive results (on average).

Alcohol cessation interventions are less clear in terms of effect since alcohol use is often not defined similarly across studies, and interventions differ. However, based upon the studies reviewed, Tonnesen et al. support interventions that lead to even short-term abstinence because liver and other organ dysfunction improves after 1-2 weeks of alcohol abstinence.

Based upon these findings and the fact that about 80% of pre-operative patients want help in changing their lifestyle prior to surgery, Tonnasen et al. recommend the following:
• Patients should be screened pre operatively for tobacco and alcohol use in order to determine whether they are daily or non-daily smokers and hazardous (> 2-3 drinks daily) or non hazardous drinkers. This identifies high- and low-risk patients.
• Interventions should be carried out between the referral date for surgery and the date of the operation.
• For both smokers and hazardous drinkers, weekly individual counseling enhances preoperative cessation. Smoking cessation programs from 3-8 weeks may be successful and must include personalized nicotine substitution schedules, diaries of tobacco consumption, advice on smoking cessation, benefits and side-effects, how to manage withdrawal symptoms and weight management strategies. Length of alcohol cessation programs varies but should include personalized alcohol withdrawal symptom treatment, supportive medications, diaries of alcohol intake, advice about alcohol cessation, benefits and side-effects, and management of withdrawal symptoms.

This article documents systematic development of evidence-based recommendations about preoperative care of patients. Nurses at St. Joseph who counsel patients undergoing surgeries should be aware of these recommendations, and help their patients seek smoking and alcohol cessation programs to assist them in preparing for surgery.

Figure 1. Postoperative complications associated with smoking and alcohol use
Postoperative complications attributed to smoking
• Impaired wound and tissue healing
• Wound infection
• Cardiopulmonary complications
Postoperative complications attributed to alcohol
• Postoperative infections
• Cardiopulmonary complications
• Bleeding episodes