This document summarizes a study that tested the effectiveness of a brief smoking cessation intervention for surgical patients. The intervention included brief counseling, smoking cessation brochures, free nicotine patches, and referral to a quitline. It significantly increased smoking abstinence before and after surgery compared to standard care. The results suggest that even relatively simple interventions can help many surgical patients quit smoking long-term.

1. 510 www.anesthesia-analgesia.org March 2015 • Volume 120 • Number 3
Copyright © 2015 International Anesthesia Research Society
DOI: 10.1213/ANE.0000000000000614
E
M
otivations for choosing the practice of medicine
vary widely among individuals, but in my expe-
rience the common denominator is a desire to
improve health. Physicians who want to have maximal
long-term impact on their patients’ health need look no
further than the most common cause of preventable death
and mortality in developed countries: cigarette smoking.1
The efficacy of interventions to help patients quit is beyond
dispute, as are the benefits to both individual patients and
society.2
As anesthesiologists, we are expanding our scope
of practice into many facets of perioperative and postopera-
tive care through models such as the perioperative surgi-
cal home.3
Our postoperative horizon cannot be limited to
when the patient is initially “out of the woods” from the
surgical intervention; we must ensure that every health
issue we identify is addressed. It is our duty as physi-
cians, and the responsibility we are advocating as part of
our professional scope, to do whatever we can to improve
long-term patient outcomes. None of us went into medicine
to become operating room technicians. We are physicians.
As such, it is our professional responsibility to address our
patients’ smoking.
But can we really make a difference? In a current4
and
a companion article previously published,5
Lee and col-
leagues show us that the answer is yes. A relatively straight-
forward intervention that could be easily implemented in
most preoperative settings was efficacious in helping ciga-
rette smokers scheduled for elective surgery to quit, both
preoperatively and long-term (at 1 year postoperatively).
There is a voluminous evidence base, well encapsulated
in clinical practice guidelines,2
that tobacco use interven-
tions work, that efficacy increases when pharmacotherapy
(e.g., nicotine patches) is a part of treatment and when
interventions are more intensive (e.g., more contacts with
the patient). So how intensive does a perioperative tobacco
use intervention need to be? The literature is actually fairly
limited. The most recent systematic review examining more
and less intensive interventions was based on only 4 stud-
ies, all of them relatively small. The authors concluded that
there was insufficient evidence that brief perioperative
interventions were efficacious and that multiple in-person
contacts initiated at least 4 to 8 weeks before surgery are
necessary.6
However, in the busy perioperative period,
this may not be feasible. The result of Lee et al. is exciting
because it suggests that perhaps the “teachable moments”
effect of surgery7
augments the efficacy of interventions that
are not very intensive.
Lee and colleagues randomized elective surgical patients
to receive either standard care (in essence, nothing) or a
tobacco use intervention initiated in a preoperative clinic
at least 3 weeks before surgery. The intervention included
several elements: (1) brief (approximately 15 minutes) coun-
seling by a nurse who had only minimal training in tobacco
control (a 1-hour training session), (2) a stop-smoking bro-
chure, (3) a free 6-week supply of nicotine patches, and
(4) referral to a free “quitline,” which provided telephone
counseling services. This intervention produced a signifi-
cant increase in abstinence from cigarettes on the morning
of surgery (from 4% to 14%). This itself is interesting, but the
extraordinary finding is that the abstinence rates at 30 days
after surgery were approximately doubled in both groups
(11% in the control group and 29% in the intervention
group), proportions that were very nearly stable over the
first year postoperatively. One year after surgery, 8% of the
control group and 25% of the intervention group remained
abstinent. This increase almost certainly reflects the power
of the teachable moment presented by surgery, changes
in behavior triggered by the surgical experience itself that
are now well-documented.7
Other studies using relatively
intensive interventions have shown similar abstinence rates
1 year after surgery (in the range of 23%–43%),8–10
which
rival the best results obtained by dedicated tobacco treat-
ment programs serving the general population.2
What is not clear from the study of Lee et al. is which
elements of the intervention may have contributed to effi-
cacy. For example, although about half of patients in the
intervention group were contacted by the quitline, only 25%
of patients received any counseling from them, and infor-
mation is not provided regarding quit rates in those who
did and did not use the quitline. Similarly, no information
is provided regarding utilization of nicotine patches. We
know that patch therapy itself can delay relapse to smok-
ing in postoperative surgical patients, even in the absence
of any behavioral intervention,11
and that providing free
patches increases both utilization of counseling services and
Helping Surgical Patients Quit Smoking:
Time to Bring It Home
David O. Warner, MD
From the Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota.
Accepted for publication November 26, 2014.
Funding: This work was not funded by extramural sources.
Conflicts of Interest: See Disclosures at the end of the article.
Reprints will not be available from the author.
Address correspondence to David O. Warner, MD, Department of Anesthesi-
ology, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905. Address
e-mail to warner.david@mayo.edu.
Editorial

2. Helping Surgical Patients Quit Smoking
March 2015 • Volume 120 • Number 3 www.anesthesia-analgesia.org 511
quit rates.12
It would have been helpful if both quitline and
patch utilization would have been analyzed as potential
mediators of treatment effect, which would be of practical
importance when considering what it takes to implement
the intervention.
However, it may not even matter “which part worked”
when the performance of the whole package was so good.
After all, none of the intervention elements is particularly
difficult to implement. Telephone quitlines are available
free of charge to many citizens of countries in the developed
world (including all United States residents—1-800-QUIT-
NOW).13
Nicotine patches are inexpensive (with an acquisi-
tion cost of approximately $1.50 USD each in my hospital,
a 6-week supply is approximately $63, less than rounding
error in a typical surgical bill). Stop-smoking brochures
specific to surgery are currently available free of charge
from the American Society of Anesthesiology. In a “train
the trainer” approach, an individual from a practice could
undergo a 1-week training as a tobacco treatment special-
ist,14
then teach others in his or her practice how to deliver
brief tobacco interventions such as used by Lee et al.; other
training approaches are also possible.
Think about how tobacco interventions in surgical
patients could impact overall health. Of the potential study
participants assessed, found to be eligible and approached,
43% consented. Similar to previous studies,15
this suggests
that many preoperative smokers are quite interested in quit-
ting and amenable to interventions. As a thought experi-
ment (illustrated in Fig. 1), take 1000 smokers scheduled for
surgery. Assuming that the results of Lee et al. apply, 430
would be willing to make a quit attempt. Of the 570 not will-
ing and who refuse interventions, assume conservatively
that 4% (or 23) would be abstinent at 1 year postoperatively,
the approximate overall annual spontaneous quit rate in the
population.2
If we did not intervene in the 430 who were
willing (the current state in most practices), 8% (or 34) would
be abstinent at 1 year. However, if we intervened, 25% (or
108) would be abstinent. Overall, of the 1000 patients, 57
would be abstinent at 1 year if we did not intervene com-
pared with 131 if we did. Thus, our intervention has net-
ted us 74 additional quitters of 1000 smokers scheduled for
surgery. With approximately 10 million smokers undergo-
ing surgical procedures in the United States annually,1,16
this
rate would translate to 740,000 additional annual quitters.
This would represent an enormous contribution of anesthe-
siologists to the health of the nation.
I would argue that the long-term impact of sustained
abstinence demonstrated by this and other studies itself
justifies the application of consistent tobacco use interven-
tions in surgical patients. However, there is an additional
bonus; perioperative abstinence can reduce perioperative
complications.6,17,18
The duration of preoperative abstinence
necessary for benefit is not well-defined and likely depends
on which complication is examined, although there is some
evidence that even just maintaining postoperative absti-
nence may be of benefit.19
Although Lee et al.5
did show a
decrease in postanesthesia care unit stay in patients receiv-
ing the intervention, neither their study nor many of the
other randomized trials of perioperative tobacco use inter-
ventions were powered to examine the effect of interven-
tions on acute perioperative complications that are plausibly
related to smoking. Indeed, because the absolute incidence
of serious smoking-related complications is fortunately low
in elective surgical patients,20
and observational studies
show relative risk values in the range of 0.7 to 0.8 for these
complications with cessation,17
definitive studies on the effi-
cacy of a given intervention to reduce the acute complica-
tions will require large numbers of patients. It is likely that
the longer the duration of abstinence, the better. However,
even if we cannot initiate tobacco use intervention weeks
or months before surgery, this should not prevent us from
intervening whenever we can. In the study by Lee et al., the
median number of preoperative days without a cigarette in
the intervention group was 1.
Systems of perioperative care are heterogeneous. Every
anesthesiapracticewillneedtodeterminehowbesttoembed
routine tobacco use interventions into its routine care. We
need to move beyond small efficacy studies of tobacco use
interventions to widespread implementation and adoption
studies to guide clinicians about how best to incorporate
such interventions into their practices. However, there is
no longer any excuse for not consistently intervening if we
truly are perioperative physicians and if we truly care about
the long-term health of our patients. The longer we delay,
the more our patients will die of tobacco-related diseases.
If concerns about the health of our patients were not
enough, there are also new incentives to intervene. The
Center for Medicare and Medicaid Services provides sep-
arate reimbursement for tobacco use interventions. The
Affordable Care Act requires that private insurers cover effi-
cacious preventive services, including tobacco use interven-
tions.21
The American Society of Anesthesiologists House of
Delegates has endorsed perioperative smoking abstinence
as a metric that is intended to become a Physician Quality
Reporting Measure for anesthesiologists. The American
Society of Anesthesiologists provides several resources
to help those who want to learn more at www.asahq.org/
stopsmoking.
Thanks to the work of Lee et al., we now know that a
relatively simple, eminently feasible tobacco use interven-
tion works to help surgical patients quit smoking. It is time
for all surgical patients entering the perioperative surgical
Figure 1. Calculation of the number of additional smokers who
would be abstinent at 1 year postoperatively if the results of Lee et
al. were widely applicable.

3. E EDITORIAL
512 www.anesthesia-analgesia.org anesthesia analgesia
home to receive such interventions as a routine part of their
care. All we need are anesthesiologists willing to open the
door. Our patients deserve nothing less. E
DISCLOSURES
Name: David O. Warner, MD.
Contribution: This author is the sole contributor to this work.
Attestation: David O. Warner approved the final manuscript.
Conflicts of Interest: David O. Warner has received a research
grant from Pfizer to develop an online educational module to
teach anesthesiology and surgery residents how to help their
patients quit smoking.
This manuscript was handled by: Steven L. Shafer, MD.
REFERENCES
1. Current cigarette smoking among adults—United States, 2011.
MMWR Morb Mortal Wkly Rep 2012;61:889–94
2. Fiore M, Jaen C, Baker T. Treating Tobacco Use and Dependence:
2008 Update. Clinical Practice Guideline. Rockville, MD: U.S.
Department of Health and Human Services, Public Health
Service, May 2008
3. Kain ZN, Vakharia S, Garson L, Engwall S, Schwarzkopf R,
Gupta R, Cannesson M. The perioperative surgical home
as a future perioperative practice model. Anesth Analg
2014;118:1126–30
4. Lee SM, Landry J, Jones PM, Buhrmann O, Morley-Forster P.
Long-term quit rates after a perioperative smoking cessation
randomized controlled trial. Anesth Analg 2015;120:582–7
5. Lee SM, Landry J, Jones PM, Buhrmann O, Morley-Forster P.
The effectiveness of a perioperative smoking cessation pro-
gram: a randomized clinical trial. Anesth Analg 2013;117:605–13
6. Thomsen T, Villebro N, Møller AM. Interventions for pre-
operative smoking cessation. Cochrane Database Syst Rev
2014;3:CD002294
7. Shi Y, Warner DO. Surgery as a teachable moment for smoking
cessation. Anesthesiology 2010;112:102–7
8. Wong J, Abrishami A, Yang Y, Zaki A, Friedman Z, Selby P,
Chapman KR, Chung F. A perioperative smoking cessation
intervention with varenicline: a double-blind, randomized,
placebo-controlled trial. Anesthesiology 2012;117:755–64
9. Møller AM, Villebro N, Pedersen T, Tønnesen H. Effect of pre-
operative smoking intervention on postoperative complica-
tions: a randomised clinical trial. Lancet 2002;359:114–7
10. Lindstrom D. The impact of tobacco use on postoperative com-
plications. Ann Surg 2008;248:739–45
11. Warner DO, Patten CA, Ames SC, Offord KP, Schroeder DR.
Effect of nicotine replacement therapy on stress and smoking
behavior in surgical patients. Anesthesiology 2005;102:1138–46
12. Cummings KM, Fix B, Celestino P, Carlin-Menter S, O’Connor
R, Hyland A. Reach, efficacy, and cost-effectiveness of free nico-
tine medication giveaway programs. J Public Health Manag
Pract 2006;12:37–43
13. Anderson CM, Zhu SH. Tobacco quitlines: looking back and
looking ahead. Tob Control 2007;16 Suppl 1:i81–6
14. PbertL,OckeneJK,EwyBM,LeicherES,WarnerD.Development
of a state wide tobacco treatment specialist training and certifi-
cation programme for Massachusetts. Tob Control 2000;9:372–81
15. Warner DO, Klesges RC, Dale LC, Offord KP, Schroeder DR,
Vickers KS, Hathaway JC. Telephone quitlines to help surgical
patients quit smoking patient and provider attitudes. Am J Prev
Med 2008;35:S486–93
16. Owings MF, Kozak LJ. Ambulatory and inpatient procedures
in the United States, 1996: National Center for Health Statistics.
Vital Health Stats 1998
17. Mills E, Eyawo O, Lockhart I, Kelly S, Wu P, Ebbert JO. Smoking
cessation reduces postoperative complications: a systematic
review and meta-analysis. Am J Med 2011;124:144–54.e8
18. Warner DO. Perioperative abstinence from cigarettes: physio-
logicandclinicalconsequences.Anesthesiology2006;104:356–67
19. Nåsell H, Adami J, Samnegård E, Tønnesen H, Ponzer S. Effect
of smoking cessation intervention on results of acute fracture
surgery: a randomized controlled trial. J Bone Joint Surg Am
2010;92:1335–42
20. Turan A, Mascha EJ, Roberman D, Turner PL, You J, Kurz A,
Sessler DI, Saager L. Smoking and perioperative outcomes.
Anesthesiology 2011;114:837–46
21. McAfee T, Babb S, McNabb S, Fiore MC. Helping smokers
quit—opportunities created by the affordable care act. NEJM
2014;372:5–7