Rizcion Dagani, DPM, MBA Podiatry Resident, PGY-3

Madigan Army Medical Center

Tobacco Use in the United states

Implications in the Surgical Patient

Effects on Bone Healing

Effects on Wound Healing

Implications for Anesthesia

Smoking Cessation

5.1% of all adults (36.5 million people) smoke cigarettes1

Use of smokeless tobacco increasing in many areas as is combination use of cigarettes and smokeless tobacco2

Image Sources: Huffington Post, Centers for Disease Control and Prevention

4000+ chemicals in cigarette smoke2 Two phases of cigarette smoke3

Volatile Phase Particulate Phase

Systems most affected4 Pulmonary Cardiovascular Immune System Wound Healing

Image Source: Centers for Disease Control and Prevention

Several studies reveal an increased prevalence of overall post-operative complications in smokers vs. non-smokers Peri-operative complications include:

Non-union or delayed union of surgical and non-surgical/traumatic fractures Delayed wound healing Pulmonary complications Increased rate of infection Increased risk of thrombus

Image Source: American Podiatric Medical Association

Prolonged healing time

Increased rates of non-union

Decreased quality of bone repair

Impaired collagen production

Decreased bone density

Impaired cellular function and formation

Image Source: Nature Reviews Rheumatology 5

Decreased peripheral blood flow Decreased tissue oxygenation and aerobic metabolism6

Direct inhibition of cellular function

Increased risk of infection

Increased risk of pulmonary complications in OR or PACU

Impaired cellular function

Reduced pulmonary capacity

Increased carbon monoxide levels

Selection of anesthetic agents

Greater frequency of chronic pain

Increased requirements of postoperative analgesia

Increased risk of DVT/PE

Reduces pulmonary and wound-related complications 2

Overall relative risk reduction of 41% across multiple surgical subspecialties 11

Effects on bone at least partially reversible 3

Each additional week of cessation decreased effect of smoking by 19% 2

Short-term success Only 22% of patients remained tobacco-free at 1 year-post-op 2

1 in 5 Americans use tobacco

Effects of tobacco can be seen particularly in bone healing, wound healing, cardiovascular complications

Pre-operative smoking cessation is beneficial as effects of smoking/risk of post-op complications can be partially reversed

1. Centers for Disease Control and Prevention. Smoking and Tobacco Use. https://www.cdc.gov/tobacco/ 2. Stephens,BF, Murphy,A & Mihalko,WM. (2013). The effects of nutritional deficiencies, smoking, and systemic disease on

orthopaedic outcomes. The Journal of bone and joint surgery. American volume, 95(23), 2152-7. 3. Lee, John J, Patel, Rakesh, Biermann, J Sybil & Dougherty, Paul J. (2013). The Musculoskeletal Effects of Cigarette Smoking The

Journal of Bone and Joint Surgery-American Volume, 95(9), 850-859. doi:10.2106/JBJS.L.00375 4. 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(3), 297-306. doi:10.1093/bja/aen401 5. Einhorn, Thomas A. & Gerstenfeld, Louis C.. (2014). Fracture healing: mechanisms and interventions Nature Reviews Rheumatology,

11(1), 45-54. doi:10.1038/nrrheum.2014.164 6. Sørensen, Lars Tue. (2012). Wound Healing and Infection in Surgery - The Pathophysiological Impact of Smoking, Smoking Cessation,

and Nicotine Replacement Therapy Annals of Surgery, 255(6), 1069-1079. doi:10.1097/SLA.0b013e31824f632d 7. Myles, Paul S., Iacono, George A., Hunt, Jennifer O., Fletcher, Helen, Morris, John, McIlroy, David & Fritschi, Lin. (2002). Risk of

Respiratory Complications and Wound Infection in Patients Undergoing Ambulatory Surgery - Smokers versus Nonsmokers Anesthesiology, 97(4), 842-847. doi:10.1097/00000542-200210000-00015

8. Kotani,N, Kushikata,T, Hashimoto,H, Sessler,DI, Muraoka,M & Matsuki,A. (2001). Recovery of intraoperative microbicidal and inflammatory functions of alveolar immune cells after a tobacco smoke-free period. Anesthesiology, 94(6), 999-1006.

9. Rutgers Virtual Labs – Cardiobvascular & Respiratory Systems. http://bio.rutgers.edu/~gb102/lab_10/skip.html 10. Warner, David O. (2007). Tobacco dependence in surgical patients Current Opinion in Anaesthesiology, 20(3), 279-283.

doi:10.1097/ACO.0b013e3280c60c3b 11. Scolaro, John A, Schenker, Mara L, Yannascoli, Sarah, Baldwin, Keith, Mehta, Samir & Ahn, Jaimo. (2014). Cigarette Smoking

Increases Complications Following Fracture: A Systematic Review The Journal of Bone and Joint Surgery-American Volume, 96(8), 674-681. doi:10.2106/JBJS.M.00081

12. Beyth, Shaul, Mosheiff, Rami, Safran, Ori, Daskal, Anat & Liebergall, Meir. (2015). Cigarette Smoking Is Associated with a Lower Concentration of CD105 + Bone Marrow Progenitor Cells Bone Marrow Research, 2015, 1-6. doi:10.1155/2015/914935

13. Bhargava, Amit & Greiss, M.E.. (2007). Effects of smoking in foot and ankle surgery—An awareness survey of members of the British Orthopaedic Foot & Ankle Society The Foot, 17(3), 132-135. doi:10.1016/j.foot.2006.12.001

14. MOSELY, LINDA H., FINSETH, FREDERICK & GOODY, MARGARET. (1978). NICOTINE AND ITS EFFECT ON WOUND HEALING Plastic and Reconstructive Surgery, 61(4), 570-575. doi:10.1097/00006534-197804000-00013

15. Miller,S. (2014). How smoking can hinder fracture healing. Emergency nurse : the journal of the RCN Accident and Emergency Nursing Association, 22(4), 28-30; quiz 31. doi:10.7748/en.22.4.28.e1219

16. Nåsell, Hans, Ottosson, Carin, Törnqvist, Hans, Lindé, Johannes & Ponzer, Sari. (2011). The Impact of Smoking on Complications After Operatively Treated Ankle Fractures—A Follow-Up Study of 906 Patients Journal of Orthopaedic Trauma, 25(12), 748-755. doi:10.1097/BOT.0b013e318213f217

17. Patel, R. A., Wilson, R. F., Patel, P. A. & Palmer, R. M.. (2013). The effect of smoking on bone healing: A systematic review Bone and Joint Research, 2(6), 102-111. doi:10.1302/2046-3758.26.2000142

18. Ring, J., Shoaib, A. & Shariff, R.. (2017). Smoking cessation advice in limb reconstruction: An opportunity not to be missed Injury, 48(2), 345-348. doi:10.1016/j.injury.2016.12.004

19. Santolini, Emmanuele, West, Robert & Giannoudis, Peter V.. (2015). Risk factors for long bone fracture non-union: a stratification approach based on the level of the existing scientific evidence Injury, 46, S8-S19. doi:10.1016/S0020-1383(15)30049-8

20. Sweetland, S., Parkin, L., Balkwill, A., Green, J., Reeves, G. & Beral, V.. (2013). Smoking, Surgery, and Venous Thromboembolism Risk in Women: United Kingdom Cohort Study Circulation, 127(12), 1276-1282. doi:10.1161/CIRCULATIONAHA.113.001428

21. Walker, N.M., Morris, S.A.C. & Cannon, L.B.. (2009). The effect of pre-operative counselling on smoking patterns in patients undergoing forefoot surgery Foot and Ankle Surgery, 15(2), 86-89. doi:10.1016/j.fas.2008.08.005

22. Wei Lei, Chad Lerner, Isaac K. Sundar & Irfan Rahman. (2017). Myofibroblast differentiation and its functional properties are inhibited by nicotine and e-cigarette via mitochondrial OXPHOS complex III Scientific Reports, 7, 43213. doi:10.1038/srep43213