This review demonstrates the long-term (≥12 months) efficacy of preoperative smoking cessation programs, providing further support for incorporation of smoking cessation programs into presurgical clinics.
Objectives: The aim of this review was to examine published randomized controlled trials (RCTs) and quasi-experimental studies that evaluate the association between preoperative smoking cessation programs and long-term smoking cessation at a minimum of 6 months, postoperatively.
Study Design: Systematic review and meta-analysis.
Methods: A systematic review was performed utilizing MEDLINE, EMBASE, CINAHL, PSYCHinfo, and COCHRANE databases. All eligible studies of smoking-cessation interventions initiated preoperatively, with cessation measured at a minimum of 6 months postoperatively, were identified. The effect of cessation interventions at 12 months postoperatively in RCTs was evaluated through meta-analyses using Mantel-Haenszel risk ratios (RRs) and 95% CIs. A fixed effects model was conducted initially; however, due to heterogeneity in study characteristics and patient cohorts, a more conservative random effects model was also performed.
Results: Four RCTs and 4 quasi-experimental studies were included. Two RCTs demonstrated an association between interventions and cessation at 12 months, and the quasi-experimental studies showed cessation rates of 48% to 56% at 12 months, postoperatively. In a fixed effects model, interventions were associated with a greater likelihood of cessation at 12 months (RR, 1.50; 95% CI, 1.05-2.15; P = .02), although this effect was not statistically significant after applying a random effects model (RR, 1.61; 95% CI, 0.88-2.96; P = .12).
Conclusions: The literature suggests that preoperative smoking cessation programs will likely precipitate long-term (≥12 months) cessation. Additional studies should identify approaches that optimize preoperative cessation programs in the promotion of short-term, and long-term cessation.
This systematic review and meta-analysis of 4 randomized controlled trials and 4 quasi-experimental studies supports the long-term (≥12 months) efficacy of preoperative smoking cessation programs.
Am J Manag Care. 2015;21(11):e623-e631Tobacco use is the leading cause of preventable death not only in the United States, but worldwide.1 Each year, 5 million deaths are attributed to tobacco use, with projections suggesting that by 2020, tobacco will kill more people than any single disease pathology—an annual mortality increase to 8 million by 2030.1-3 Further, smokers die on average 10 years earlier than their nonsmoking counterparts.1,4 These are particularly troubling trends in the context of plateaued progress in smoking cessation rates since 1990.3
Diseases associated with tobacco use include, though are not limited to, cancer, cardiovascular disease, respiratory disease, and both ischemic and embolic events. In the United States alone, the economic cost and healthcare expenditure associated with tobacco use is estimated at $97 billion and $96 billion, respectively.1 In a paradigm emphasizing cost reduction in healthcare provision, tobacco use should be a prime target for behavioral intervention to generate cost savings.
In the primary care setting, patients present to their primary care physician with multiple complaints at a majority of appointments; therefore, integration of preventative protocols may continuously prove more challenging. Alternate strategies should be explored; perioperative care presents a unique opportunity in both patient capture and incentivization.
It is estimated that approximately 10 million tobacco smokers undergo surgical intervention in the United States each year.5-7 Moreover, surgery precipitates spontaneous uptake of risk-reducing health behaviors8—it is a documented “teachable moment” for smoking cessation.9 Studies suggest that preoperative smoking cessation interventions can increase postoperative abstinence by up to 60%,10 with each additional week of cessation producing an improved cumulative effect.11 Surgeons, anesthesiologists, nurses, and other presurgical staff should seize this opportunity, not only to improve surgical outcomes, but also to promote smoking cessation.
After adjusting for demographic characteristics and baseline cigarette consumption, patients who have undergone continuous cessation for longer periods (≥3 months) are more likely to be continuously abstinent at approximately 2 years12—this highlights the importance of assessing long-term cessation. Additionally, despite a robust foundation of literature discussing the effectiveness of perioperative care as a teachable moment for smoking cessation at 3 months, few studies examine the effect at periods longer than 3 months.13
Two systematic reviews conducted in 2008 and 2010 to evaluate the impact of preoperative smoking cessation programs solicited the need for additional studies to more fully assess the impact of preoperative smoking cessation interventions on long-term abstinence.13,14 This systematic review and meta-analysis sought to evaluate the current literature with regard to the impact of preoperative smoking cessation programs on long-term cessation beyond 6 months postoperatively.
Two authors (NLB and CMC) independently conducted a literature search using: 1) Ovid MEDLINE, 2) Ovid EMBASE, 3) EBSCO CINAHL, 4) Ovid PSYCHinfo, and 5) the COCHRANE Database of Systematic Reviews, Database of Abstracts and Review of Effects, and Central Register of Controlled Trials for studies published prior to July 19, 2013.
The authors searched Ovid MEDLINE with the following search strategy: first, they performed a search including the Medical Subject Heading (MeSH) terms and Boolean connectors, “smoking cessation” (exploded and focused) OR “tobacco use cessation” (exploded and focused) AND “surgery.mp” OR “perioperative care” (exploded) OR “perioperative period” (exploded) OR “anesthesia” (exploded) with an additional limit to the English language. This produced 208 articles. Similar search strategies were applied to the Ovid EMBASE (344 articles), EBSCO CINAHL (148 articles), and Cochrane databases (66 articles). The authors also searched Ovid PSYCHinfo with the MeSH term, key words, and Boolean connectors, “smoking cessation” (expanded and focused) AND “surgery” or “surgical patients,” which produced 20 articles.
Study Selection, Inclusion and Exclusion Criteria
After duplicates were removed, the authors independently screened the 506 remaining abstracts against the following inclusion and exclusion criteria defined a priori (Figure 1). Studies that met eligibility for inclusion employed a smoking cessation intervention begun preoperatively with a primary or secondary outcome of smoking cessation. In addition, only prospective interventional studies, including randomized controlled trials (RCTs) or quasi-experimental study designs, were considered for inclusion to improve the specificity of patient information reported, as well as to evaluate a prospectively designed cessation intervention. The remaining studies were excluded if smoking cessation was not measured at a minimum of 6 months postoperatively, if the sample included patients not undergoing surgery, or if the intervention failed to include a behavioral component of the smoking cessation program. The inclusion of an individualized behavioral component in smoking cessation programs, such as motivational interviewing, has been shown to assist with smoking cessation.15
Two authors (NLB and CMC) independently reviewed potentially eligible studies and selected relevant studies for inclusion in this review. All disagreements were resolved through discussion between the 2 authors until consensus was achieved. Of the 506 articles initially identified, the authors excluded 341 upon review of titles and abstracts; among the 165 remaining articles, 157 were excluded upon full review of the article against the exclusion criteria. The 2 most common reasons for exclusion were: 1) failure to meet study design inclusion criteria and 2) no smoking cessation intervention was performed.
Data Extraction and Statistical Analysis
Two authors (NLB and CMC) extracted data independently; discrepancies were resolved through reexamination until consensus was achieved. Extracted data included study design, sample size, patient demographics, depression screening, preoperative assessment of alcohol intake, type of surgery, intervention duration, intervention start relative to operation date, cessation team, modes of contact, postoperative follow-up period, nicotine-replacement therapy (NRT) use, and the method of verifying cessation at 6, 9, and 12 months.
All statistical analyses were performed using RevMan5 software (The Nordic Cochrane Centre, The Cochrane Collaboration, Copenhagen, Denmark).16 Mantel-Haenszel risk ratios and 95% CIs assuming both fixed and random effects models were used for the meta-analysis. Heterogeneity was tested using the I2 statistic, with a value of less than 25% representing no heterogeneity; 25% to 49%, low heterogeneity; 50% to 74%, moderate heterogeneity; and 75% or more, high heterogeneity.17
Eight studies18-25 met full eligibility criteria and, consequently, were included in this review. The studies took place in an array of developed countries (including Australia,20 Canada,21 Sweden,22 Denmark,23,24 the United Kingdom,25 and the United States18,19), and all, except a single article,18 were published between 2000 and 2010, included academic and nonacademic facilities, and encompassed a broad range of surgical specialties. In total, 716 patients were included, of which 604 patients were involved in RCTs. The characteristics of the 8 included studies are summarized in Table 1.
There were similarities and differences in patient demographics comprising the study samples. Patient age was relatively consistent.20-24 Gender was not equally distributed between the studies; female constitution of the intervention groups ranged from 22%18 to 100%,23 with the latter attributable to the context of a breast cancer clinic.
In the RCTs, potential confounding and effect-modifying variables were measured and controlled. The study samples included a broad spectrum of surgery types, including general, orthopedic, vascular, breast, and thoracic, as well as obstetrics and gynecology. The effect of alcohol intake was controlled through exclusion criteria or randomization in 4 studies.21-24 Depression or depressive symptoms were measured and controlled through exclusion criteria or randomization in 4 studies.21-24 The Fagerstrom Test for Nicotine Dependence, a validated test26 of physiological dependence, was included in the baseline assessment of 5 studies.19,21-24
The specific intervention characteristics of the preoperative smoking cessation programs are summarized in Table 2. All smoking cessation interventions included a behavioral component, as well as follow-up of at least 6 months postoperatively. The intervention length ranged from a single 45- to 90-minute counseling session23 to 2 counseling sessions over the course of 6 months.25 The intervention was either “brief” (no extension into the post hospital discharge period) or “extended” (extension into the post hospital discharge period); 5 of the studies applied a brief intervention approach,18,20,23-25 and the remaining studies employed an extended approach.19,21,22
The cessation interventions began a minimum of 3 to 7 days23 to a maximum of 6 months25 preoperatively, and, most commonly, emphasized a theme of self-efficacy.19-24 Four of the reviewed studies utilized a nurse-driven approach19,21,22,24 and 1 study utilized an interactive computerized smoking cessation program.20 All but a single study20 employed a face-to-face method of contact during the intervention, with 3 studies also including phone contact.19,21,22 NRT was offered free of charge in 4 studies21-24 and was highly encouraged in 1 quasi-experimental study.19 Only 2 studies indicated the timing or length of the NRT: in 1 study,23 patients were given nicotine replacement 6 to 8 weeks prior to the operation, and in the other study,23 patients were given the therapy during the perioperative period of 2 days before the operation until 10 days postoperatively.
The verification method for smoking cessation at 6, 9, and 12 months postoperatively varied among the studies. Three studies utilized biochemical verification through measuring either expired carbon monoxide or urine cotinine,19,21,24 and the 5 remaining studies relied on self-reporting of smoking cessation behavior.
Effect of Cessation Program
The primary outcome for the included studies was smoking cessation at 6 or more months, postoperatively. Three studies found a statistically significant association between preoperative intervention and smoking cessation at 12 months.18,22,24 Additionally, 1 study found an association at 6 months—this association was not significant at 12 months postoperatively, however21—and 1 study demonstrated a nonsignificant trend in the same direction.23 Although no statistical analysis was reported, another study cited a 48% cessation rate.25
The rate of cessation at 12 months in the intervention groups ranged from 13% 23 to 33%22 compared with 4.4%24 to 19.7%21 in the control groups in the 4 RCTs. In the quasi-experimental studies, the rate of smoking cessation at 12 months postoperatively ranged from 48%25 to 56.3%.18 When smoking status at 12 months was assessed in RCTs using a fixed effects model, preoperative cessation interventions significantly predicted cessation (risk ratio [RR], 1.50; 95% CI, 1.05-2.15; P = .02). Moderate heterogeneity (57%) was likely attributable to disparate study population characteristics with regard to the surgical interventions and variations in applied interventions. Given the level of heterogeneity, the decision was made to also include a random effects model as a more conservative assessment of the available data. When subjected to this model, the perceived effect was not statistically significant (RR, 1.61; 95% CI, 0.88-2.96; P = .11) (Figure 2).
Assessment of Risk of Bias
An assessment for potential sources of bias, including loss to follow-up, lack of allocation concealment or blinding, and not using an intent-to-treat analysis was performed for RCTs. Generally, these studies were comprehended to demonstrate a low risk of bias. The bias assessment is summarized in Table 3. According to predefined risk of bias categories, the average study quality design was 90.6%. One study demonstrated a loss-to-follow up proportion of greater than 20%,21 and all RCTs included an intention-to-treat analysis. Additionally, consequent to the lack of randomization inherent to the quasi-experimental studies, these studies demonstrated a higher risk of bias when compared with their RCT counterparts.
At the outcome level, a risk of bias was identified in 2 RCTs,22,23 as well as in 3 of the 4 quasi-experimental studies18,20,25 for failure to utilize a method of biochemical verification to ascertain smoking status at 12 months postoperatively. The failure to report baseline characteristics and loss to follow-up may have also predisposed 1 study25 to greater risk of bias.
The studies conducted by Sadr Azodi (2009),22 Villebro (2008),24 and Aldrete (1987)18 suggest the efficacy of preoperative cessation interventions on precipitating long-term cessation. Other studies provide further support for this association, with Walker (2008)21 demonstrating a 48% cessation rate at 12 months following preoperative intervention and Ratner (2004)25 showing an association at 6 months postoperatively. The meta-analysis of the pooled RCT results at 12 months (RR, 1.50; P = .02) confirms this association under a fixed effects model. These findings cumulatively support the preoperative period as a “teachable moment”9 for precipitating long-term (12 months) smoking cessation behaviors.
When subjected to a random effects model, the association between preoperative smoking cessation interventions and cessation at 12 months postoperatively was not statistically significant. This discrepancy highlights an important opportunity: a random effects model is considered more conservative when contrasted with its fixed effects counterpart and, therefore, is more likely to attribute the association to chance alone—a phenomenon also appreciated with studies of low power. It is likely that the attenuated association in the random effects model of the meta-analysis derives from a deficit in number of studies (low power) exploring the efficacy of the association. Therefore, the discrepancy in significance importantly illustrates the need for further RCTs to explore this issue.
Limitations and Strengths
The included studies encompass an array of cessation program characteristics, patient populations, and surgical services. The heterogeneity of these characteristics, however, resulted in an inability to draw conclusions about specific groups of patients, types of surgery, or intervention strategies that most effectively predict and produce long-term cessation. Further studies are needed to assess how the severity of the patients’ clinical diagnoses and association with a personal smoking history may play a role in the efficacy of cessation programs. The significance of these limitations is minimized by the cumulative demonstration that cessation interventions could effectively yield long-term smoking cessation. Another limitation of this review is the restricted number of high-quality studies measuring the outcome of smoking cessation at 12 months following preoperative intervention. This deficit, however, is reflective of a shortcoming in the current literature and highlights the continued need for further research.
Additionally, the included studies were limited by the reliance upon self-reported smoking behaviors to measure the primary outcome of long-term cessation, which may also highlight a potential measurement bias of the existing literature. Five of the included studies relied on self-report, including 2 RCTs and 3 quasi-experimental studies. Although self-report is considered a validated measure of cessation behavior, a systematic review in 2009 documented trends of underestimation of smoking behavior.27,28 Future studies of preoperative smoking cessation programs should weigh the costs and benefits of direct measurement to determine if increased precision through biochemical verification is justified for the study purposes. One quasi-experimental study18 was performed prior to 1990, potentially limiting generalizability to more current dates. This study was not included in the meta-analysis due to study design; thus, there was no effect on the pooled results of the included RCTs.
There are several strengths to this review. The first is the geographic breadth of the included studies, which affords strength to the drawn conclusions and is further enhanced by the quality of the included literature. Additional strengths include the novel contributions of this paper—a broader inclusion of prospective interventional studies and a more comprehensive search of relevant databases. However, although the diversity of study locations may afford strength to the drawn conclusions, generally, it may also theoretically limit specific applicability to the United States. Two of the 8 total studies included in this review were conducted in the United States. It is possible that cultural differences exist between the study locations that may have an effect on the association between preoperative smoking cessation programs and long-term cessation. Notably though, the estimated annual cigarette consumption per adult in these study locations did not differ dramatically from that of the United States.29 Further research should be pursed to confirm this association among patients in the United States, with increased attention to understand the role of healthcare setting, patient demographics, and intervention characteristics.
Toward the Future
The heterogeneity of the study characteristics precludes conclusions to be drawn about the most effective intervention strategies and is beyond the aim of this paper. However, it is notable that 3 studies21,22,24 demonstrating statistical significance utilized nurse-driven interventions in academic hospital settings. The benefits of a nurse-driven cessation program include that nurses may be an effective and less costly alternative to physicians for providing 10 to 15 minutes of cessation counseling and that physicians may not have sufficient time to perform regular face-to-face counseling for their surgical patients in busy clinical settings.30 Given these advantages and the findings of the current literature, nurse-driven interventions may be an effective approach to preoperative smoking cessation programs and should be considered more closely.
The timing of the cessation intervention also deserves further examination. The studies demonstrating a significant association between preoperative smoking cessation interventions and long-term cessation at 12 months varied in duration, with the shortest intervention beginning in the pre-anesthetic visit and extending into the perioperative period,18 and the longest intervention beginning 6 to 8 weeks prior to the operation and extending to 10 days postoperatively.24 This prevented determination of the impact of intervention duration on long-term cessation behavior. Several studies suggest that more intensive preoperative interventions, both in frequency and duration, precipitate improved long-term (at 12 months) cessation.12,13
The impact of brief versus intensive interventions should also be further analyzed to determine if interventions are effective if completed in the preoperative period, or if extension into the postoperative period is beneficial. Future research should seek to elucidate the optimal preoperative time frame during which to initiate smoking cessation interventions31; therefore, additional trials should be conducted to examine length of intervention duration, the ideal preoperative time frame for implementation, and the impact of purposeful care coordination (between surgical and primary care services).
The barriers to embracing smoking cessation strategies have been widely documented. Briefly, they include (though are not limited to) a lack of organizational support, perceived patient objection, perceived lack of efficacy of cessation care, and the prohibitive cost to provide cessation intervention care.32 With knowledge of these barriers, solutions should be pursued, especially in the context of proposals demonstrating the cost-effectiveness of preoperative smoking cessation interventions.33 Reimbursement for engaging in smoking cessation counseling reflects the desirability of integration of this behavior into healthcare provision—the Current Procedural Terminology Codes 99406 and 99407 reimburse for tobacco cessation counseling.
Systems deficits should also be addressed. It is established that consistent cessation counseling is not optimally applied to all smokers. For example, one study found that patients who smoked more than 11 cigarettes per day were preferentially receiving cessation counseling compared with their counterparts smoking 10 cigarettes or fewer.34 This is exacerbated by the statistics that only 30% of anesthesiologists and 58% of surgeons engage their patients in preoperative cessation counseling discussions.6,35 With a growing emphasis on quality initiatives, surgeons and hospitals may have greater incentive to implement smoking cessation interventions as a means for improving surgical outcomes, as well as promoting long-term health benefits.
There exists a notion that the brief nature of current preoperative interventions precludes the attainment of long-term cessation14—the results of this review challenge this concept. This review acknowledges the robust foundation of evidence that supports the effectiveness of preoperative interventions on smoking cessation at less than 3 months, but establishes that long-term (12 months) cessation may also be achievable within the current paradigm of preoperative smoking cessation interventions. The understanding that individuals who execute longer periods of abstinence have an enhanced likelihood of cessation,12 further reinforces the need for preoperative cessation programs to be designed with dual outcomes—maintaining perioperative, as well as long-term, cessation.
The evidence in this review supports conclusions documented in the existing literature: preoperative smoking cessation interventions effectively enhance cessation rates.9,11,13,14 Through embracing broader study design criteria and expanding the databases investigated, this systematic review enhances the foundation of supporting evidence. This review specifically generates (some) evidence supporting the efficacy of preoperative smoking cessation interventions on likely precipitating long-term cessation at 12 months. In doing so, it strengthens and reemphasizes the previously identified need for studies analyzing this association.13,14 Further, it identifies an important opportunity to improve health and lessen the burden that adverse personal behavior places on our health system. Author Affiliations: Yale School of Public Health, Yale University (NLB), New Haven, CT; School of Medicine (NLB, CMC) and School of Public Health (CB), University of Colorado, Aurora, CO, Denver-Seattle Center of Innovation, VA Eastern Colorado Health Care System (CB), Denver, CO.
Source of Funding: None.
Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.
Authorship Information: Concept and design (NLB, CMC, CB); acquisition of data (NLB, CMC); analysis and interpretation of data (NLB, CMC, CB); drafting of the manuscript (NLB, CMC); critical revision of the manuscript for important intellectual content (NLB, CMC, CB); and statistical analysis (NLB, CMC).
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Address correspondence to: Catherine Battaglia PhD, RN, University of Colorado School of Public Health, 13808, East 19th Ave, Mail Stop 8700, Aurora, CO 80045. E-mail: Catherine.Battaglia@ucdenver.edu.