January 2014 marked the 50th anniversary of a milestone. On January 11, 1964, Luther L. Terry, MD, then Surgeon General of the U.S. Public Health Service, released the first report of the Surgeon General’s Advisory Committee on Smoking and Health. Based on the analysis of more than 7,000 articles relating to smoking and disease, the committee concluded that cigarette smoking is: (1) a cause of lung cancer and laryngeal cancer in men, (2) a probable cause of lung cancer in women, and (3) the most common cause of chronic bronchitis.1
The release of the report was the first in a series of steps to diminish the impact of tobacco use on the health of the American people. In the 50 years that have elapsed since then, individual citizens, private organizations, public agencies, and elected officials have pursued the advisory committee’s call for “appropriate remedial action.” Following Dr. Terry’s report, the U.S. Congress adopted the Federal Cigarette Labeling and Advertising Act of 1965 and the Public Health Cigarette Smoking Act of 1969.2,3 These laws required that cigarette packages include a health warning, banned cigarette advertising in the broadcast media, and called for an annual report on the health consequences of smoking.
Negative effects on society
Tobacco use is the leading cause of preventable disease and death in the U.S., and roughly 20 percent of Americans smoke. The global use of tobacco products is increasing, killing 5.4 million people each year and accounting for one in 10 adult deaths worldwide.4 Almost half of the world’s children breathe air polluted with tobacco smoke.4
Smoking costs the U.S. $133 billion in direct medical costs and $156 billion in lost productivity annually.5 An estimated 30 percent of elective surgery patients are smokers, meaning that approximately 10 million procedures are performed on smokers annually.6
Surgeons see firsthand the detrimental effects of smoking. Smoking within one year of surgery has been linked to delayed wound healing and wound infections; increased risk of deep venous thrombosis, hypertension, and myocardial infarction; shortness of breath and risk of respiratory infections; and implant and graft loss (see figure).
Most surgeons have spent at least some time counseling patients to quit smoking before they undergo surgical procedures (see Table 1). Studies show that most patients are asked about their smoking habits but are not routinely offered advice and counseling on how to quit. Elective surgery consultations provide a teachable moment, and the perioperative time may be an ideal opportunity for patients to quit, as abstinence is mandatory during hospitalization, and postoperative withdrawal symptoms may decrease due to the absence of smoking cues.
Table 1. Health care provider practices
|Inquired about patients’ tobacco habits||
|Advised patients to stop smoking||
|Provided smoking cessation counseling||
|*Yankie VM, Price HM, Nanfito ER, Jasinski DM, Crowell NA, Health J. Providing smoking cessation counseling: A national survey among nurse anesthetists. Crit Care Nurs Clin North Am.2006;18(1):123-129.|
|†France, EK, Glasgow, RE, Marcus, AC. Smoking cessation interventions among hospitalized patients: What have we learned? Prev Med. 2001;32:376-388.|
Despite the higher reimbursement associated with billing for smoking cessation counseling to Medicare patients through the use of Current Procedural Terminology (CPT) codes 99406, 99407, G0436, G0437, the adverse consequences of tobacco use continue to be documented in the postoperative period. Examples of these negative outcomes include increasing incidence of wound infections and incisional hernias, which necessitate subsequent operations; use of expensive mesh products; and additional hospital stays, which, in turn, create the opportunity for further postoperative morbidity and mortality. (See Table 2 for complications by specialty.)
Table 2. Smoking-related complications by specialty
|General surgery||Superficial and deep wound infections, sepsis, anastomotic leaks, myocardial infarction, pneumonia, prolonged intubation, stroke|
|Cardiac||Pulmonary complications, sternal wound infection, vein graft failure, prolonged ventilator support, intensive care unit readmission|
|Plastic||Increased scarring, asymmetry, delayed wound healing, reduced skin flap survival, implant loss (breast)|
|Orthopaedic||Pneumonia, surgical site infections, impaired bone healing, increased postoperative pain, stroke|
|Pediatrics (parents smoking)||Anesthesia-related respiratory complications|
|Source: Khullar D, Maa J. The impact of smoking on surgical outcomes. J Am Coll Surg. 2012;215(3):418-426.|
ACS efforts to encourage surgeon action
The antismoking campaign of the last half-century can be viewed as a major public health success, but have we done enough in our individual discussions with patients relative to the adverse consequences of smoking?
This issue of the Bulletin includes the American College of Surgeons (ACS) “Statement on the effects of tobacco use on surgical complications and the utility of smoking cessation counseling.” The statement reviews the mounting evidence against smoking since the Surgeon General’s warning in 1964 and supports the following recommendations to reduce smoking-related surgical complications and smoking prevalence:
- Smoking cessation counseling at all non-emergent patient consultations
- Education programs on effective smoking cessation strategies and proper coding of interventions
- Development and dissemination of quality educational materials for surgeons to use in conjunction with their smoking cessation counseling
- Support for government regulation of tobacco products and incentives for individuals to avoid tobacco use
- Continued measurement and reporting of surgical outcomes of smokers versus nonsmokers
In addition, the ACS 2013 Clinical Congress featured a panel discussion, It Pays for Your Patients to Quit Smoking before Surgery: Outcomes, Interventions, and Reimbursement. The moderators and speakers provided details on the physiologic effects of nicotine and smoking on the public and on surgical outcomes. The panelists also described the various smoking cessation methods, the types and benefits of counseling, the incentives available to surgeons through the Affordable Care Act, and essential resources available to patients (see Tables 3 and 4).
Table 3. Tobacco cessation counseling
|Individual||Face-to-face patient contact||Patient must be competent and alert at counseling|
|Intermediate: Greater than 3 minutes and less than 10 minutes|
|Counseling by a qualified physician or practitioner|
|Intensive: Greater than 10 minutes|
|Group||Nicotine Anonymous||Search by state or call 877-TRY-NICA (877-879-6422)|
|Quit for Life coaching (American Cancer Society)|
|Quitlines||Telephone-based support programs with trained counselors||All 50 states have free quitlines, smokefree.gov, or 1-800-QUIT-NOW (800-784-8669)|
Table 4. Coding for tobacco cessation interventions
|Type of code||Eligible codes for symptomatic patients||Eligible codes for asymptomatic patients|
|CPT codes||99406, Smoking and tobacco-use cessation counseling visit||G0436, Smoking and tobacco cessation counseling visit for the asymptomatic patient|
|Intermediate: Greater than 3 minutes; up to 10 minutes||Intermediate: Greater than 3 minutes, up to 10 minutes|
|99407, Smoking and tobacco-use cessation counseling visit||G0437, Smoking and tobacco cessation counseling visit for the asymptomatic patient|
|Intensive: Greater than 10 minutes||Intensive: Greater than 10 minutes|
|ICD-9 Diagnosis codes||305.1, Tobacco use disorder and ICD-9 of condition adversely affected or condition for which treatment is adversely affected by tobacco use||Not specified|
|649.0x, Tobacco use disorder complicating pregnancy, childbirth, or puerperium|
|989.84, Toxic effect of other substances, chiefly nonmedicinal as to source, tobacco*|
|*2011 American Academy of Family Physicians.|
The ACS has developed a one-hour continuing medical education webinar, Quit Smoking, to help surgeons thoroughly understand smoking’s deleterious effects on surgical outcomes, the importance and methods for smoking cessation counseling, motivational interviewing, effective pharmacotherapy agents for a quit program and quitlines, and resources for patients. The launch date of the webinar will be announced in an upcoming issue of the weekly ACS NewsScope.
The ACS Quit Smoking brochure is a detailed and valuable resource to inform and help patients prepare an action plan for their smoking cessation initiative. (See sidebar for resources to which surgeons may refer patients.)
The brochure is also information-button ready, and meets all meaningful use and electronic health record requirements. The ACS patient resource, Quit Smoking Before Your Operation, is available.
In addition, the ACS supports a series of informational podcasts that are dedicated to topics of interest to the College, its Fellows, and the public. A recent episode of The Recovery Room was dedicated to smoking cessation and approaches to the patient who smokes.7 In this segment, host Frederick (Rick) Greene, MD, FACS, a surgical oncologist from Charlotte, NC, and an author of this article, interviews Eric Skipper, MD, FACS, chief of adult cardiothoracic surgery at the Sanger Heart & Vascular Institute, Charlotte; and Michael Rosen, MD, FACS, professor of surgery and chief of gastrointestinal and general surgery at Case Western Reserve University, Cleveland, OH, on how they approach and educate surgical patients who smoke.
Recommit to helping patients kick the habit
Throughout the last several decades, increasing attention has been given to smoking cessation, especially with respect to children and adolescents in the U.S. Landmark legislation banning the sale of cigarettes to those under the age of 21 in New York, NY, has spread throughout the country, perhaps reflecting a national desire to recognize that smoking is the primary inciting agent for a number of diseases and that the consequences of smoking are additive over time.8
More recently, we are challenged with the unknown consequences of electronic cigarettes and their possible addictive nature, raising the question: Is it only the carcinogens in cigarette and tobacco smoke, or is it nicotine as an antismoking crutch that has its own deleterious consequences? As 2014 marks a significant anniversary in our nation’s antitobacco campaign, perhaps now is the time for surgeons to recommit to educating patients about the consequences of smoking and potential life-threatening adverse outcomes for their surgical procedures. The best time in the elective surgical setting to begin educating and encouraging patients to work with their surgeon to reduce operative complications is at the preoperative stage.
The surgical community must continue to take the lead and highlight the significant consequences of smoking. All of the nation’s efforts to improve health care and to support health care reform will be meaningless unless we challenge patients to take responsibility for their own health and to reduce habits that, if nothing else, portend poor and preventable surgical outcomes.
- Terry L. Smoking and Health: Report of the Advisory Committee to the Surgeon General of the United States. U-23 Department of Health, Education, and Welfare. Public Health Service Publication No. 1103. 1964. Available at: http://profiles.nlm.nih.gov/ps/retrieve/ResourceMetadata/NNBBMQ). Accessed June 27, 2014.
- Federal Cigarette Labeling and Advertising Act of 1965. Public Law 89-92, U.S. Statutes at Large 79 (1965). Available at: www.gpo.gov/fdsys/pkg/STATUTE-79/pdf/STATUTE-79-Pg282.pdf. Accessed June 27, 2014.
- Reducing Tobacco Use. Public Law 91-222. Surgeon General’s Report. Available at: www.surgeongeneral.gov/library/reports/50-years-of-progress/sgr50-chap-1.pdf. Accessed June 27, 2014.
- World Health Organization. Report on the Global Tobacco Epidemic: 2009. Available at: www.who.int/tobacco/mpower/2009/mpower_report_2009_executive_summary_EN_11b.pdf. Accessed June 30, 2014.
- U.S. Department of Health and Human Services. The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2014.
- Tonnesen H, Nielsen PR, Lauritzen JB, Moller AM. Smoking and alcohol intervention before surgery: Evidence for best practice. Br J Anaesth. 2009;102(3):297-306.
- American College of Surgeons. The Recovery Room, Episode 23: Smoking Cessation and the Surgical Patient. Available at: www.facs.org/recoveryroom/episodes/023-smoking-cessation.html. Accessed June 24, 2014.
- American Lung Association. State of tobacco control. Available at: www.stateoftobaccocontrol.org/state-grades/new-york/highlights.html. Accessed June 30, 2014.