Over 42 million adults in the United States are smokers and every year, millions of smokers are required to undergo surgery with anesthesia. A large percentage of this group want to quit smoking, as it is a well-known fact that it can increase the risk of post-operative complications. Still, many patients will not be able to quit or think they do not need to. Most know that there is always free help available to get them to quit. So, what is your role in motivating patients? Do you even have a role at all? As a doctor, it is your job to engage and educate your patients on their health, as well as the benefits and risks associated with surgical procedures. A time to undergo surgery is a teachable moment for you to promote smoking cessation and motivate patients to adopt healthy behaviors that reduce risk.
Studies have shown that the need to undergo surgery is an excellent motivation for patients to stop smoking. At this time, or rather quit date, patients do not report added stress, nor do they experience an increased craving for cigarettes. The reasons remain unknown but experts stress that it could be due to pain medications provided following surgery and a disruption in daily routine. Still, it has been found that quitting smoking before surgery can lower the risk of post-operative complications.
For several years now, the American Society of Anesthesiologists (ASA) has been educating and raising awareness among the public on smoking and offering much-needed resources to doctors for helping their patients. Since most doctors are not specifically trained in smoking cessation, the ASA strongly recommends a tactic that promotes open doctor-patient communication, called - Ask, Advise, and Refer. This tactic refers to asking the patient if they smoke. Even though you have patients’ medical histories on file, it helps to ask the patient face-to-face about their smoking status as part of their evaluation before undergoing surgery. This also shows your concern for their well-being. Next, you should advise the patient to quit smoking by focusing on two main points: letting them know that they can recover more easily and much better after the surgery if they do not smoke and letting them know that surgery is an excellent time to permanently stop smoking. Whether it is an initial 15-minute appointment or several appointments into their care, you should encourage the patient to avoid smoking before and after they have undergone surgery. Finally, you should refer the patient to telephone quit lines that provide free counseling and advice from experts on how to abstain from smoking. Nowadays, several practices have even set up patient referral programs such as tobacco treatment programs.
A recent study was conducted among 175 doctors and 347 patient-smokers, where each individual was asked to complete a written questionnaire about their behaviors and attitudes toward quitting smoking. It was found that over 50% of the patients had made 2-5 attempts throughout their lives to quit smoking. Their motivation came from concerns for their own health, concern for the health of their family members and friends, as well as high cost of cigarettes. The study also found that both the doctors and the patients agreed the limitations to smoking cessation came from withdrawal symptoms and addiction. However, the differences were seen in perception. Over 78% of doctors said that they started the initial dialogue about smoking cessation, while 63% of the patient-smokers said that they started the initial dialogue. While both groups saw the value of health as being the most significant factor for quitting smoking, both groups differed in their perception of who initiated the conversation.
This goes to show that there may be times when your patients will believe they can quit smoking on their own without receiving any medical advice or they may be embarrassed to talk to you out of fear of being lectured. In any case, your patients expect you to address their smoking because it does have an impact on their health. In fact, surveys have found that patients who smoke are more satisfied with their care if their doctors address their smoking using an empathetic approach. “Several studies have shown that in current smokers, frequent exercise and healthy food can mitigate some of the harmful effects of cigarette smoking. Exercise may help with smoking cessation as well. In addition, by discussing stress reduction in smokers who smoke because they are stressed out, we again may ultimately help them to quit. The take home message is that next time you encounter a patient who smokes and does not wish to quit, instead of rolling your eyes back and brushing him or her off, actively pursue other positive lifestyle changes,” wrote Tamir Katz, family physician.
By building solid relationships with your patients, you can help change their perceptions, especially when it comes to risks associated with surgical procedures. If your patients have the same beliefs and motivation toward the importance of maintaining good health, they should be open to dialogue and much-needed change. By enforcing powerful tactics, you can help make a difference in the lives of your patients who are smokers. “More and more hospitals, insurers, and clinics are providing tobacco cessation counseling resources. In addition, you can discuss the use of over-the-counter or prescription smoking cessation medications, if appropriate, to help relieve withdrawal symptoms. Of course, if you take just a few minutes to offer the patient some brief counseling before referring them to another resource, this is even better and can make a big difference. For patients who are not interested in quitting, saying something as simple as - I'm here to help you whenever you are ready to quit - can leave the door open for them to raise this issue in the future while letting them know that you care,” wrote Dr. Tim McAfee, Director of the Office on Smoking and Health at CDC.
You may even consider leaving a few pamphlets on smoking in the waiting room of your practice or in your office, just as a helpful reminder when it comes to addressing the issue of smoking cessation. In addition, get involved in your community and emphasize the need to reduce smoking and support tobacco control efforts. The main point to be made is that patients who are smokers and who need to undergo surgery are at an increased risk of experiencing complications post-surgery. What’s more, smoking-related diseases increase anesthetic risks, on top of complications during surgery and post-operative care. Anesthesia is much safer and more predictable in non-smokers because the heart, lungs, blood vessels, and nervous systems are able to function much better. Educate your patients on such matters – they may be more receptive to your advice than you think.
It is no secret that as a doctor, you want the best outcomes for your patients. You do not want to deny them surgery but at the same time, you want to prevent them from experiencing complications. For this reason, ask your patients who smoke to stop at least 4-6 months before and after their surgery. Sit down with them and prompt an open dialogue on the barriers that are preventing them from quitting. Together, explore what it would take to get them to be more interested in quitting – either with use of medications, social support, or any other method that could improve their chances of quitting. Your role is important in identifying, assessing, treating, following-up, and referring your patients who are smokers. Remember that more than 75% of smokers want to quit and even a small piece of advice from you can make a big difference. Use resources at your disposal that will help support your efforts and will give your patients that extra push they need in order to quit for good.