Smoking Cessation in Orthopaedic Surgery

Effects on Fracture and Fusion Healing

Osteoblast Dysfunction:

• Reduced proliferation and differentiation
• Decreased alkaline phosphatase activity
• Impaired bone matrix production
• Reduced response to BMP-2 and growth factors [2,3]

Angiogenesis Impairment:

• Decreased VEGF (vascular endothelial growth factor) expression
• Reduced capillary formation in fracture callus
• Impaired hematoma organization
• Delayed revascularization [4]

Mechanical Consequences:

• Reduced callus strength and stiffness
• Delayed mineralization
• Increased time to radiographic union
• Higher rates of delayed union and nonunion [5]

This section covers the bone healing impairment caused by smoking.

Effects on Soft Tissue and Wound Healing

Tissue Hypoxia:

• Vasoconstriction from nicotine (alpha-adrenergic stimulation)
• Carbon monoxide reduces oxygen-carrying capacity
• Decreased tissue PO2 by 30-50%
• Impaired cellular metabolism [6]

Immune Dysfunction:

• Reduced neutrophil chemotaxis and phagocytosis
• Impaired complement activation
• Decreased antibody production
• Reduced macrophage function [7]

Fibroblast Impairment:

• Reduced proliferation and migration
• Decreased collagen synthesis (Types I and III)
• Impaired extracellular matrix deposition
• Delayed epithelialization [8]

Clinical Consequences:

• Surgical site infection rates 3-6 times higher
• Wound dehiscence more common
• Delayed healing
• Hypertrophic scarring

This completes the wound healing section.

Specific Effects in Joint Arthroplasty

Periprosthetic Infection:

• 3-6x increased risk of deep infection in THA/TKA
• Biofilm formation enhanced
• Reduced antibiotic penetration
• Impaired host defenses [9]

Aseptic Loosening:

• Impaired osseointegration
• Reduced bone quality around implant
• Accelerated wear particle-induced osteolysis
• Higher revision rates at 10 years [10]

Other Complications:

• Increased dislocation risk (THA)
• Periprosthetic fracture
• Delayed mobilization
• Longer hospital stay

This completes the arthroplasty-specific effects.

Key Toxic Components in Tobacco Smoke

This section completes the mechanism review.

Smoking Status Classification

Quantifying Smoking Exposure

Pack-Years Calculation:

• Pack-years = (Cigarettes per day ÷ 20) × Years smoked
• Example: 20 cigarettes/day for 25 years = 25 pack-years

Fagerström Test for Nicotine Dependence

Key Questions:

1. How soon after waking do you smoke your first cigarette?
2. Do you find it difficult to refrain from smoking in places where it is forbidden?
3. Which cigarette would you hate most to give up?
4. How many cigarettes per day do you smoke?
5. Do you smoke more frequently in the first hours after waking?
6. Do you smoke if you are so ill that you are in bed most of the day?

Score Interpretation:

• 0-2: Very low dependence
• 3-4: Low dependence
• 5: Medium dependence
• 6-7: High dependence
• 8-10: Very high dependence

Preoperative Smoking Assessment

Essential History:

• Current smoking status (current, former, never)
• Cigarettes per day and pack-years
• Previous quit attempts and methods used
• Reasons for relapse if applicable
• Readiness to quit (stages of change)
• Household/social smoking exposure

Physical Examination Findings:

• Tobacco staining of fingers/teeth
• Chronic cough or sputum production
• Signs of COPD (barrel chest, prolonged expiration)
• Peripheral vascular disease signs
• Wound healing quality from previous surgeries

Stages of Change Assessment

Risk Stratification

Smoking Status Verification

Self-Report:

• Standard in clinical practice
• Generally accurate when patient trusts provider
• May underreport in settings where consequences exist

Biochemical Markers:

Preoperative Workup in Smokers

Consider Based on Smoking History:

• Chest X-ray (if greater than 20 pack-years or symptoms)
• Spirometry (if COPD suspected)
• ECG (if cardiac risk factors)
• Blood gas or SpO2 at rest (if respiratory symptoms)

Cotinine Testing Interpretation

Thresholds:

• Less than 10 ng/mL (serum/urine): Non-smoker
• 10-100 ng/mL: Light smoker or heavy secondhand exposure
• Greater than 100 ng/mL: Active smoker

Caveats:

• NRT use causes positive cotinine (use anabasine to differentiate)
• Passive smoke exposure can elevate levels
• Renal impairment affects clearance

Anabasine Testing:

• Tobacco-specific alkaloid
• Not present in NRT
• Differentiates NRT use from continued smoking
• More expensive, less widely available

Cessation Management Algorithm

First-Line Approach

1. Brief counseling (5 A's framework)
2. Pharmacotherapy - offer to ALL motivated smokers
3. Quitline referral (13 7848)
4. Set quit date - ideally 8+ weeks before surgery
5. Follow-up - within 1 week of quit date

Stepped Care Model

Level 1 - Brief Intervention (All Smokers):

• Ask, Advise, Refer
• Less than 5 minutes
• Prescribe pharmacotherapy or refer

Level 2 - Standard Care (Motivated Smokers):

• Full 5 A's counseling
• Pharmacotherapy prescription
• Quitline referral
• 2-4 follow-up contacts

Level 3 - Intensive Support (High Dependence, Failed Previous Attempts):

• Combination pharmacotherapy (varenicline + NRT or bupropion + NRT)
• Smoking cessation clinic referral
• Multiple behavioral sessions
• Extended pharmacotherapy (24 weeks)
• Address comorbidities (depression, anxiety, other substance use)

Intraoperative Management of Smokers

Anesthetic Considerations:

• Increased airway reactivity - higher risk of bronchospasm
• May need higher oxygen concentrations
• Impaired mucociliary clearance - secretion management
• Carbon monoxide displaces O2 - optimize oxygenation

Surgical Technique Modifications:

• Meticulous hemostasis (impaired wound healing)
• Consider tissue-sparing approaches when possible
• Avoid excessive tension on wound closure
• Thoughtful incision placement away from pressure points

Nicotine Replacement Perioperatively

Why Continue NRT Perioperatively?

Evidence supports continuing NRT:

• NO increase in wound complications with NRT
• Reduces withdrawal symptoms and agitation
• Decreases postoperative relapse risk
• Nicotine alone (without combustion products) is relatively safe

Common Misconception:

• Some anesthetists request stopping NRT preoperatively
• This is NOT evidence-based and increases relapse risk
• The harm from combustion products (CO, tar, etc.) far exceeds any theoretical nicotine concerns

Intraoperative Monitoring

• SpO2 may be falsely elevated in recent smokers (carboxyhemoglobin)
• Consider arterial blood gas if concern about tissue oxygenation
• Monitor for bronchospasm during intubation/extubation

Smoking-Related Surgical Complications

Management of Complications in Smokers

Nonunion:

• Address smoking BEFORE revision surgery
• Bone stimulation may help (limited evidence)
• Consider biologics (BMP, bone graft)
• Higher index of suspicion at follow-up

Wound Infection:

• Lower threshold for deep samples
• May need longer antibiotic courses
• Wound healing support measures

Procedure-Specific Complication Rates

Postoperative Cessation Support

Immediate Postoperative (Day 0-3):

• Continue or resume NRT as soon as tolerated
• If patch removed for surgery, reapply in PACU
• Acknowledge difficulty of quitting during recovery
• Provide short-acting NRT for breakthrough cravings

Hospital Stay:

• Smoke-free environment supports abstinence
• Address pain adequately (pain increases relapse risk)
• Offer ongoing behavioral support
• Consider inpatient smoking cessation consultation

Duration of Postoperative Cessation

Relapse Prevention Postoperatively

High-Risk Periods:

• First 1-2 weeks (highest risk)
• Hospital discharge (return to triggers)
• Pain crises (association with smoking for coping)
• Stress and boredom during recovery

Strategies:

• Continue pharmacotherapy through healing period (minimum 12 weeks)
• Schedule follow-up contact specifically for cessation support
• Identify triggers and develop coping strategies
• Engage family/social support
• Consider extended pharmacotherapy (24 weeks) for high-risk patients

Follow-Up Protocol

• Week 1-2: Phone or in-person check on cessation status
• Week 6: Surgical review + reinforce cessation
• Week 12+: Review healing + celebrate sustained cessation
• Ongoing: Continue offering support at all visits

Outcomes with Smoking Cessation

Complication Reduction:

• 50-60% reduction in overall surgical complications with 6-8 week preoperative cessation
• Wound complications reduced from 31% to 5% (Møller RCT)
• Pseudarthrosis reduced from 40% to 17% with cessation (Glassman)

Quit Rates with Intervention:

• Brief advice alone: 3-5% at 1 year
• Varenicline: 25-30% at 1 year
• NRT: 15-20% at 1 year
• Combination (behavioral + pharmacotherapy): 30-40% at 1 year

Benefits of Cessation by Duration

Evidence Summary for Cessation Outcomes

Long-Term Benefits

Beyond the Index Surgery:

• Reduced lifetime orthopaedic complication risk
• Cardiovascular risk reduction (50% at 1 year)
• Pulmonary function improvement
• Cancer risk reduction (slow but significant)
• Life expectancy gain (quitting at 40 gains ~9 years; at 60 gains ~3 years)

Spinal Fusion Outcomes

Landmark Studies:

• Glassman et al. (2000): 40% pseudarthrosis rate in smokers vs 8% in non-smokers undergoing posterolateral lumbar fusion [12]
• Andersen et al. (2001): 4-fold increased risk of nonunion in smokers [13]
• M�ller et al. (2002): Intensive smoking cessation intervention reduced complications by 50% [14]

Key Findings:

• Pseudarthrosis rates 2-4x higher in smokers
• Effect most pronounced in posterolateral fusion (uninstrumented)
• Interbody fusion somewhat more resistant but still affected
• Dose-dependent effect - heavier smokers worse outcomes

Cessation Benefits:

• 4-8 weeks preoperative cessation reduces pseudarthrosis risk
• 12+ weeks postoperative continuation essential for fusion consolidation
• Even brief cessation provides measurable benefit

This completes the spinal fusion evidence.

Fracture Nonunion and Delayed Union

Meta-Analyses and Systematic Reviews:

• Hernigou et al. (2012): Smoking associated with 4.7-fold increased nonunion risk across all fractures [15]
• Scolaro et al. (2014): Tibial fractures in smokers - nonunion rate 23% vs 6% [16]
• Calori et al. (2011): Smoking identified as strongest modifiable risk factor for nonunion [17]

High-Risk Fracture Sites:

• Tibial shaft fractures: 4-8x increased nonunion risk
• Scaphoid fractures: 2-3x increased nonunion risk
• Femoral neck fractures: Increased AVN and nonunion
• Clavicle fractures: Delayed union common
• Open fractures: Combined effect with contamination

Dose and Timing:

• Risk increases with pack-years
• Quitting at time of injury still beneficial
• Continued smoking postoperatively negates surgical efforts

This section covers fracture healing evidence.

Total Joint Arthroplasty

Infection Risk:

• Singh et al. (2011): 3.6-fold increased SSI risk in TKA smokers [18]
• Namba et al. (2012): 2-fold increased revision risk in THA smokers at 10 years [19]
• M�ller et al. (2002): 6-8 weeks cessation reduced wound complications by 50% [14]

Other Complications:

• Periprosthetic fracture: Increased risk from reduced bone quality
• Aseptic loosening: Impaired osseointegration
• Dislocation (THA): Some evidence for increased risk
• Delayed mobilization: Pain, complications slow recovery

Revision Surgery:

• Higher infection rates in revision procedures
• Poorer bone stock
• Reduced healing capacity
• Longer hospital stay

This completes the arthroplasty section.

Other Orthopaedic Procedures

Arthroscopy:

• Increased infection risk (though lower baseline rate)
• Delayed soft tissue healing
• Suboptimal rehabilitation outcomes
• Rotator cuff repair: higher re-tear rates [20]

Osteotomy:

• Delayed union common
• Nonunion rates higher
• Hardware failure more frequent

Ligament Reconstruction:

• ACL reconstruction: impaired graft incorporation
• Delayed return to sport
• Higher re-injury rates

This completes other procedure evidence.

Varenicline (Champix)

Mechanism:

• Partial agonist at �4�2 nicotinic acetylcholine receptors
• Reduces craving and withdrawal (partial agonist effect)
• Blocks rewarding effects of nicotine (competitive antagonism)

Efficacy:

• Most effective pharmacotherapy available
• Triples quit rates compared to placebo (30% vs 10% at 1 year) [22]
• Superior to bupropion and single-agent NRT [23]
• NNT = 10 (number needed to treat to achieve one additional quitter)

Dosing:

• Standard course: 12 weeks
• Start 1 week before quit date
• Days 1-3: 0.5mg once daily
• Days 4-7: 0.5mg twice daily
• Day 8 onwards: 1mg twice daily
• Can extend to 24 weeks for relapse prevention

Adverse Effects:

• Nausea (30% - usually transient, dose with food)
• Vivid dreams or insomnia (20%)
• Headache (15%)
• Neuropsychiatric concerns: Rare mood changes, depression (FDA black box warning removed 2016 after safety review)

Contraindications:

• Severe renal impairment (dose reduction required)
• Pregnancy (insufficient data - use only if benefit outweighs risk)
• History of serious psychiatric illness (use with caution, monitor closely)

Australian Context:

• PBS listed - restricted benefit (requires certain criteria)
• Typically AU$42.50 per script (general patient)
• Cost-effective given efficacy

This completes the varenicline section.

Nicotine Replacement Therapy

Rationale:

• Provides nicotine without toxic combustion products
• Reduces withdrawal symptoms and cravings
• Safe in perioperative period - does not increase complications [11]

Available Forms:

1. Nicotine Patch (Long-Acting):

• 24-hour or 16-hour formulations
• Dosing: 21mg, 14mg, 7mg (step-down protocol)
• For heavy smokers (over 10/day): start 21mg
• Apply to clean, dry, hairless skin
• Rotate sites to reduce skin irritation

2. Nicotine Gum (Short-Acting):

• 2mg or 4mg pieces
• "Chew and park" technique: chew until peppery taste, then park between cheek and gum
• For heavy smokers: 4mg gum
• Use 8-12 pieces per day initially
• Avoid acidic beverages 15 min before/during use

3. Nicotine Lozenge (Short-Acting):

• 2mg or 4mg
• Dissolve slowly in mouth (20-30 min)
• Easier to use than gum
• Similar efficacy to gum

Combination NRT:

• Patch (baseline) + short-acting form (breakthrough cravings) more effective than either alone
• Recommended for heavy smokers or failed single-agent attempts
• Safe - no overdose risk at recommended doses

Efficacy:

• Doubles quit rates vs placebo (NNT = 20)
• Combination NRT superior to single agent

Safety:

• Safe in cardiovascular disease (including recent MI - benefits outweigh risks)
• Safe perioperatively - does NOT impair wound healing
• Minimal adverse effects (skin irritation with patch, mouth irritation with gum/lozenge)

Australian Context:

• PBS listed for NRT products
• Also available over-the-counter
• Quitline provides free NRT starter packs in some states

This covers nicotine replacement therapy.

Bupropion (Zyban)

Mechanism:

• Atypical antidepressant
• Inhibits dopamine and norepinephrine reuptake
• Reduces craving and withdrawal symptoms

Efficacy:

• Doubles quit rates vs placebo (similar to single NRT)
• Less effective than varenicline
• May be preferred in patients with depression

Dosing:

• Start 1-2 weeks before quit date
• Day 1-3: 150mg once daily
• Day 4 onwards: 150mg twice daily
• Standard course: 7-12 weeks
• Can extend for relapse prevention

Adverse Effects:

• Insomnia (common - avoid evening dose)
• Dry mouth
• Nausea
• Headache
• Seizure risk: 0.1% (1 in 1000)

Contraindications:

• Seizure disorder (absolute contraindication)
• Eating disorder (increased seizure risk)
• MAO inhibitor use (within 14 days)
• Severe hepatic cirrhosis

Drug Interactions:

• Lowers seizure threshold - caution with other medications
• CYP2B6 substrate - multiple potential interactions

Australian Context:

• PBS listed - restricted benefit
• Alternative to varenicline if contraindicated or not tolerated

This completes the bupropion section.

Other and Emerging Options

E-cigarettes (Vaping):

• Controversial - some evidence for harm reduction
• Not TGA approved as cessation aid in Australia
• Nicotine vaping requires prescription in Australia
• May be considered for patients unable to quit with approved therapies
• Not recommended as first-line - insufficient long-term safety data

Cytisine:

• Plant-based partial nicotine agonist (similar to varenicline)
• Used in Eastern Europe
• Not currently available in Australia
• Promising efficacy and lower cost

Nortriptyline:

• Tricyclic antidepressant
• Second-line option (when first-line fails)
• Doubles quit rates vs placebo
• More adverse effects than bupropion

Clonidine:

• Alpha-2 agonist
• Second-line option
• Modest efficacy
• Significant side effects (sedation, dry mouth, hypotension)

Combination Pharmacotherapy:

• Varenicline + NRT patch: Some evidence for additive benefit [24]
• Bupropion + NRT: Superior to either alone
• Consider for highly dependent smokers or those who failed monotherapy

This covers other pharmacotherapy options.

Acute Trauma and Urgent Surgery

Challenge: Limited time for preoperative cessation in acute fractures or urgent procedures.

Approach:

• Still counsel to quit even if surgery imminent
• Emphasize postoperative cessation for bone healing (12+ weeks)
• Initiate pharmacotherapy immediately (NRT can start same day)
• Even brief cessation provides benefit - every day counts
• For urgent surgery (within 24-48 hours): focus on postoperative plan

Evidence:

• Quitting at time of injury still reduces complications vs continued smoking
• 12-week postoperative cessation critical for fracture union
• Provide intensive support during hospitalization (captive audience)

Specific Recommendations:

• Open fractures: Infection risk paramount - aggressive cessation counseling
• Tibial fractures: Nonunion risk 4-8x - emphasize critical importance
• Femoral neck: AVN and nonunion risk - strongly advise cessation

This covers urgent/trauma scenarios.

Patient Unwilling to Quit

Ethical and Practical Considerations:

Should surgery be denied?

• Generally no - exception may be elective cosmetic procedures
• For medically necessary procedures: proceed but document counseling
• Consider delaying elective procedures to allow cessation attempts
• Discuss increased complication risks explicitly - obtain informed consent

Documentation:

• Document smoking status (pack-years)
• Document counseling provided (5 A's)
• Document patient refusal to quit or attempt cessation
• Document increased risk discussion and patient understanding
• Document plan for managing potential complications

Risk Mitigation:

• Optimize other factors (nutrition, diabetes control, etc.)
• Consider longer course of prophylactic antibiotics (controversial, not standard)
• Lower threshold for postoperative concerns (wound, healing)
• Continue offering cessation support - patient may change mind

Informed Consent:

• Explicitly discuss increased risks: nonunion, infection, revision surgery
• Some surgeons include smoking status in consent form
• Patient should understand that smoking may compromise surgical outcome

This covers refusal scenarios.

Multiple Failed Quit Attempts

Approach:

• Quitting smoking is often difficult - multiple attempts common before success (average 8-10 attempts)
• Do not give up - continue offering support
• Reassure patient: "Most people need several tries before quitting for good. Let's figure out what will work for you."

Intensify Intervention:

• Switch to most effective pharmacotherapy (varenicline if not already tried)
• Consider combination therapy (varenicline + NRT, or bupropion + NRT)
• Increase behavioral support intensity (Quitline, group counseling, individual counseling)
• Address barriers: Depression, anxiety, substance use, social factors
• Consider referral to smoking cessation clinic (specialist support)

Alternative Harm Reduction:

• For patients unable to achieve complete abstinence: reduce smoking (fewer cigarettes)
• Some benefit vs continued heavy smoking
• Not ideal but pragmatic approach
• Continue working toward complete cessation

This covers failed quit attempts.

Special Populations

Aboriginal and Torres Strait Islander Peoples:

• Higher smoking rates (39% vs 16.5% overall Australian population)
• Cultural sensitivity essential
• Engage Aboriginal Health Workers for culturally appropriate counseling
• Consider community-based programs
• Address social determinants of smoking (stress, trauma, social norms)

Patients with Mental Health Conditions:

• Higher smoking rates (25-30% in depression, 60-90% in schizophrenia)
• Myth: "Patients with mental illness can't quit or shouldn't quit" - FALSE
• Smoking cessation improves mental health outcomes (reduces anxiety, depression long-term)
• May need higher doses of pharmacotherapy or combination therapy
• Close monitoring during cessation (mood changes, though rare)
• Coordinate with psychiatry/psychology if complex

Pregnant Patients:

• Orthopaedic trauma during pregnancy (MVA, falls)
• Smoking cessation critical for maternal and fetal health
• Behavioral counseling first-line in pregnancy
• NRT if behavioral fails (benefits likely outweigh risks)
• Varenicline/bupropion: insufficient safety data - avoid unless exceptional circumstances

Adolescents:

• Pediatric orthopaedic patients (e.g., scoliosis surgery)
• Engage parents/guardians in cessation plan
• Behavioral counseling emphasizing immediate benefits (sports performance, appearance)
• Pharmacotherapy safe in adolescents (over 12 years for some agents)

This covers special populations.