1. Keating, Stefanie DNP, MS, ACNP-BC


Those facing surgery for smoking-related illnesses may be especially receptive.


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Smoking is the leading cause of preventable death in the United States, with more than 16 million people affected by a smoking-related disease. Smokers who undergo surgery tend to have longer hospital stays and a greater likelihood of readmission. A 2011 systematic review by Singh found that patients who are current smokers have a 24% higher risk of developing postoperative complications.

Figure. Stefanie Kea... - Click to enlarge in new window Stefanie Keating

Tobacco screening and cessation counseling for patients is a Joint Commission core health care quality measure. While the long-term benefits of quitting smoking are well established, preoperative smoking cessation of just several weeks has been associated with a significant reduction in postoperative complications. A 2011 meta-analysis by Mills and colleagues found that preoperative smoking cessation was associated with a 41% reduction in postoperative complications. Although the ideal timing of preoperative smoking cessation is not known, the same study found that the greater the number of weeks before surgery the patients had quit smoking, the fewer postsurgical complications they were likely to experience.


Presurgical testing provides an opportune moment for smoking cessation counseling. The presurgical interview can be seen as a teachable moment, in which a clinician can help the patient take a necessary step in the transtheoretical model of behavior change described by Prochaska and Velicer in 1997, which progresses through six stages: precontemplation, contemplation, preparation, action, maintenance, and termination.


Patients facing surgery may be anxious about the upcoming procedure, which may make them more receptive to counseling on reducing the risk of postoperative complications. A 2010 study by Shi and Warner found that undergoing surgery for smoking-related illnesses increased patients' likelihood of quitting smoking. As identified in a 2003 paper by McBride and colleagues, the three elements in a teachable moment for smoking cessation are: increased knowledge of risk, heightened emotional response, and changed self-concept. The provider can increase the patient's knowledge by counseling about tobacco cessation, and elicit an emotional response when the risks of possible negative postoperative outcomes are explained. Finally, this encounter can influence a patient's self-concept, heightening the patient's awareness of being a smoker and of the need to quit.


An NP's duty-and that of all nurses-is to provide patients with education on all aspects of their health. It is a disservice to the patient to neglect to mention smoking cessation during the presurgical encounter. In this setting, patients can be taught strategies for reducing wound complications, promoting wound healing, and preventing readmission. The NP can offer the resources needed to quit smoking, such as nicotine replacement therapy, counseling, and antidepressants. With the goal of inspiring the patient to quit, smoking cessation counseling in the presurgical setting can provide the patient with successful programs and tactics.


Despite potential barriers to its implementation, such as timing and paperwork, providing smoking cessation counseling in the preoperative setting can improve patient outcomes and overall survival rate. The American Academy of Orthopaedic Surgeons supports the presurgical encounter as a teachable moment and stresses the importance of smoking cessation prior to surgery in order to promote healing. The presurgical testing and interview process can be used to equip patients of all ages and health statuses with the tools necessary to quit smoking and maintain a smoke-free life.


Intervention is crucial for both those who are unaware of their problem and those who have been unsuccessful in past attempts to quit. While presurgical counseling may not lead in every case to sustained abstinence, it can be an important first step in the difficult path to finally quitting.