The recent submission of the Tobacco and Vapes Bill to parliament has shone a spotlight on British public health legislation. If passed, anyone born after 2009 will be banned from buying tobacco products. Despite the success of other public health policies in reducing smoking over the past 20 years, tobacco remains the leading cause of premature, preventable death in the UK and worldwide, killing about half of lifelong smokers.1 Smoking is particularly common among surgical patients, reported in up to 50% of trauma patients in North America.2 In Britain, approximately 25% of patients admitted to hospital under surgical specialties currently smoke, compared to 13% of the general population.3,4 Worryingly, the prevalence appears to be rising in some cohorts, such as vascular surgery, and is as high as 33% in those undergoing lower limb bypass surgery.5 This may reflect increased risk of surgical pathology in smokers, but nonetheless highlights an opportunity to improve surgical health outcomes and to reach a population that seems more resistant to the available community-based smoking cessation interventions.

As the demand for surgical care increases globally, and surgical populations become older and increasingly comorbid, there is an urgent need to optimise perioperative care pathways. For many patients, this now involves a preoperative assessment clinic and access to prehabilitation. The Royal College of Anaesthetists Centre for Perioperative Care (CPOC) has identified smoking cessation as one of seven key perioperative interventions to improve efficiency and tackle waiting lists, but cessation support services are often poorly integrated into current pathways.6 Substantial geographical and socioeconomic variation in smoking prevalence also represents a clear quality improvement target.5

The detrimental impact of smoking on surgical outcomes is well established; it is associated with a 38% increase in 30-day mortality, higher risk of complications such as pneumonia, myocardial infarction and stroke, and a longer average hospital stay.7 Wound healing delay, infection and incisional hernia are all twice as common in patients who smoke.8 Quitting smoking is one of the most effective interventions to improve outcomes and the benefits are seen even if cessation occurs shortly before surgery. Forty-eight hours after quitting, heart rate, blood pressure and blood nicotine levels fall; after 3 weeks the risk of wound infection reduces and after 4 weeks the risk of other postsurgical complications declines.9

Although discussing smoking with patients can be challenging, there is increasing evidence that smoking cessation interventions are effective in the perioperative setting. A recent systematic review found that these interventions reduce smoking on the day of surgery and at 12 months postoperatively (number needed to treat 7 and 9, respectively).10 Importantly, this included contemporary randomised controlled trials with a shift from traditional methods of smoking cessation towards intensive behavioural interventions, which were most effective for long-term abstinence.

Furthermore, the rapid expansion in popularity of e-cigarettes or ‘vapes’ over recent years has transformed the smoking-cessation landscape. These are electronic devices which heat a fluid or ‘e-liquid’ to produce an aerosol which is inhaled. E-cigarettes are generally acceptable to patients and are more effective than other forms of abstinence from tobacco smoking.11 Early evidence suggests the health risks associated with e-cigarettes are lower than with tobacco smoking, however, the long-term effects are not known. They should therefore not be used by people who do not already smoke.

 The rising popularity of e-cigarettes amongst never-smokers, particularly children and young adults, is concerning.12

Current National Institute of Health and Care Excellence (NICE) guidance on smoking cessation supports a multi-modal approach and focuses on the treatment of tobacco, rather than nicotine, addiction.13 Treatment should include referral to specialist services for individual or group behavioural support, alongside pharmacological treatment. First line pharmacological choices are combination NRT (nicotine replacement therapy – concurrent long and short-acting products, for example a patch and lozenges), e-cigarettes or nicotine analogues (Cytisine or Varenicline).

The National Centre for Smoking Cessation and Training (NCSCT) and NICE recommend healthcare professionals deliver Very Brief Advice (VBA) on smoking using an “Ask, Advise, Act” approach.14 This involves:

If the patient is not interested in quitting at the time of the consultation, NICE supports harm-reduction approaches, such as cutting down on cigarette use or not smoking on the day of surgery.

Unfortunately, efficient implementation of tobacco cessation interventions is lacking. A 2021 audit of acute hospital admissions found that 21% of patients had no documented smoking status. Of those who smoked, only 45% were provided with VBA on smoking and fewer than 5% were prescribed the most effective treatments for tobacco dependence.15 Opportunities to intervene are being missed.

Multiple factors make supporting surgical patients to quit smoking challenging. Some surgeons report feeling a sense of responsibility for the issue, but feel unable to motivate patients to quit or to provide the specific, ongoing support required.16 A recent national survey of vascular anaesthetists in the UK found that most were unaware of the NICE guidance but had no training in smoking cessation interventions. Many cited limited time or resources as additional barriers.17 These barriers should not provoke pessimism, but rather highlight the need to make specialist smoking cessation services more available within the perioperative setting. This would empower surgical teams to help patients access evidence-based cessation support, without adding undue burden.

The perioperative period presents a unique “teachable moment”, in which patients may be more receptive to advice and motivated to make positive health-related lifestyle changes.18 Furthermore, hospital admission supports abstinence by placing patients in a no smoking environment and allowing easy access to prescribed NRT. This opportunity is especially important for socioeconomically-deprived populations who face more barriers to quitting. It may also be a cost-effective way to improve outcomes in lower-resource settings such as low-and middle-income countries where smoking prevalence is highest.1

A guide for the perioperative treatment of tobacco dependence has recently been released by the Royal College of Anaesthetists CPOC, targeting all healthcare professionals who care for surgical patients.19 In the longer term, local services must be standardised to ensure universal access to cessation support. Preoperative pathways should be streamlined to facilitate quick referral to specialist services and provision of pharmacological treatment. Furthermore, smokers should be highlighted as high-risk patients who may benefit from prehabilitation and higher levels of aftercare.

The success of public health interventions in reducing smoking is a significant achievement and the proposed new UK legislation is potentially ground-breaking. However, it will not directly benefit the high proportion of surgical patients who currently smoke. More must be done to ensure that evidence-based interventions reach the most underserved communities and those most at risk of coming to harm from smoking. Work to modernise smoking cessation support must include plans to integrate it into contemporary perioperative pathways.