Short-term preoperative smoking cessation and postoperative complications: a systematic review and meta-analysis

Purpose

The literature was reviewed to determine the risks or benefits of short-term (less than four weeks) smoking cessation on postoperative complications and to derive the minimum duration of preoperative abstinence from smoking required to reduce such complications in adult surgical patients.

Source

We searched MEDLINE, EMBASE, Cochrane, and other relevant databases for cohort studies and randomized controlled trials that reported postoperative complications (i.e., respiratory, cardiovascular, wound-healing) and mortality in patients who quit smoking within six months of surgery. Using a random effects model, meta-analyses were conducted to compare the relative risks of complications in ex-smokers with varying intervals of smoking cessation vs the risks in current smokers.

Principal findings

We included 25 studies. Compared with current smokers, the risk of respiratory complications was similar in smokers who quit less than two or two to four weeks before surgery (risk ratio [RR] 1.20; 95% confidence interval [CI] 0.96 to 1.50 vs RR 1.14; CI 0.90 to 1.45, respectively). Smokers who quit more than four and more than eight weeks before surgery had lower risks of respiratory complications than current smokers (RR 0.77; 95% CI 0.61 to 0.96 and RR 0.53; 95% CI 0.37 to 0.76, respectively). For wound-healing complications, the risk was less in smokers who quit more than three to four weeks before surgery than in current smokers (RR 0.69; 95% CI 0.56 to 0.84). Few studies reported cardiovascular complications and there were few deaths.

Conclusion

At least four weeks of abstinence from smoking reduces respiratory complications, and abstinence of at least three to four weeks reduces wound-healing complications. Short-term (less than four weeks) smoking cessation does not appear to increase or reduce the risk of postoperative respiratory complications.     

Is nicotine replacement therapy for smoking cessation effective in the “real world”? Findings from a prospective multinational cohort study

BACKGROUND: Increasing smoking cessation rates is an important goal in preventing lung cancer and chronic obstructive pulmonary disease. Nicotine replacement therapy (NRT) has been found in clinical trials to improve the chances of success at stopping, but recent cross-sectional survey data have raised doubts as to whether it is effective when used by smokers making quit attempts unsupervised outside clinical trials. Because of biases inherent in cross-sectional surveys, this issue can only be adequately addressed using longitudinal studies. This paper reports the first study of its kind to examine the issue. METHODS: The ATTEMPT cohort is a multinational cohort study with data collection by the internet which recruited smokers of > or = 5 cigarettes per day aged 35-65 years who were intending to stop smoking within the next 3 months. Phase 1 began in spring 2003 and involved 2009 smokers from the USA, UK, Canada and France. Phase 2 involved 3645 smokers and included the same countries plus Spain. Follow-up assessments were carried out every 3 months. 492 smokers who made a quit attempt without formal behavioural support or bupropion in the first 3-month follow-up period were identified from phase 1, 357 of whom were followed up for a further 6 months. The phase 2 sample involved 906 smokers making quit attempts, 732 of whom were followed up. At baseline, demographic characteristics, smoking history and nicotine dependence were assessed. Smokers who made quit attempts were questioned on methods used to aid them. The main outcome measure was self-report of complete abstinence throughout both the 3-month periods following the quit date. RESULTS: 35.6% of smokers followed up in phase 1 and 29.6% of those followed up in phase 2 used NRT. The odds ratios comparing abstinence for 6 months in those using and those not using NRT, adjusting for nicotine dependence, were 3.0 (95% CI 1.2 to 7.5) for the phase 1 sample and 2.1 (95% CI 1.0 to 4.1) for the phase 2 sample. The difference in success rates between those using NRT and those not using it, adjusted for the Fagerstrom test for nicotine dependence (FTND) score, was 6% in the phase 1 sample and 3.7% in the phase 2 sample. The improved odds of success were not explicable in terms of motivation to use some form of aid to cessation or differential loss to follow-up. CONCLUSION: NRT use by smokers making self-initiated quit attempts without formal behavioural support is associated with improved long-term abstinence rates.     

Risk factors for subarachnoid hemorrhage

OBJECTIVE: Cigarette smoking has been demonstrated to increase the risk of subarachnoid hemorrhage (SAH). Whether cessation of smoking decreases this risk remains unclear. We performed a case-control study to examine the effect of smoking and other known risk factors for cerebrovascular disease on the risk of SAH. METHODS: We reviewed the medical records of all patients with a diagnosis of SAH (n = 323) admitted to Johns Hopkins Hospital between January 1990 and June 1997. Controls matched for age, sex, and ethnicity (n = 969) were selected from a nationally representative sample of the Third National Health and Nutrition Examination Survey. We determined the independent association between smoking (current and previous) and various cerebrovascular risk factors and SAH by use of multivariate logistic regression analysis. A separate analysis was performed to determine associated risk factors for aneurysmal SAH. RESULTS: Of 323 patients admitted with SAH (mean age, 52.7+/-14 yr; 93 were men), 173 (54%) were hypertensive, 149 (46%) were currently smoking, and 125 (39%) were previous smokers. In the multivariate analysis, both previous smoking (odds ratio [OR], 4.5; 95% confidence interval [CI], 3.1-6.5) and current smoking (OR, 5.2; 95% CI, 3.6-7.5) were significantly associated with SAH. Hypertension was also significantly associated with SAH (OR, 2.4; 95% CI, 1.8-3.1). The risk factors for 290 patients with aneurysmal SAH were similar and included hypertension (OR, 2.4; 95% CI, 1.8-3.2), previous smoking (OR, 4.1; 95% CI, 2.7-6.0), and current smoking (OR, 5.4; 95% CI, 3.7-7.8). CONCLUSION: Hypertension and cigarette smoking increase the risk for development of SAH, as found in previous studies. However, the increased risk persists even after cessation of cigarette smoking, which suggests the importance of early abstinence from smoking.     

Effect of smoking, abstention, and nicotine patch on epidermal healing and collagenase in skin transudate

Delayed wound healing may explain postoperative tissue and wound dehiscence in smokers, but the effects of smoking and smoking cessation on the cellular mechanisms remain unclear. Suction blisters were raised in 48 smokers and 30 never smokers. The fluid was retrieved and the epidermal roof was excised. Transepidermal water loss (TEWL) was measured after 2, 4, and 7 days. Then, the smokers were randomized to continuous smoking or abstinence with a transdermal nicotine patch or a placebo by concealed allocation. The sequence was repeated after 4, 8, and 12 weeks in all smokers and abstainers and in 6 never smokers. Matrix metalloproteinase (MMP)-8 and MMP-1 levels in suction blister fluid were assessed by an enzyme-linked immunosorbent assay. Random-effects models for repeated measurements were applied and p ≤0.05 was considered significant. One week after wounding the TEWL was 17.20 (14.47–19.92) g/cm² hour (mean, 95% CI) in smokers and 13.89 (9.46–18.33) in never smokers ( p <0.01). In abstinent smokers TEWL was 18.95 (15.20–22.70)( p <0.01, when compared with smokers). In smokers, MMP-8 was 36.4 (24.3–48.5) ng/mL (mean, 95% CI) and 15.2 (1.4–30.2) ng/mL in never smokers ( p <0.01). Abstinent smokers' MMP-8 level was 21.2 ng/mL (6.6–43.0) ( p =0.02, when compared with smokers). MMP-1 was unaffected by smoking and abstention. Transdermal nicotine patch did not affect any parameter. We conclude that smoking attenuates epidermal healing and may enhance extracellular matrix degradation. Three months of abstinence from smoking does not restore epidermal healing, whereas 4 weeks of abstinence normalizes suction blister MMP-8 levels. These findings suggest sustained impaired wound healing in smokers and potential reversibility of extracellular matrix degradation.     

Risk of hospital admission for COPD following smoking cessation and reduction: a Danish population study

BACKGROUND: Little is known about the effects of changes in smoking habits on the subsequent risk of chronic obstructive pulmonary disease (COPD). The aim of this study was to investigate the relationship between smoking cessation and reduction and admission to hospital for COPD in a general population sample. METHODS: A total of 19,709 participants from three prospective population studies in Copenhagen were followed with record linkage for date of first hospital admission for COPD until 1998 (mean follow up 14 years). Heavy smokers (>/=15 cigarettes/day) who reduced their tobacco consumption by at least 50% between the two initial examinations without quitting and smokers who stopped smoking during this time were compared with continuous heavy smokers using a Cox proportional hazards model. RESULTS: During the follow up period 1,260 subjects (741 men and 519 women) were admitted to hospital for COPD. After multivariate adjustment, quitting smoking was associated with a significant reduction in the risk of hospital admission. The relative hazard (HR) was 0.57 (95% confidence interval (CI) 0.33 to 0.99). Those who reduced smoking did not show a significantly lower risk of hospitalisation than continuing heavy smokers (HR 0.93 (95% CI 0.73 to 1.18)). Exclusion of events during the first 5 study years, detailed adjustment for lung function, or restriction of analyses to participants with impaired pulmonary function did not reverse the observed trend. CONCLUSIONS: Self-reported smoking cessation is associated with a reduction in the risk of COPD morbidity of approximately 40%; the benefit of smoking reduction is questionable.     

Association of cigarette smoking with albuminuria in the United States: the third National Health and Nutrition Examination Survey

BACKGROUND: The association of cigarette smoking with albuminuria has been reported but not examined in a representative U.S. population. No study has evaluated the association between serum cotinine (a biological marker for tobacco exposure) and kidney damage. METHODS: A cross-sectional analysis was conducted among 15,719 adult participants of the third National Health and Nutrition Examination Survey to assess the association between smoking exposure and kidney damage. Smoking was assessed by self-reported lifetime cigarette use and serum cotinine. Kidney damage was assessed by urine albumin-to-creatinine ratio (ACR), with albuminuria defined as ACR of > or =17 microg/mg in males and > or =25 microg/mg in females. RESULTS: The analysis included 13,121 with normal albumin (mean ACR 6.3 microg/mg) and 2,414 with albuminuria (mean ACR 143 microg/mg); hypertension was prevalent in 27% and 59%, respectively. Former smoking was similar between groups (21%), while current smoking was more common in persons with albuminuria (26%) compared to normal ACR (21%). Adjusted for other risk factors, among hypertensives, current smokers were 1.85 (95% CI: 1.29, 2.64) times more likely to have albuminuria than never smokers. Current smokers with a > or =40 pack-year history were at highest risk for albuminuria. Among non-smoking hypertensives, those exposed to passive smoke (highest versus lowest quartile of serum cotinine) were 1.41 (95% CI: 1.04, 1.90) times more likely to have albuminuria. Former smoking with cessation of > or =1 year among hypertensives was not associated with albuminuria. Among non-hypertensives, smoking and albuminuria were not consistently associated. CONCLUSION: Current and passive smoking, but not former smoking, were associated with the presence of albuminuria in the general U.S. population with hypertension, indicating a benefit to the kidney from smoking cessation.     

Interventions for smoking cessation in hospitalised patients: a systematic review

BACKGROUND: An admission to hospital provides an opportunity to help people stop smoking. Individuals may be more open to help at a time of perceived vulnerability, and may find it easier to quit in an environment where smoking is restricted or prohibited. Providing smoking cessation services during hospitalisation may help more people to attempt and sustain an attempt to quit. The purpose of this paper is to systematically review the effectiveness of interventions for smoking cessation in hospitalised patients. METHODS: We searched the Cochrane Tobacco Addiction Group register, CINAHL, and the Smoking and Health database for studies of interventions for smoking cessation in hospitalised patients. Randomised and quasi-randomised trials of behavioural, pharmacological, or multi-component interventions to help patients stop smoking conducted with hospitalised patients who were current smokers or recent quitters were included. Studies of patients admitted for psychiatric disorders or substance abuse, those that did not report abstinence rates, and those with follow up of less than 6 months were excluded. Two of the authors extracted data independently for each paper, with assistance from others. RESULTS: Intensive intervention (inpatient contact plus follow up for at least 1 month) was associated with a significantly higher cessation rate compared with controls (Peto odds ratio (OR) 1.82, 95% CI 1.49 to 2.22). Any contact during hospitalisation followed by minimal follow up failed to detect a statistically significant effect on cessation rate, but did not rule out a 30% increase in smoking cessation (Peto OR 1.09, 95% CI 0.91 to 1.31). There was insufficient evidence to judge the effect of interventions delivered only during the hospital stay. Although the interventions increased quit rates irrespective of whether nicotine replacement therapy (NRT) was used, the results for NRT were compatible with other data indicating that it increases quit rates. There was no strong evidence that clinical diagnosis affected the likelihood of quitting. CONCLUSIONS: High intensity behavioural interventions that include at least 1 month of follow up contact are effective in promoting smoking cessation in hospitalised patients.     

Effectiveness of a Cognitive Orientation Program With and Without Nicotine Replacement Therapy in Stopping Smoking in Hospitalised Patients

IntroductionWe have analyzed the effectiveness of high-intensity cognitive-behavioral intervention initiated during hospitalization, compared with minimal intervention. We have also analyzed whether the combination of intervention with nicotine replacement therapy (NRT) can increase smoking abstinence rates after 12 months of follow-up.MethodsWe studied 2,560 active smokers during their hospital stays. Of these, 717 smokers declined to participate in the study, and after minimal intervention they were asked for permission to telephone them one year later to ask if they continued to smoke. The remaining 1,843 smokers received high-intensity cognitive therapy and were randomized to receive NRT or not. The follow-up after hospital discharge was completed either in the outpatient consultation or by telephone sessions.ResultsOne year later, 7% of the patients who declined to participate in the study maintained smoking abstinence, compared with 27% of those who did participate in the study (p<0.001). There were significant differences between the group that only received behavioral treatment (21% abstinence) compared with the group that also received NRT (33% abstinence; p = 0.002). In this last group, there were significant differences (p = 0.03) between those who attended outpatient consultation (39% abstinence) and those who had telephone sessions (30%). In the multivariate analysis, the predictors for abstinence 12 months later were: having used NRT (OR 12.2; 95% CI, 5.2-32; p = 0.002) and a higher score on the Richmond test (OR 10.1; 95% CI, 3.9-24.2; p = 0.01).ConclusionsCognitive orientation interventions initiated in hospitalized smokers increase 12-month abstinence rates compared with minimal intervention, and said rates increase significantly when NRT is added.     

Tobacco and the risk of pancreatic cancer: a review and meta-analysis

Background/Aim Smoking is a recognized risk factor for pancreatic cancer. The aim of this study was to perform a meta-analysis to provide a robust estimate of the strength of the association between smoking and pancreatic cancer, to determine the risk of pipe and cigar smoking, and to estimate the duration of an elevated risk after smoking cessation. Methods We performed a meta-analysis of 82 published studies containing epidemiologic information about smoking and pancreatic cancer. Information on studies published between 1950 and 2007 was abstracted and prepared for analysis using standard meta-analytic procedures. Results The overall risk of pancreatic cancer estimated from the combined results for current and former smokers was, respectively, 1.74 (95% CI 1.61–1.87) and 1.2 (95% CI 1.11–1.29). The risk of pancreatic cancer for current and former pipe and/or cigar smokers was respectively 1.47 (95% CI 1.17–1.83) and 1.29 (95% CI 0.68–2.45). For former cigarette smokers, the risk remains elevated for a minimum of 10 years after cessation. Conclusions Based on estimates from four continents, smoking cigarettes causes a 75% increase in the risk of pancreatic cancer compared to non-smokers, and the risk persists for a minimum of 10 years after smoking cessation. This implies that in a population where the prevalence of smoking is 30%, the population’s attributable risk (the proportion of pancreatic cancer explained by smoking) is estimated to be 20%. Supported by grants from the Italian Association for Cancer Research (AIRC), Solvay Pharmaceuticals, and the C.D. Smithers Foundation.     

Smoking, gender and rheumatoid arthritis-epidemiological clues to etiology. Results from the behavioral risk factor surveillance system

OBJECTIVES: This study was undertaken to confirm and extend our earlier observation that gender is a biological effect modifier of smoking-rheumatoid arthritis (RA) relationship in a diverse national survey sample in the United States. METHODS: Smoking history of 644 cases of RA and 1509 geographically matched general population controls were compared using weighted logistic regression. RESULTS: There were 644 respondents with RA (cases) and 1509 geographically matched controls. Cases were significantly younger, less educated, more likely to be single and female than controls. Among cases 57% were smokers while among controls 49% smoked. Among women, after adjusting for age, hysterectomy had an age adjusted odds ratio 1.45, (95% CI 0.99-2.10) and menopause an adjusted odds ratio 1.18 (95% CI 0.99-2.10) were associated with smoking. In univariable analysis ever-smoking was associated with increased risk of RA (odds ratio 1.34, 95% CI 1.0-1.81). Among the strata of smokers, there was an increasing gradient of risk with increasing exposure to smoking (P = 0.041). In separate multivariable models, smoking increased the risk in men (odds ratio 2.29, 95% CI 1.35-3.90) while in women the risk was not elevated (odds ratio 0.98, 95% CI 0.67-1.42). After adjusting for the statistically significant interaction both female gender (odds ratio 2.30, 95% CI 1.39-3.83) and having ever smoked (odds ratio 2.31, 95% CI 1.36-3.94) emerged as significant risk factors for RA. CONCLUSIONS: Gender interacts with smoking in by an unknown mechanism to lead to differential risk of RA.     

Double-blind, randomized trial of cessation of smoking after audiotape suggestion during anaesthesia

We studied the use of intraoperative tape suggestion to improve the rate of cessation of smoking in 363 smokers who wanted to stop smoking. They were allocated randomly to hear a taped message encouraging them to stop smoking or to a blank tape, played during general anaesthesia. Overall 56 patients (15.4%, 95% confidence interval (CI) 11.7-19.1%) had claimed to have stopped smoking at 2 months and 29 patients (8.0%, 95% CI 5.9-10.1%) were confirmed to have stopped smoking at 6 months. There was no significant difference between the groups at either 2 or 6 months (risk ratios 1.06 and 1.09, respectively, P = 0.78). A preoperative:postoperative ratio of a visual analogue scale measuring the patient's motivation to stop smoking was not significantly different (control group 1.13 vs message group 1.10, P = 0.55). This study does not support the hypothesis that intraoperative tape suggestion can change smoking behaviour.      

Interventions in the preoperative clinic for long term smoking cessation: A quantitative systematic review

PURPOSE: To assess the efficacy of interventions offered to patients in the preoperative clinic to promote long-term (> or = three months) smoking cessation following surgery. METHODS: We searched The Cochrane Library, MEDLINE, EMBASE and CINAHL for all randomized controlled trials (RCTs) on smoking-cessation interventions initiated in the preoperative clinic. Trial inclusion, quality assessment, and data extraction were performed independently by two authors. Standard meta-analytic techniques were applied. RESULTS: Four RCTs (n = 610 patients) were included in the review. Interventions included pharmacotherapy, counseling, educational literature and postoperative telephone follow-up. The follow-up period ranged between three to 12 months with only one RCT following up patients for > one year. Two studies used biochemical methods to validate subjects' self-reporting of smoking cessation at the follow-up assessment. Overall, the interventions were associated with a significantly higher cessation rate vs control at the three to six month follow-up period (pooled odds ratio: 1.58, 95% confidence interval (CI) 1.02-2.45, P value = 0.01, I(2) = 0%). The only trial with longer follow-up period (12 months), however, failed to show any significant difference between the intervention and control groups (odds ratio: 1.05, 95% CI 0.53-2.09, P value = 0.88). CONCLUSION: This systematic review suggests that smoking-cessation interventions initiated at the preoperative clinic can increase the odds of abstinence by up to 60% within a three- to six-month follow-up period. To evaluate the possibility of longer abstinence, future trials with at least one-year follow-up are recommended.     

Smoking and the risk of fracture in older men.

The role of smoking on fracture risk in older men was studied within a longitudinal population-based cohort study. Using time-dependent exposure information and analysis, smoking was detected to be a stronger, dose-dependent and a more long lasting risk factor for fracture than has previously been estimated. INTRODUCTION: Although several studies have indicated a negative influence of smoking on fracture risk in women, there are few studies in men. No study in either sex has considered that smoking exposure may vary during follow-up in a cohort study. There is a need for a prospective study with repeated measures to analyze smoking exposure and fracture risk in men. MATERIALS AND METHODS: A total of 2322 men, 49-51 years of age, were enrolled in a longitudinal, population-based cohort study. Smoking status and other lifestyle habits were established at baseline and additionally at 60, 70, and 77 years of age. One or more fractures were documented in 272 men during 30 years of follow-up. Cox proportional hazards regression was used to determine the rate ratio (RR) of fracture according to time-dependent smoking habits and covariates. RESULTS: The overall adjusted fracture risk was increased in current (RR, 2.71; 95% CI, 1.86-3.95) and former smokers (RR, 1.66, 95% CI; 1.18-2.34), and persistent until 30 years after cessation. Among current smokers, the adjusted risk of any fracture increased by 30% (95% CI, 6-58%) for every 5 g of tobacco smoked each day. Smoking duration did not substantially influence fracture risk in either current or former smokers. One-half (52%; 95% CI, 35-65%) of all fractures were attributable to current smoking. CONCLUSIONS: Tobacco smoking seems to be a long-lasting major risk factor for fracture in older men, and the risks depends both on recency of smoking and on the daily amount of tobacco smoked, rather than smoking duration.     

Association of smoking with urgency in older people

OBJECTIVE: To evaluate the association of smoking with urgency in older people. METHODS: A population-based survey involving 1,059 people aged 60-89 years. A stratified sampling method was used and data were collected by interviews. The response rate was 82%. The indicators were urgency, former and current smoking, alcohol and coffee drinking. Prevalences of urgency were calculated for 15-year age groups of the two genders. Logistic regression models were used to analyse the age-adjusted association of urgency with smoking, use of alcohol and coffee drinking in the whole study population and separately in the two gender groups. RESULTS: The prevalence of urgency was lowest among younger men (6.6%) and highest among older women (19.5%). In the whole study population including both genders the current smokers were at greater risk of suffering from urgency [OR (odds ratio) 2.76; 95% CI (confidence interval) 1.43-5.32] than the never-smokers while the OR of urgency for former smokers was 1.63 (95% CI 0.97-2.74). In the separate models for the two genders the current male smokers (OR 2.55; 95% CI 1.13-5.73) and the former female smokers (OR 2.62; 95% CI 1.14-6.0) were at greater risk. The OR for current female smokers was 2.54 (95% CI 0.79-8.22), but the group was very small. Alcohol use and coffee drinking were not associated with urgency. CONCLUSION: Smoking is associated with urgency in older people. Especially current smokers are at greater risk than never-smokers. The prevalence of urgency is higher among women and is increased in both genders with advancing age. The study material being cross-sectional the causal relationship cannot be confirmed.     

Abdominal aortic aneurysms in the New Zealand Maori population

BACKGROUND: Abdominal aortic aneurysm (AAA) is believed to be a rare disease in people of non-European descent. Maori, New Zealand's indigenous people, are thought to originate from South East Asia, so their incidence of AAA might also be expected to be low. The aim was to investigate the incidence and phenotypic factors associated with AAA in the New Zealand Maori population. METHODS: A retrospective study was performed using the audit database of the New Zealand Society of Vascular Surgeons. Age-standardized rates of admission and death were calculated for Maori and non-Maori. RESULTS: Maori comprised 3.9 per cent of the population who had an AAA repaired, similar to the percentage of the Maori population aged over 65 years. However, the death rate from AAA in Maori was 2.4 times the rate in non-Maori. Maori were younger at diagnosis than non-Maori (65.2 versus 71.8 years; P < 0.001), had more emergency procedures (46.6 versus 30.2 per cent; P = 0.018) and a significantly higher proportion of Maori admissions were for a ruptured aneurysm. CONCLUSION: Maori had a higher mortality rate from AAA than non-Maori New Zealanders. Although admission rates between Maori and non-Maori were similar, the earlier age of onset and the increased proportion of ruptured aneurysms may indicate that the disease is more severe in Maori.     

Modifiable patient factors are associated with reverse vein graft occlusion in the era of duplex scan surveillance

OBJECTIVE: Modifiable patient factors that contribute to graft occlusion may be addressed after surgery. To determine risk factors associated with reverse vein graft (RVG) occlusion, we examined the characteristics and duplex scan surveillance (DS) patterns of patients with RVGs. METHODS: Patients treated with RVG from January 1996 through December 2000 were identified from a prospective registry. The study population consisted of all patients with RVGs performed during the study period with grafts that subsequently occluded. Patients whose grafts remained patent served as age-matched and gender-matched control subjects. The prescribed DS regimen was every 3 months for the first postoperative year and every 6 months thereafter. Early DS failure was defined as having no DS within the first 3 months. Cox proportional hazards analysis was used to compare the two groups. Hazard ratios were calculated. RESULTS: During the study period, 674 patients underwent RVG. Fifty-five patients with occluded RVGs were compared with 118 with patent RVGs. The follow-up period for occluded grafts was 13.40 +/- 12.59 months and for patent grafts was 32.40 +/- 15.61 months. Dialysis therapy, a known hypercoagulable state, continued smoking, and DS failure were independent factors associated with RVG occlusion. The hazards ratio for dialysis was 6.45 (95% CI, 3.07 to 13.51; P <.001), for current smoking was 4.72 (95% CI, 2.5 to 8.85; P <.001), for hypercoagulable state was 2.99 (95% CI, 1.47 to 6.10; P =.003), and for early DS failure was 2.43 (95% CI, 1.29 to 4.59; P =.006). CONCLUSION: Continued smoking and failure to undergo DS within the first three postoperative months are modifiable factors associated with RVG occlusion. Smoking cessation and graft surveillance must be stressed to optimize patency of infrainguinal RVGs.     

A programme for reducing smoking in pre-operative surgical patients: randomised controlled trial

We assessed the efficacy of a comprehensive programme for stopping smoking in 210 smokers scheduled for surgery, before admission and 3 months after attending a pre-operative clinic. Participants were randomly allocated to receive an intervention incorporating nicotine replacement therapy for patients smoking more than 10 cigarettes per day ("dependent smokers"), or to a control group to receive usual care. Dependent smokers allocated to the intervention group were more likely to report abstinence before surgery than those allocated to receive usual-care (63 (73%) vs. 29 (56%), respectively; OR 2.2 (95% CI 1.0-4.8)), and 3 months after attendance (16 (18%) vs. 3 (5%), respectively; OR = 3.9 (95% CI 1.0-21.7).     

Persistence of urothelial carcinoma of the bladder risk among former smokers: Results from a contemporary,prospective cohort study

ObjectivesCigarette smoking is a known risk factor for urothelial carcinoma (UC) of the bladder. However, the persistence of an increased risk for UC following smoking cessation is not well established. We assessed the risk of UC among former smokers using a recent, prospective cohort with a high proportion of former smokers.Materials and methodsStudy participants were members of the VITamins And Lifestyle cohort (VITAL), a group of 77,719 men and women between the ages of 50 and 76 years from western Washington State. Smoking history and other risk factors were obtained at the time of recruitment. The primary outcome was a new diagnosis of UC (n =385), as determined through linkage to a population-based cancer registry.Results and limitationsThe cohort included 8% current and 44% former smokers, and among the UC cases, 15% were current and 60% former smokers. Both the current and former smoker had an increased risk of UC compared with never smokers (hazard ratio [HRs]: 3.81; 95% confidence intervals [CI] 2.71–5.35 and 2.0; 95% CI 1.55–2.58, respectively). Among former smokers, the risk of UC increased with the pack-years smoked and decreased with the years since quitting. When both the measures of smoking were considered together, the risk of UC was similar for long-term quitters and recent quitters for a given level of pack-years. For example, for those with pack-years of 22.5–37.5, the HR of UC was 1.91 (95% CI 1.17–3.11) for the distant quitters (≥23.5 y before baseline) and HR = 1.92 (95% CI 1.26–2.94) among the recent quitters. Limitations include the small number of cases at the extremes of smoking history and errors in self-reported smoking history.ConclusionsThe risk of bladder cancer in former smokers remains elevated>32 years after quitting, even among those with moderate smoking histories. This argues that a history of smoking confers a lifelong increased risk of UC.     

Transdermal nicotine patch enhances type I collagen synthesis in abstinent smokers

Cigarette smokers deposit less collagen, expressed as hydroxyproline, in granulation tissue than nonsmokers. We studied the effect of abstinence from smoking and transdermal nicotine patches on deposition of hydroxyproline, proline, type I procollagen, and total proteins. Fifty-four healthy smokers were studied during 10 days of smoking and again from days 10 to 20 following smoking cessation. After the first 10 days of abstinence they were randomized to double-blind treatment with transdermal nicotine patches of 25 mg/day or placebo for a period of 10 days. During this period and during smoking, an expanded polytetrafluoroethylene tube was implanted into the subcutis. Following removal of the implant, total amino acids and peptides were extracted. Hydroxyproline and proline were analyzed by high-pressure liquid chromatography, type I procollagen was analyzed by enzyme-linked immunoassay, and total proteins were determined colorimetrically. In the 39 subjects who complied with the study protocol, abstinence from smoking did not affect the deposition of hydroxyproline, proline, type I procollagen, or total protein in the implants. During abstinence, the type I procollagen level increased by 18% in the transdermal nicotine patches group and decreased by 10% in the placebo group (p<0.05). We conclude that 20 days of abstinence from smoking does not affect collagen deposition in granulation tissue. However, in abstinent smokers, transdermal nicotine patches appears to increase type I collagen synthesis.