Smoking behavior and perceived stress in cigarette smokers undergoing elective surgery

BACKGROUND: The forced abstinence from cigarettes accompanying surgery in smoke-free facilities may increase psychological stress by removing a coping mechanism and by nicotine withdrawal. The authors tested the hypothesis that abstinence from cigarette smoking contributes to psychological stress in the perioperative period. METHODS: The authors assessed measures of nicotine withdrawal (Hughes-Hatsukami nicotine withdrawal scale) and perceived stress (including the Perceived Stress Scale) in 141 cigarette smokers scheduled to undergo elective surgery. To separate the effects of stress arising from tobacco abstinence from the effects of other perioperative stressors, such as pain, these measures were also obtained in 150 surgical patients who did not use tobacco. Assessments were performed at intervals beginning at the time of preoperative medical evaluation and ending 30 days postoperatively. RESULTS: Perceived Stress Scale scores were significantly (P < 0.001) higher in smokers throughout the study period. There was little significant interaction between smoking status and time, indicating that changes in Perceived Stress Scale score during the perioperative period did not differ between smokers and nonsmokers. The same result was found if analysis was restricted to data collected before hospital discharge (and thus during assured abstinence). Similar results were found for the nicotine withdrawal scale, suggesting that smokers did not experience more withdrawal symptoms relative to nonsmokers. CONCLUSIONS: Although smokers report increased baseline stress, smoking status does not affect changes in perceived stress over the perioperative period. Nicotine withdrawal symptoms do not seem to be a clinically significant problem in the perioperative period for most smokers.     

Effect of nicotine replacement therapy on stress and smoking behavior in surgical patients

BACKGROUND: Many surgical patients are dependent on nicotine. Smoke-free policies in healthcare facilities mandate abstinence from smoking, which could contribute to psychological stress in the perioperative period. The authors tested the hypothesis that nicotine replacement therapy decreases psychological stress in cigarette smokers scheduled to undergo elective surgery and determined whether nicotine replacement therapy affects postoperative smoking behavior, even when not specifically prescribed to promote abstinence. METHODS: In this double-blind, placebo-controlled trial, 121 smokers, of whom 116 received a study intervention, were randomly assigned to receive either active (nicotine-containing) or placebo patches, beginning on the morning of surgery and continuing for up to 30 days after discharge from the hospital. Outcomes included the Perceived Stress Score, the Nicotine Withdrawal Score, and subject self-report of smoking behavior. RESULTS: The Perceived Stress Score and the Nicotine Withdrawal Score did not change significantly from baseline over the immediate perioperative period and did not differ between active or placebo patch groups (all P > 0.19). The percentage of placebo versus active patch subjects reporting 7-day abstinence at 30 days postoperatively (30% vs. 39%; P = 0.29) did not differ significantly between groups. At 30 days postoperatively, subjects in both groups significantly reduced their cigarettes smoked per day from baseline, but those receiving active patches reported a greater decrease (a mean decrease of 11 +/- 11 vs. 15 +/- 7 cigarettes/day in placebo and active groups; P = 0.045). CONCLUSION: Routine nicotine replacement therapy is not indicated in smokers undergoing surgery for the purposes of managing nicotine withdrawal and stress but can modify some aspects of postoperative smoking behavior.     

Effect of Nicotine Replacement Therapy on Stress and Smoking Behavior in Surgical Patients

Background: Many surgical patients are dependent on nicotine. Smoke-free policies in healthcare facilities mandate abstinence from smoking, which could contribute to psychological stress in the perioperative period. The authors tested the hypothesis that nicotine replacement therapy decreases psychological stress in cigarette smokers scheduled to undergo elective surgery and determined whether nicotine replacement therapy affects postoperative smoking behavior, even when not specifically prescribed to promote abstinence.

Methods: In this double-blind, placebo-controlled trial, 121 smokers, of whom 116 received a study intervention, were randomly assigned to receive either active (nicotine-containing) or placebo patches, beginning on the morning of surgery and continuing for up to 30 days after discharge from the hospital. Outcomes included the Perceived Stress Score, the Nicotine Withdrawal Score, and subject self-report of smoking behavior.

Results: The Perceived Stress Score and the Nicotine Withdrawal Score did not change significantly from baseline over the immediate perioperative period and did not differ between active or placebo patch groups (all P > 0.19). The percentage of placebo versus active patch subjects reporting 7-day abstinence at 30 days postoperatively (30% vs. 39%; P = 0.29) did not differ significantly between groups. At 30 days postoperatively, subjects in both groups significantly reduced their cigarettes smoked per day from baseline, but those receiving active patches reported a greater decrease (a mean decrease of 11 +/- 11 vs. 15 +/- 7 cigarettes/day in placebo and active groups; P = 0.045).     

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.     

Effects of Nicotine on Spinal Cord Injury Pain: A Randomized,Double-Blind,Placebo Controlled Crossover Trial

Background:

One factor affecting spinal cord injury (SCI)–related pain may be nicotine. Case reports have described a worsening of neuropathic pain from smoking and relief from abstinence. Neurobiological correlates also implicate the potential effect of nicotine on SCI-related pain.

Method:

The current study employed a randomized, placebo-controlled crossover design to examine the effect of nicotine exposure on subtypes of SCI-related pain among smokers and nonsmokers.

Results:

Whereas nonsmokers with SCI showed a reduction in mixed forms of pain following nicotine exposure, smokers with SCI showed a converse increase in pain with regard to both mixed and neuropathic forms of pain. The exacerbation of pain in chronic nicotine or tobacco users may not only elucidate possible pain mechanisms but may also be of use in smoking cessation counseling among those with SCI.     

Perioperative abstinence from cigarettes: physiologic and clinical consequences

Chronic exposure to cigarette smoke produces profound changes in physiology that may alter responses to perioperative interventions and contribute to perioperative morbidity. Because of smoke-free policies in healthcare facilities, all smokers undergoing surgery are abstinent from cigarettes for at least some period of time so that all are in various stages of recovery from the effects of smoke. Understanding this recovery process will help perioperative physicians better treat these patients. This review examines current knowledge regarding how both short-term (duration ranging from hours to weeks) and long-term smoking cessation affects selected physiology and pathophysiology of particular relevance to perioperative outcomes and how these changes affect perioperative risk. It will also consider current evidence regarding how nicotine replacement therapy, a valuable adjunct to help patients maintain abstinence, may affect perioperative physiology.     

围术期戒烟病理生理与国内外麻醉医师对戒烟干预研究进展

背景 吸烟患者在围术期均处于不同的戒烟期,麻醉医师在围术期承担重要角色,但戒烟对围术期病理生理的影响有多大,哪些因素影响患者的围术期戒烟及戒烟实施情况并不十分清楚. 目的 提高麻醉管理水平,改善围术期吸烟患者的预后. 内容 回顾当前关于短期(时间范围从数小时到数周)和长期戒烟病理生理方面的变化,尤其是与术后转归密切相关的几个方面.此外,还探讨围术期戒烟的影响因素、国内外麻醉医师在围术期戒烟中的作用与实践. 趋向 围术期戒烟还有很长的路要走,需要今后的临床研究和实验进一步探讨,以便更好地帮助患者围术期甚至长期戒烟,减少麻醉手术相关并发症.     

The influence of smoking on complications after primary amputations of the lower extremity

A total of 165 primary above-the-knee (AK) and below-the-knee (BK) amputations in 137 patients were reviewed retrospectively. Of the 77 patients who smoked, 44 smoked cigarettes, 30 cheroots, and three a pipe. There were 88 nonsmokers. At the time of surgery, the smokers were on average 6.4 years younger than the nonsmokers. The review revealed no discrepancy between smokers and nonsmokers with regard to amputation level, the BK to AK ratio being 2:1. In cigarette smokers the risk of infection and reamputation was 2:5 times higher than in cheroot smokers or nonsmokers. The poor results obtained in cigarette smokers may be ascribed to the fact that this group of patients smoked during the phase of healing and that only cigarette smokers tend to inhale. Inhalation of smoke leads to high concentrations of nicotine, which compromise the cutaneous blood-flow velocity and increase the risk of the formation of microthrombi. Consequently, amputees should abstain from cigarette smoking during the phase of healing. Preferably, the habit should be broken one week before surgery, which is the requisite period for the process of coagulation and the fibrinogen level to normalize and for free radicals to be eliminated.     

Nicotine smoking: Influences on perioperative pain management

BackgroundThe complex relationship between smoking and pain has clinical relevance in the practice of anesthesiology and pain medicine. The present study investigated the effect of heavy nicotine smoking on perioperative pain management.MethodsThis prospective controlled study was carried out in Alexandria Main University hospital on 80 adult ASA I and II patients scheduled for lower limb fractures fixation under general anesthesia after an informed written consent and approval of the Medical Ethics Committee. Patients were divided into 2 groups: group N included nonsmokers and group S included the heavy smokers. Intraoperative heart rate (HR), mean arterial blood pressure (MAP) and intraoperative analgesia were recorded. Postoperatively; HR, MAP, pain visual analog scale (VAS) and total postoperative analgesic requirements were recorded.ResultsIntraoperative and postoperative HR and MAP showed significantly higher values in group S patients than group N patients. VAS values were significantly lower in group N than group S at recovery, 8 and 24 h postoperatively. Total intraoperative and postoperative analgesic requirements of meperidine were significantly lower in group N than group S.ConclusionsChronic nicotine smoking increases the incidence of perioperative pain. Heavy smokers need more perioperative analgesia than nonsmokers.     

Abstinence from smoking reduces incisional wound infection: a randomized controlled trial

OBJECTIVE: Clinical studies show that the incidence of postoperative wound complications is higher in smokers than nonsmokers. In this study, we evaluated the effect of abstinence from smoking on incisional wound infection. METHODS: Seventy-eight healthy subjects (48 smokers and 30 never-smokers) were included in the study and followed for 15 weeks. In the first week of the study, the smokers smoked 20 cigarettes per day. Subsequently, they were randomized to continuous smoking, abstinence with transdermal nicotine patch (25 mg per day), or abstinence with placebo patch. At the end of the first week and 4, 8, and 12 weeks after randomization, incisional wounds were made lateral to the sacrum to excise punch biopsy wounds. At the same time identical wounds were made in 6 never-smokers. In 24 never-smokers a wound was made once. All wounds were followed for 2 weeks for development of wound complications. RESULTS: A total of 228 wounds were evaluated. In smokers the wound infection rate was 12% (11 of 93 wounds) compared with 2% (1 of 48 wounds) in never-smokers (P <0.05). Wound infections were significantly fewer in abstinent smokers compared with continuous smokers after 4, 8, and 12 weeks after randomization. No difference between transdermal nicotine patch and placebo was found. CONCLUSIONS: Smokers have a higher wound infection rate than never-smokers and 4 weeks of abstinence from smoking reduces the incidence of wound infections.     

Einfluss des Zigarettenrauchens auf die Hautdurchblutung der Hand

BACKGROUND: Cigarette consumption leads to postoperative wound healing disturbances by impairing skin circulation. MATERIALS AND METHODS: Fourteen nonsmokers and 44 smokers were investigated and classified according to age (<40 and >40 years) and duration of cigarette consumption. Circulation at the tip of the middle finger was measured in both groups under standard conditions with laser Doppler imaging. RESULTS: There was a reduction in skin blood circulation of 24% in smokers (young 39%, older 11%, P=0.001) and 30% in nonsmokers (young 35%, older 18%, P=0.019). With longer duration of cigarette consumption, the effect grew weaker (<10 years 25%, 11-30 years 18%, >30 years 15%). There was no correlation between the number of cigarettes consumed per day and impaired circulation. CONCLUSION: Younger subjects react to cigarette consumption with a stronger reduction in circulation. In elective surgery, especially in young smokers we recommend a 6- to 8-week nicotine abstinence prior to surgical intervention.     

Urinary cotinine measurement in patients with Buerger's disease--effects of active and passive smoking on the disease process

Although Buerger's disease is known to be closely related to smoking, no objective analysis of the smoke-associated problems has been performed. In this study, cotinine, the major metabolite of nicotine, was used as a sensitive marker to measure levels of active smoking and the exposure of nonsmokers to tobacco smoke because it has a relatively long half-life and because cotinine levels can be determined by noninvasive means in urine. According to urinary cotinine levels, 40 patients with Buerger's disease were classified as (1) smokers: those with urinary cotinine levels above 50 ng/mg creatinine; (2) passive smokers: those with levels between 10 and 50 ng/mg creatinine; and (3) nonsmokers who did not experience noticeable passive smoking: those with levels below 10 ng/mg creatinine. There were 10 smokers, 9 passive smokers, and 21 nonsmokers. The course of the disease, after the initial treatment at our hospital, was studied retrospectively. Seven of the 10 smokers, none of the 9 passive smokers, and 4 of the 21 nonsmokers experienced aggravation of the disease. Of the four nonsmokers who experienced aggravation, three had still been smokers and one had been exposed to tobacco smoke in the workplace at the time of relapse. There was a significant difference in the aggravation rate between the smokers' group and the other two groups. Among the smokers, the seven patients whose conditions worsened showed significantly higher cotinine levels than the three remaining patients who were in the stage of remission.(ABSTRACT TRUNCATED AT 250 WORDS)     

Trends in sales weighted tar, nicotine, and carbon monoxide yields of UK cigarettes

BACKGROUND: Reducing tar yields of manufactured cigarettes has been an important plank of government policy on tobacco, but sale weighted yields are not routinely published. METHODS: Tar, nicotine, and carbon monoxide yields measured by the Laboratory of the Government Chemist were combined with cigarette brand market shares from national surveys of smoking behaviour to generate sales weighted yield estimates for the period 1972-99. RESULTS: Sales weighted mean tar yields have declined steadily and in 1999 were 9.6 mg per cigarette, less than half their level in 1972. Over the same period nicotine yields have come down from 1.33 mg to 0.79 mg per cigarette. Carbon monoxide yields have shown smaller declines. At the same time as absolute yields have declined, there have also been changes in tar to nicotine ratios. Smokers in 1999 were exposed to 22% less tar per unit of nicotine than in 1973, and smokers of low tar brands have consistently been exposed to less tar per unit of nicotine than smokers of other brands. CONCLUSIONS: The value of reducing cigarette tar and nicotine yields has been questioned, since the tendency of smokers to compensate for reductions in nicotine delivery undermines the policy. The favourable trends in tar to nicotine ratios suggest that, despite this, there may have been some modest public health benefit. It cannot be assumed that future reductions from present levels would necessarily result in further improvement in tar to nicotine ratios. An explicit focus on the ratio of tar to nicotine may provide a metric of greater relevance for public health than the present emphasis on absolute tar yields.     

Crucial aspects of smoking in wound healing after breast reduction surgery.

BACKGROUND: The aim of this study was to investigate the influence of cigarette smoking on wound-healing in patients undergoing breast reduction. METHODS: In our prospective study, 50 patients (25 smokers, 25 nonsmokers) scheduled for breast reduction have been evaluated. Urine cotinine levels were measured to analyse perioperative smoking habits. Urine samples were taken preoperatively and on the fourth postoperative day. Cotinine as a metabolite of nicotine allows precise evaluation of nicotine exposure. To assess the progress of woundhealing we classified secreting, instable, inflamed or necrotic wound conditions, which required a dressing after the tenth postoperative day as impaired wound healing. For statistical analysis non-parametrical tests for independent and dependent data were used. RESULTS: Ten of 25 smokers presented impaired wound healing compared to 4 of 25 nonsmokers. The median cotinine level of smokers was 1964 (783/3963)ng/cc preoperatively and 432 (148/1695)ng/cc postoperatively. Nonsmokers had a preoperative cotinine level of 18 (7/37)ng/cc and 15 (4/34)ng/cc postoperatively. Smokers who developed impaired wound-healing showed higher levels of cotinine pre- (2117 ng/cc) and especially postoperatively (485 ng/cc) compared to smokers with regular woundhealing (1614 ng/cc and 389 ng/cc). Both differences in cotinine levels were statistically significant (p=0.03 and p=0.02). CONCLUSIONS: The data of the present study confirm the negative effect of smoking on wound healing in patients undergoing breast reduction.     

Smoking and degenerative changes of the cervical spine: a roentgenographic study.

BACKGROUND CONTEXT: Cigarette smoking has been implicated in low back pain and intervertebral disc degeneration; however, there is no conclusive evidence that cigarette smoking is an important contributing factor to intervertebral disc degeneration. PURPOSE: The objective of this study is to determine whether heavy cigarette smoking is a contributing factor to the development and severity of degenerative disc disease of the cervical spine. STUDY DESIGN: This is a comparative roentgenographic study of degenerative changes of the cervical spine in age- and sex-matched smokers and nonsmokers. PATIENT SAMPLE: Two hundred asymptomatic subjects, 100 women and 100 men, were equally divided into 50 nonsmokers and 50 heavy smokers. OUTCOME MEASURES: A numerical grading system previously developed was used to grade the presence and severity of degenerative changes at each cervical level, and cervical lordosis was measured. This was performed on a lateral cervical spine roentgenogram. METHODS: A single lateral roentgenogram of the cervical spine was taken in each individual, and in the smokers a short questionnaire was administered to determine the amount and duration of smoking. The roentgenograms were read by the three authors. Average values of all three observers were used for statistical analysis. RESULTS: There were no statistically significant differences between smokers and nonsmokers. CONCLUSIONS: Based on the evidence of the plain roentgenograms used in this study, we found no evidence to suggest that cigarette smoking is a causative factor in asymptomatic people in the development of degenerative disc disease in the cervical spine. Whether cigarette smoking has a significant effect in people with neck symptoms cannot be determined by this study.     

Response and acclimatisation of symptomless smokers on changing to a low tar, low nicotine cigarette.

Ten symptomless smokers were switched from their usual cigarette to a low tar, low nicotine test cigarette for two weeks to investigate their immediate response and subsequent acclimatisation to the test cigarette. The tar (T) and nicotine (N) yields of the test cigarettes were T = 3.8 mg, N = 0.6 mg; the median yields of the usual cigarettes were T = 16.4 mg, N = 1.4 mg. The subjects were monitored over a six week period comprising a control period (usual cigarette), a test period (test cigarette), and a return period (usual cigarette), each lasting two weeks. The inhaled smoke volume (smoke from the burning tip of the cigarette which is subsequently inhaled) was measured with a non-invasive radiotracer technique. Puffing indices were recorded using an electronic smoking analyser and flowhead cigarette holder. Measurements were made at the beginning of the control period, at the beginning and end of the test period, and at the end of the return period. Subjects kept records of their cigarette consumption during each of the three periods. Apart from a small change in puff duration, cigarettes were smoked in the same way during the control and return periods. Mean and total puff volumes increased with the low tar, low nicotine cigarette but did not change from the beginning to the end of the test period. There was no significant change between the control, test, and return periods for mean inhaled smoke volume, total inhaled smoke volume, or cigarette consumption. It is concluded that when smokers are switched to a low tar, low nicotine cigarette the puff volume increases but there is no change in the inhaled smoke volume or daily consumption.     

Absorption of nicotine and carbon monoxide from passive smoking under natural conditions of exposure.

Seven non-smokers were exposed to tobacco smoke under natural conditions for two hours in a public house. Measures of nicotine and cotinine in plasma, saliva, and urine and expired air carbon monoxide all showed reliable increases. The concentrations of carbon monoxide and nicotine after exposure averaged 15.7% and 7.5% respectively of the values found in heavy smokers. Although the increase in expired air carbon monoxide of 5.9 ppm was similar to increases in smokers after a single cigarette, the amount of nicotine absorbed was between a tenth and a third of the amount taken in from one cigarette. Since this represented a relatively extreme acute natural exposure, any health risks of passive smoking probably depend less on quantitative factors than on qualitative differences between sidestream and mainstream smoke.     

Smokers, Risks, and Complications in Abdominal Dermolipectomy

Cigarette smoke has many detrimental effects on health, with consequences such as cardiovascular diseases, respiratory diseases, and tumors. In plastic surgery, these effects appear during the wound healing process. This retrospective study showed wound healing in 57 patients who had undergone abdominal dermolipectomy surgery. The patients were divided into two groups: smokers and nonsmokers. According to the results, smokers face a great complication risk for surgical wounds, which cause aesthetically more undesirable scars than observed in nonsmokers. The authors hypothesize that abstinence from smoking for 4 to 12 weeks before surgery would improve the quality of the scars.     

Sensitivity of upper airway reflexes in cigarette smokers: effect of abstinence

In two studies we have compared the upper airway reflex sensitivity(UARS) of chronic cigarette smokers with that of non-smokersand also the effect of different periods of abstinence on UARSin the smoking groups. UARS was measured by recording the thresholdconcentration of dilute ammonia vapour required to stimulatereflex glottic closure. The first study compared UARS in 20non smokers with 20 smokers, followed by another measurementin the smoking group after 24 h of abstinence. In study two,we measured UARS repeatedly over a period of 3–4 weeksin 16 smokers, half of whom had stopped smoking on day 0. Chroniccigarette smokers were found to have significantly greater UARScompared with non-smokers; the sensitivity was unaltered after24 h of abstinence but was found to reduce over several days,the change commencing between 24 and 48 h, with most achievinga consistent change within 10 days.     

Relationship between type of tobacco used and localization of tumour in patients with gastric cancer.

The relationship between the type of tobacco used and the localization of the tumour was studied in 493 patients with gastric cancer. The relative frequency of tumour site was found to vary significantly with the type of tobacco. In men who used all kinds of tobacco, a pipe was the most common form of smoking. Women smoked only cheroots or cigarettes or both. Male smokers showed a significantly higher percentage of tumours at the cardia than did female smokers. Female smokers had a significantly higher percentage of tumours involving the entire stomach than male smokers. Male smokers with tumours at the cardia were significantly more often pipe smokers and cigarette smokers than cheroot smokers. Male smokers with tumours involving the entire stomach were significantly more often cheroot smokers than cigarette smokers. The localization of tumours in cigarette smokers differed in men and women, indicating that cigarette smoking per se possibly plays a subordinate causal role. On the other hand, the distribution pattern of the localization among cheroot smokers was practically the same in both sexes, which might indicate that this type of smoking plays an important role. The same probably applies to pipe smoking, especially when combined with snuff or chewing tobacco, but these types of tobacco had not been used by the women. It is mentioned that not only the nature of tobacco used, but also concurrent factors may influence the localization of the tumours.