Smoking cessation in elective surgical patients offered free nicotine patches at listing: a pilot study

Preoperative intervention for smoking cessation: A systematic review

BACKGROUND

Smoking is associated with increased postoperative complications. Pre-surgical smoking cessation remains a challenge. Our aim was to summarize pre-hospital smoking cessation interventions and impact on smoking cessation rates.

METHODS

Independent review of English language articles identified from systematic searches of MEDLINE, PubMed, PsycInfo, Embase, Web of Science, and Cumulative Index to Nursing & Allied Health Literature databases from 1998 to 2019 was performed (PROSPERO registration number CRD42021247927). Studies of adult patients enrolled in a pre-hospital smoking cessation intervention were included. Studies with historical controls or only self-reported outcomes were excluded.

RESULTS

Nine articles including 1762 patients were identified. Exhaled CO was used to confirm cessation. Six studies reported smoking status day of surgery. Interventions included NRT, hand-held technology, e-cigarettes, decision aids/counseling and medications. Four studies demonstrated a difference in smoking cessation rates. Ethics and study appraisal were assessed using ROB2.

CONCLUSIONS

Based on the variability of interventions, settings, and outcomes, best practice for successful pre-hospital smoking cessation in surgery clinics would benefit from ongoing investigation.

Does offering small financial incentives to smokers at the time of being wait-listed for surgery increase smoking cessation by the day of surgery? A randomised feasibility trial

OBJECTIVE

This study aims to assess whether offering small financial incentives to smokers on elective surgery wait-lists is feasible and increases quitting before surgery.

DESIGN

Randomised controlled trial, prospective, double-blinded.

SETTING

Single-centre, Australian metropolitan public hospital.

PARTICIPANTS

620 adult smokers (≥10 cigarettes per day) were randomised on being wait-listed for elective surgery and 404 underwent operations (28 January 2021-31 July 2022) at the hospital (65.2%) by trial's end.

INTERVENTION

Intervention participants were offered at wait-listing an $A70 supermarket voucher for verified abstinence on the day of surgery, provided they registered an intention to quit before surgery. Registrants intending to quit were also referred to Quitline. Neither intervention was offered to control participants (usual care). Smokers wait-listed from 17 May 2021 were offered an increased incentive of $A140.

MAIN OUTCOME MEASURES

Primary outcome, quitting at least 24 hours before surgery, verified by exhaled carbon monoxide testing. Feasibility outcomes were the proportion taking up offers, ease of patient contact and disputes about quit status.

RESULTS

Of 620 randomised participants (control 312, intervention 308), 404 had surgery at the hospital during the trial (control 214, intervention 190), which was lower than expected (for COVID-19 reasons). Offering $A70 resulted in 21.9% registering to quit, increasing to 32.6% with $A140. Telephone calls were the most effective means to gain registrations. The proportion of intervention group patients verified quit at least 24 hours before surgery was similar to controls (9.5% vs 8.9%, OR 1.1, 95% CI 0.5 to 2.2). Quitline contact was higher in the intervention group (13.2% vs 2.3%, OR 6.3, 95% CI 2.3 to 21.6). Disputes over test results did not occur, but 17.4% of intervention participants claiming quit failed verification.

CONCLUSION

A single offer of financial rewards for perioperative cessation was feasible, without achieving clinically important quit differences.

TRIAL REGISTRATION NUMBER

ACTRN12620000130965.

Peri-operative tobacco cessation interventions: a systematic review and meta-analysis

Tobacco smoking is associated with a substantially increased risk of postoperative complications. The peri-operative period offers a unique opportunity to support patients to stop tobacco smoking, avoid complications and improve long-term health. This systematic review provides an up-to-date summary of the evidence for tobacco cessation interventions in surgical patients. We conducted a systematic search of randomised controlled trials of tobacco cessation interventions in the peri-operative period. Quantitative synthesis of the abstinence outcomes data was by random-effects meta-analysis. The primary outcome of the meta-analysis was abstinence at the time of surgery, and the secondary outcome was abstinence at 12 months. Thirty-eight studies are included in the review (7310 randomised participants) and 26 studies are included in the meta-analysis (5969 randomised participants). Studies were pooled for subgroup analysis in two ways: by the timing of intervention delivery within the peri-operative period and by the intensity of the intervention protocol. We judged the quality of evidence as moderate, reflecting the degree of heterogeneity and the high risk of bias. Overall, peri-operative tobacco cessation interventions increased successful abstinence both at the time of surgery, risk ratio (95%CI) 1.48 (1.20-1.83), number needed to treat 7; and 12 months after surgery, risk ratio (95%CI) 1.62 (1.29-2.03), number needed to treat 9. More work is needed to inform the design and optimal delivery of interventions that are acceptable to patients and that can be incorporated into contemporary elective and urgent surgical pathways. Future trials should use standardised outcome measures.

Anesthesiologists and the Other Pandemic: Tobacco Use

Tobacco use will kill a projected 1 billion people in the 21st century in one of the deadliest pandemics in history. Tobacco use disorder is a disease with a natural history, pathophysiology, and effective treatment options. Anesthesiologists can play a unique role in fighting this pandemic, providing both immediate (reduction in perioperative risk) and long-term (reduction in tobacco-related diseases) benefits to their patients who are its victims. Receiving surgery is one of the most powerful stimuli to quit tobacco. Tobacco treatments that combine counseling and pharmacotherapy (e.g., nicotine replacement therapy) can further increase quit rates and reduce risk of morbidity such as pulmonary and wound-related complications. The perioperative setting provides a great opportunity to implement multimodal perianesthesia tobacco treatment, which combines multiple evidence-based tactics to implement the four core components of consistent ascertainment and documentation of tobacco use, advice to quit, access to pharmacotherapy, and referral to counseling resources.

Framework, component, and implementation of enhanced recovery pathways

The introduction of enhanced recovery pathways (ERPs) has led to a considerable paradigm shift towards evidence-based, multidisciplinary perioperative care. Such pathways are now widely implemented in a variety of surgical specialties, with largely positive results. In this narrative review, we summarize the principles, components and implementation of ERPs, focusing on recent developments in the field. We also discuss ‘special cases’ in ERPs, including: surgery in frail patients; emergency procedures; and patients with Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2/COVID-19).

Offering mailed nicotine replacement therapy and Quitline support before elective surgery: a randomised controlled trial

Objective

To assess whether offering free mailed nicotine replacement therapy (NRT) and telephone counselling to smokers on elective surgery waiting lists increases quitting before surgery.

Design, setting

Randomised, controlled trial at Frankston Hospital, a public tertiary referral hospital in Melbourne.

Participants

Adult smokers added to elective surgery waiting lists for operations at least ten days in the future, 1 April 2019 ‒ 3 April 2020.

Intervention

In addition to normal care, intervention participants received a brochure on the risks of low frequency smoking, an offer of Quitline call‐back registration, and an offer of mailed NRT according to reported daily smoking: 1‒9 cigarettes/day, 2 mg lozenges; 10‒15/day, 7‒14 mg patches [three weeks] and 2 mg lozenges; > 15/day, 7‒21 mg patches [five weeks] and 2 mg lozenges.

Main outcome measures

Primary outcome: quitting at least 24 hours before surgery, verified by exhaled carbon monoxide testing. Secondary outcomes: quitting at least four weeks before surgery, adverse events, and (for those who had quit before surgery) abstinence three months after surgery.

Results

Of 748 eligible participants (control, 363; intervention, 385), 516 (69%) had undergone elective surgery when the trial was terminated early (for COVID‐19‐related reasons) (intervention group, 274; control group, 242). 122 of the 385 intervention participants (32%) had accepted the offer of cessation support. The proportions of intervention participants who quit at least 24 hours before surgery (18% v 9%; odds ratio [OR], 1.97; 95% CI, 1.22‒3.15) or at least four weeks before surgery (9% v 4%; OR, 2.20; 95% CI, 1.08–4.50) were larger than for the control group. Three months after surgery, 27 of 58 intervention (47%) and 12 of 25 control participants (48%) who quit before surgery reported not smoking in the preceding seven days. No major adverse events were reported.

Conclusion

Uptake of free mailed NRT and Quitline support by smokers on elective surgery waiting lists was good, and offering additional support was associated with higher proportions of smokers quitting before surgery.

Trial registration

Australian New Zealand Clinical Trials Registry, ACTRN12619000032156 (prospective).

Guidelines for Perioperative Care in Bariatric Surgery: Enhanced Recovery After Surgery (ERAS) Society Recommendations: A 2021 Update

Background

This is the second updated Enhanced Recovery After Surgery (ERAS®) Society guideline, presenting a consensus for optimal perioperative care in bariatric surgery and providing recommendations for each ERAS item within the ERAS® protocol.

Methods

A principal literature search was performed utilizing the Pubmed, EMBASE, Cochrane databases and ClinicalTrials.gov through December 2020, with particular attention paid to meta-analyses, randomized controlled trials and large prospective cohort studies. Selected studies were examined, reviewed and graded according to the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. After critical appraisal of these studies, the group of authors reached consensus regarding recommendations.

Results

The quality of evidence for many ERAS interventions remains relatively low in a bariatric setting and evidence-based practices may need to be extrapolated from other surgeries.

Conclusion

A comprehensive, updated evidence-based consensus was reached and is presented in this review by the ERAS® Society.

Hospital entrance smoking is reduced by broadcasting recorded antitobacco messages from Australian primary school children over entrance public address system

ISSUE ADDRESSED

Smoking near hospital entrances occurs frequently despite smoke-free policies, resulting in multiple issues including second-hand smoke exposure (SHS) to vulnerable populations. Primary school children were engaged through their health curriculum to produce antismoking audio recordings for broadcast over a hospital entrance loudspeaker system to determine if this reduced smoking.

METHOD

Students produced original recordings against hospital grounds smoking during class workshops, from which a collection (n = 16) was selected. Episodes of entrance smoking and total entrance traffic were recorded using security camera infrastructure over a 5-week period. A computer-controlled entrance loudspeaker played a message which was followed by silence until a new (different) message was played. Intensity of messaging was moderate in week 3 (every 5 minutes), increasing to high in week 4 (3 minutely) and compared to no messages (weeks 1-2 preintervention) and week 5 (postintervention).

RESULTS

Smokers presented 316 times, smoking 523 cigarettes over 155 hours of observation (patients 70.6%, visitors 29.4%). SHS exposure was high given 172 others used the entrance/hour. Smoking was highest in the preintervention period (weeks 1-2), median five cigarettes/hr [IQR,3-7 (min = 0, max = 12)], falling to four cigarettes/hr during 5-minutely broadcasts [IQR,2-5 (min = 1, max = 14)] (P = .06), but zero cigarettes/hr during 3-minutely broadcasts [IQR,0-1(min = 0, max = 7)] (P < .0001). Postintervention (no broadcasts), smoking increased from zero to 1 cigarette/hr [IQR,0-3 (min = 0, max = 5)]; (P = .052). Nonsmoker movements did not change significantly between each period.

CONCLUSION

Intensive (3 minutely) broadcasting of short antismoking messages significantly reduced hospital entrance smoking. SO WHAT?: Health services can positively interact with the health curriculum of primary schools against tobacco use while developing low-cost strategies to effectively deter entrance smoking.