Disclosures: Callaghan reports he receives IP royalties for product development from DePuy, A Johnson & Johnson Company. Goldstein reports he has stock or stock options with 7D Surgical; is a paid consultant for Augmedics, Auxano, Globus Medical, Integrity Spine; has stock or stock options with Johnson & Johnson; receives IP royalties from NuVasive and Regeneration Technologies; and has stock or stock options with Simplify and St. Teresa Medical. Bedard, Garrigues, Matuszewski and Zalavras report no relevant financial disclosures.
September 14, 2020
11 min read

Surgeons: Helping patients who smoke is important medicine

Education, 'hard stop' for surgery encourage preoperative smoking cessation

Disclosures: Callaghan reports he receives IP royalties for product development from DePuy, A Johnson & Johnson Company. Goldstein reports he has stock or stock options with 7D Surgical; is a paid consultant for Augmedics, Auxano, Globus Medical, Integrity Spine; has stock or stock options with Johnson & Johnson; receives IP royalties from NuVasive and Regeneration Technologies; and has stock or stock options with Simplify and St. Teresa Medical. Bedard, Garrigues, Matuszewski and Zalavras report no relevant financial disclosures.
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Tobacco use and smoking, in particular, wreak widespread havoc on the musculoskeletal system.

The effect of smoking ranges from its negative effect on bone mineral density and the small blood vessels to its association with osteoporosis, osteonecrosis, poor wound healing and a predisposition to post-surgical infection, and other problems.

The negative effects nicotine has on bone and soft tissue, and the upsides of smoking cessation to help improve the outcomes and quality of life for patients with orthopedic injuries and conditions who smoke need to be better communicated, according to sources interviewed for this Cover Story. Furthermore, sources said orthopedic surgeons are in an ideal position to convey this information and walk along side their patients as they reduce — and ultimately stop — their tobacco use.

Nicholas A. Bedard, MD, said that preoperatively he tells patients who smoke that stopping smoking is just as important to surgical safety and success as lowering BMI or controlling diabetes.

Source: University of Iowa Health Care Marketing and Communications

However, sources said smoking cessation to reduce the effects of smoking on musculoskeletal health is not an easy or straight forward process.

“In my mind, it would be wrong to actively pursue elective primary total joint replacement without at least working on smoking cessation prior to surgery,” Nicholas A. Bedard, MD, assistant professor of orthopedic surgery at University of Iowa Hospitals & Clinics, told Orthopedics Today.

The first report by the Surgeon General of the United States to focus on the topic of smoking cessation in 30 years, released in January, noted rates of tobacco use reached a historic low of 14% in 2018. A press release from Jan. 23, the day the report was released, noted, “more than two-thirds of U.S. adult cigarette smokers report interest in quitting cigarette smoking.”

“We know more about the science of quitting than ever before. As a nation, we can and must do more to ensure that evidence-based cessation treatments are reaching the people [who] need them,” U.S. Surgeon General Vice Adm. Jerome M. Adams, MD, MPH, said in the release. “I’m calling on health care professionals, health systems, employers, insurers, public health professionals and policy makers to take action to put an end to the staggering — and completely preventable — human and financial tolls that smoking takes on our country.”




Despite such progress, 34 million Americans report smoking even when effective apps, medications, hotlines, text-based help and counseling are available to help them quit, according to the U.S. Surgeon General’s report.

Enter the orthopedic surgeon.

Among orthopedic surgeons, it is widely known patients who smoke have increased postoperative morbidity and mortality. Therefore, smoking cessation should be encouraged.

Unfortunately, specific guidelines do not exist concerning how long a patient should stop smoking before surgery or the extent of improved postoperative healing and other benefits of cessation, such as when trauma patients should stop smoking postoperatively.

Jeffrey A. Goldstein

“I think we all agree nicotine is a poison, and it’s not good for anybody; but specifically, to spine surgery, it’s a poison when it comes to spinal fusion. It is in their best interest for patients stop smoking ... prior to surgery,” Jeffrey A. Goldstein, MD, an Orthopedics Today Editorial Board Member, told Orthopedics Today.

Patients who smoke do not heal as quickly and are at higher risk for degenerative disc disease, said Goldstein, director of the spine service and director of the spine fellowship at NYU Langone Orthopedic Hospital and NYU Langone Health.

Paul E. Matuszewski

“Smoking has been shown to be associated with an increased rate of complications and poor outcomes in elective and trauma orthopedic patients,” trauma surgeon Paul E. Matuszewski, MD, of University of Kentucky in Lexington, Kentucky, told Orthopedics Today. Findings of research that he and his colleagues conducted showed “while patients know the general negative effectives of smoking (eg, lung cancer, heart disease), patients are less apt to know the effects of smoking on bone and wound healing,” he said. “As such, orthopedists have the unique ability to educate during this teachable moment and effect change in patients who may not otherwise interact with the health care system. Many surgeons feel they can’t influence smoking behavior in their patients, but an orthopedic injury is the perfect time to relate the negative effects of smoking with something that affects them today as opposed to 20 years from now.”

Consensus data

The relationship between smoking and orthopedic infection was highlighted multiple times the 2018 International Consensus Meeting on Musculoskeletal Infection held in Philadelphia.

“There was a strong recommendation to stop smoking and that smoking was related to infection, and therefore you should try to stop smoking before you have [surgery],” John J. Callaghan, MD, Lawrence and Marilyn Dorr Chair and emeritus professor at University of Iowa, told Orthopedics Today. “That is the recommendation today both for wound healing and infection, as well as other complications.”

“The consensus statement summarizes the data well, too. Basically, they said it is a relative contraindication to proceed with total joint replacement in active smokers and recommended at least 4 weeks of cessation prior to surgery,” Bedard said.

Opportunity to intervene

Grant E. Garrigues

“The public health agencies are understandably focused on stroke, heart attacks, lung cancer and birth defects. Orthopedic surgeons need to take on the role of education and counseling about the effect of smoking on musculoskeletal health,” Grant E. Garrigues, MD, shoulder and elbow reconstruction surgeon at Midwest Orthopaedics at Rush, in Chicago, told Orthopedics Today.

“Smoking, and particularly the nicotine component, affects the small vessels, the small vasculature. That’s so important in the shoulder, particularly with the rotator cuff,” which has a marginal blood supply that decreases with age, he said.

“If you further damage that tenuous blood supply by having nicotine products in your body, that is a well known and established risk factor for development of rotator cuff tears. Unfortunately, it gets you coming and going, because it not only causes the rotator cuff tears; it also makes the rotator cuff repair twice as likely to not heal,” Garrigues said.

Charalampos G. Zalavras

Charalampos G. Zalavras, MD, MD, PhD, FACS, told Orthopedics Today, “By asking patients [about their smoking], assessing the risk and educating them and helping them stop smoking, we can improve the outcome of their injury or condition for which they have come to see us. So, we can help them in that regard. We can avoid a lot of postoperative complications. Also, it is a unique opportunity to guide someone toward stopping to smoke, which can have great health benefits many years down the road. Smoking, as we all know, is the leading cause of preventable death and disease in the United States.”

Smoking impacts all the tissues of the musculoskeletal system and produces a wide range of effects, many of which are not widely publicized or known to patients, Zalavras, professor of clinical orthopedics and director of orthopedic resident research in the department of orthopedic surgery at Keck School of Medicine of USC, said.

“Regarding fractures, smoking decreases the bone mineral density and is a risk factor for osteoporosis. It has been shown that smokers have a higher risk for sustaining fractures. Also, when a patient has sustained a fracture, then if that patient smokes, the healing will be delayed,” he said, noting a higher proportion of patients who smoke may not heal their fractures and go on to have a nonunion complication. He said patients who smoke are also highly predisposed to osteonecrosis.

Best time to stop smoking

The orthopedic surgeons interviewed placed importance on educating patients about the harms of nicotine use, be it from smoking cigarettes, cigars or pipes, using e-cigarettes or vaping, because patients are unlikely to get this information from other sources. They agreed orthopedic surgeons need to play a greater role in motivating their patients to stop smoking.

“That role is even more important given the popularity of e-cigarettes and vaping today,” said Garrigues, who encourages his patients to quit smoking prior to surgery. He tells them the body is remarkable in how it can heal itself from the negative effects of nicotine given the opportunity and enough time. Moreover, Garrigues cites evidence in the literature that supports stopping smoking — within 7 years of quitting smoking the risk of developing lung cancer declines where it is equivalent to patients who have never smoked.

“I’m not going to ask my patients to wait 7 years before they have their rotator cuff fixed. However, the point is, every little bit helps. We recommend patients stop smoking, and we’d like it to be 6 weeks. That’s a totally arbitrary number with no data. I do think patients who are off cigarettes for 6 weeks or more have a lower recidivism rate than those who just stop for a few days,” he said.

Garrigues takes his patients’ word that they quit and does not test them.

Duration of cessation

There are mixed opinions about how long prior to surgery patients should be nicotine-free. Goldstein tells patients they should stop smoking 1 month preoperatively. However, if they stop any time prior to surgery and do not start again, “that’s a win.”

Bedard said, at his hospital, orthopedic surgeons have patients work on smoking cessation and offer them tools, counseling and other resources to help with quitting.

“Once they have quit smoking, we do test patients with a year of urine nicotine tests. Then, if they are negative, we sign them up for surgery,” he said, noting that tact adds time to the cessation period because it includes added time from the time the patient quits smoking until TJR surgery occurs.

Lacking supporting data, we “suspect that the longer [patients] quit prior to surgery, the better optimization you would have,” Bedard said.

Programs to quit smoking

Goldstein said, “It is in patients’ best interest to stop smoking, stop taking nicotine products prior to surgery. Vaping doesn’t help. It has benefits, but it still has nicotine. Nicotine gum has nicotine, and the nicotine is the problem when it comes to spinal fusion.”

He tells every patient who smokes, “and there’s not many,” they must stop smoking prior to surgery. He helps them access the hospital smoking cessation program or refers them to their primary care physician to explore options to help them be successful in quitting.

“At NYU Langone Health, we have a great smoking cessation program. It’s never been easier to refer a patient. Just like we screen patients for osteoporosis, we can screen them for smoking. Frankly, with a few motivating words to the patient and a click on the button on our electronic medical record, we probably have a positive influence on these patients,” Goldstein said.

Zalavras and Matuszewski, whose institutions provide resources they give their patients refer patients to the California 1-800-NO-BUTTS and national 1-800-QUIT-NOW stop-smoking hotlines, respectively. Zalavras said the California hotline offers one-on-one counseling in multiple languages, texting support, a mobile app and information about in-person support groups, most of which are free. “There’s a wide range of support options for our patients, and we direct them to these,” he said.

Effective cessation

If used, the quit line can be 20% to 30% effective, Matuszewski said. A randomized trial Matuszewski and colleagues conducted, which was scheduled to be presented at this year’s American Academy of Orthopaedic Surgeon’s Annual Meeting, investigated 266 patients with operatively treated fractures who smoked. Patients in each group received different levels of support to quit smoking and were assessed at 3 months and 6 months postoperatively for exhaled carbon monoxide-confirmed quit status.

The 430-patient control group received advice at discharge from a nurse (the standard of care), 111 patients received the standard of care and 10-minute inpatient counseling, and 115 patients received standard of care, inpatient counseling and extended follow-up counseling.

At the 3-month and 6-month assessments of smoking cessation, “rates of smoking between the controls and the two groups were similar despite the different levels of counseling,” Matuszewski said.

Researchers found that surprising. Also surprising was the high number of patients in the control group who quit smoking. “Depending on the metric, exhaled carbon monoxide or self-reported status, anywhere from 10% to about 31% quit,” he said, and noted this was significantly higher than the current 4% self-quit rate and 6% to 7% physician-assisted quit rate.

According to Matuszewski, even though counseling did not increase cessation, “we showed increased referral to and acceptance of the quit line.”

Perhaps getting exhaled carbon monoxide assessed at each clinic visit may have influenced behavior, Matuszewski noted. “[It] is a point-of-care tool that’s rapid and gives instantaneous visual and auditory feedback to the patient” about smoking status, he said, noting results can be a jumping-off point for referral to smoking cessation programs. Use of exhaled carbon monoxide is also a billable service.

Smokers get ‘hard stop’ for surgery

Some TJR surgeons have a surgery “hard stop” for smokers and will not proceed with the operation.

Bedard said his hospital has been working on an abstinence from smoking prior to TJR surgery for a long time and the word is out in Iowa City and the surrounding area that TJR will not take place in patients who smoke.

“That’s what you have to have to make it effective,” Callaghan said. “It’s got to be a culture” and patients who come in and are referred to us understand that is part of our system.

“The buy-in becomes a lot easier that way,” he said.

Garrigues does not have that policy. He said, “I will tell patients that to smoke is a risk factors for retear. It’s a risk factor for the wound not healing. I would like you to stop smoking, but I’m not going to insist on it.”

Re-revisions of a rotator cuff repair for smokers are another story.

“Those already have a high rate of retear, especially if it is a massive tear,” Garrigues said. Instead he delays until the patient has been off nicotine, “because the results of healing that in a smoker are so dismal. I don’t feel comfortable offering them a surgery that I know is not going to work.”

According to Zalavras, “We should do our best to encourage our patients, to help them and to motivate them not to smoke; but, if it is a surgery that would greatly improve their quality of life, then it may not be the best course of action not to proceed with surgery.”

Goldstein said patients are better educated today on the negative effects of smoking. The number of his patients today who smoke is less now than when he started his orthopedic career, which, he said, is due, in part, to how well-educated patients are and how the cost of the habit has increased.

The pseudarthrosis rate for Goldstein’s patients who undergo spinal fusion is also lower now than it once was. He attributes this to the use of interbody fusion with bone graft extenders or bone morphogenetic proteins, which has increased fusion rates and decreased pseudarthrosis rates. He said, it is also due to the “fact that I have less patients who smoke.” Bedard said during preoperative visits he conveys to patients who smoke that they are part of the orthopedic team. “I tell them, and it is the same thing I would tell any family member, I will try to get you through this as safely as possible,” he said, and emphasizes that stopping smoking is just as important as lowering BMI or getting diabetes under control to the overall surgical safety and success.

During discussions with patients, Callaghan instructs them that their role on the team is to help mitigate some of the risks of TJR.

“If you can influence just one patient to quit or cut down, it’s worth your time,” said Matuszewski. “Smoking counseling during a clinic visit is now an additional billable service for Medicare/Medicaid, so there is no excuse to not talk to your patients about smoking cessation.” – by Susan M. Rapp and Casey Tingle