ANZCA Bulletin June 2012 - final.pdf - Australian and New Zealand ...

The “chance” for cardiovascularimprovement appeared not to motivatemost patients, who continued to smokeuntil the day of surgery. Perhaps manybelieved their lungs and heart were fine.Perhaps others would be motivated iftold their chance was increased by 30to 100 per cent for a range of majormorbidity including surgical site infection,pneumonia, myocardial infarction, strokeand septic shock 10 . Whether patients“need to let the...anaesthetist know”about their smoking or whether it is ourresponsibility to ask is a point that could beargued. However an audit of preoperativeassessments in the UK showed smokingstatus was documented in less than 25 percent of cases so perhaps there is a needfor smokers to volunteer the information 11 .The existing brochure was weak and 50per cent of surgical patients who smokedid not recall receiving this limited advice 12 .Fewer than 40 per cent of smokers wereaware that smoking increased anaestheticcomplications or made wound infectionsmore likely 13 . Clinicians were not talkingto their patients about smoking either.Only 9 per cent of smokers were told tostop by an anaesthetist and 25 per centby a surgeon 12 . Surgeons advised quittingsmoking in only 6.5 per cent of patients ina previous study at a Melbourne teachinghospital 14 . Clinician behaviour in thisregard may be influenced by concerns thatcessation just prior to surgery increasedrespiratory complications, although thisis increasingly recognised as medicalmyth that has persisted far too long 2,7,15 .In taking advantage of the “teachablemoment” that surgery provided for smokingcessation, it appeared that clinicians haddropped the ball.Stop before the opFrom August 2011, all smokers enteringthe Peninsula Health waiting list weresent a locally developed quit pack, whichaddressed the deficiencies identifiedabove. This was marketed as the “Stopbefore the op” program.It consisted of a colour brochuredetailing how quitting before surgerycould reduce postoperative morbidity/mortality and improve long-term healthif staying quit. A referral form for Quitlinewas included together with a reply-paidenvelope to our anaesthetic department.The brochure advised signing and postingthis form, which would be faxed to Quitline.It advised that Quitline is staffedby smoking cessation specialists whooffered a standard service of six freetelephone counselling sessions that wouldat least double the chances of long-termabstinence compared with trying alone 2 .Quitlines in all Australian states and NewZealand offer a similar service. Prior to“Stop before the op” less than 2 percent of smokers having surgery had usedQuitline in the past year.The new brochure included links forother support options such as face-to-facecounselling offered by Peninsula HealthCommunity Health.During the six-month pilot program,650 quit packs were posted to smokersentering the waiting list, resulting in 83requests (12.8 per cent) for Quitlineservices. Other patients contacted theanaesthetic department to say they hadquit without Quitline or saw a GP for help.Data was collected prior to the pilot showsthat although some patients did quit whileon the waiting list, this mostly occurredwithin a few weeks of surgery when theremay be little benefit (see figure below).“Stop before the op” increased Quitline usemore than fivefold and transformed quittingto clinically meaningful times of a month ormore. Following this success, the programis now permanent with a slightly modifiedquit pack being sent to every waitinglistpatient (smokers and non-smokers)as identification of smokers was timeconsumingand sometimes difficult.More lifeboats on the TitanicSince 1944, there have been more than300 papers showing the adverse effectsof smoking on surgical outcome, includingincreased risks of perioperative myocardialinfarction 10,16 . While it is appropriate toexplore risk reduction strategies throughresearch on beta-blockers (POISE),clonidine/aspirin (POISE-2) or nitrous oxideavoidance (ENIGMA-2), smoking cessationis a life-boat that is here and now.Our responsibility is to ensure thatall patients are offered the chance toget in the lifeboat if they choose.Dr Ashley WebbFrankston Hospital, VictoriaDistribution of quit durations before surgeryfollowing implementation of “stop beforethe op” quit pack: increased % of clinicallymeaningful quit times (>1 month)6 months31.8 27.3 29.5 11.4 11.1 16.7 72.2 5.6Before quit packsAfter quit packsReferences:Links: Australian Quitline referral form: www.quitnow.gov.au/internet/quitnow/publishing.nsfNew Zealand Quitline referral form:www.quit.org.nz/94/helping-others-quit/healthprofessionals1. Spignesi SJ. The Titanic For Dummies. Hoboken:John Wiley & Sons; 2012.2. Webb A. Smoking and surgery: time to clear theair. In: Riley R, ed. Australasian Anaesthesia 2011.Melbourne: ANZCA; 2012:115-124.3. Henningfield J, Pankow J, Garrett B. Ammonia andother chemical base tobacco additives and cigarettenicotine delivery: issues and research needs.Nicotine Tob Res. Apr 2004;6(2):199-205.4. Heydon NJ, Kennington KS, Jalleh G, Lin C. WesternAustralian smokers strongly support regulations onthe use of chemicals and additives in cigarettes. TobControl. May 2012;21(3):381-382.5. AIHW. Australia’s Health 2010. Australia’s healthseries No. 12. In: Welfare AIoHa, ed. Vol Cat. No122. Canberra: AIHW; 2010.6. Shi Y, Warner DO. Surgery as a teachable momentfor smoking cessation. Anesthesiology. Jan2010;112(1):102-107.7. Myers K, Hajek P, Hinds C, McRobbie H. StoppingSmoking Shortly Before Surgery and PostoperativeComplications: A Systematic Review and Metaanalysis.Arch Intern Med. Jun 2011;171(11):983-989.8. Wolfenden L, Wiggers J, Knight J, et al. Increasingsmoking cessation care in a preoperative clinic:a randomized controlled trial. Prev Med. Jul2005;41(1):284-290.9. Lee B, Webb A. Smoking cessation strategies atpublic hospital preadmission clinics in Victoria, NSWand ACT. ANZCA Annual Scientific Meeting 2012;www.anzca.edu.au/events/ANZCA per cent20annualper cent20scientific per cent20meetings/2012-anzca-annual-scientific-meeting/epostersessions-2012/asm-2012_435.pdf.10. Turan A, Mascha EJ, Roberman D, et al. Smokingand perioperative outcomes. Anesthesiology. Apr2011;114(4):837-846.11. Simmonds M, Petterson J. Anaesthetists’ records ofpre-operative assessment. Clin Perform Qual HealthCare. 2000;8(1):22-27.12. Webb A, Robertson N, Sparrow M, McCormackM, Connell G. Smoking cessation before electivesurgery: who is telling patients to stop beforethe operation? ANZCA ASM 2012; www.anzca.edu.au/events/ANZCA per cent20annual percent20scientific per cent20meetings/2012-anzcaannual-scientific-meeting/eposter-sessions-2012/asm-2012_382.pdf.13. Webb A, Robertson N, Sparrow M, McCormack M,Connell G. Elective surgical patients who smokehave low awareness of their increased perioperativerisks. ANZCA ASM 2012; www.anzca.edu.au/events/ANZCA per cent20annual per cent20scientific percent20meetings/2012-anzca-annual-scientificmeeting/eposter-sessions-2012/asm-2012_381.pdf.14. Myles PS, Iacono GA, Hunt JO, et al. Risk ofrespiratory complications and wound infectionin patients undergoing ambulatory surgery:smokers versus nonsmokers. Anesthesiology.Oct 2002;97(4):842-847.15. Shi Y, Warner DO. Brief preoperative smokingabstinence: is there a dilemma? Anesth Analg.Dec 2011;113(6):1348-1351.16. Peters MJ, Morgan LC, Gluch L. Smoking cessationand elective surgery: the cleanest cut. Med J Aust.Apr 2004;180(7):317-318.33