We are all familiar with the general warning, from surgeons, on the multiple hazards of smoking. Yet those of us who have fallen prey to this addictive social habit consciously choose to ignore it. Though, if you are planning to undergo surgery, Dr Alexandra Grubnik, a plastic and recontructive surgeon, explains why it is now time to cut out smoking.
The history of smoking
Since ancient times, tobacco was known and cultivated. Columbus, who encountered it while exploring the Native American culture, brought it to the Western world. It rapidly spread through the Courts of Europe.
Nicotine, the active ingredient in tobacco, is named after Jean Nicot. He was the French ambassador to Lisbon in the 16th century, and was responsible for introducing tobacco to the French Court.
In the era of industrialisation, tobacco smoking became fashionable. Not to mention glamorised by both print ad campaigns and Hollywood movies. It is estimated that tobacco companies spend $13 billion yearly on advertising in the US alone.
What’s in a cigarette?
Cigarette smoke contains over 4000 identified chemical compounds, of which 250 are known to be harmful. The four components most commonly implicated in causing postsurgical complications are: nicotine, carbon monoxide, hydrogen cyanide and nitric oxide.
Nicotine is an alkaloid found in the leaves of tobacco plants. It serves as a poison, protecting the plant from insects and animals. Therefore, it should not be surprising that this poison is equally toxic to humans.
In the setting of surgery, it actively reduces blood flow to the wound by narrowing blood vessels and making the blood more viscous (sticky). Because the blood can’t reach the wound edges, no nutrients or oxygen can be delivered to the wound. Thus, making the wound predisposed to infections and breakdown.
Carbon monoxide is a colourless, odourless, poisonous gas. Carbon monoxide poisoning is well-known and documented in accidents and suicide attempts. This poisonous gas also comprises 4% of cigarette smoke.
In the body, it attaches to haemoglobin – a molecule designed to carry oxygen to the tissues. As this poison takes the place of oxygen in the blood, the body feels that it is suffocating and responds by producing more haemoglobin molecules. This in turn makes the blood more viscous and further impairs its ability to pass through small blood vessels to the edges of the wound.
Hydrogen cyanide is a highly-toxic chemical used in chemical weapons and rodent poison. When inhaled in cigarette smoke, it damages the cells by impairing their ability to repair themselves. It also damages the white blood cells that are responsible for wound healing and fighting infection. This also leads to wound breakdown and sepsis (a potentially life-threatening complication of an infection).
Nitric oxide is a biological molecule present in cigarette smoke in high concentrations. It is responsible for dilatation of the air passages (bronchioles) and the blood vessels in the lungs. This unfortunately leads to higher absorption of the preceding three poisonous compounds.
Surgery and smoking
The American College of Surgeons carried out an analysis of smoking and surgical complications in over 40 000 patients who underwent plastic surgical procedures. It showed that smokers had a higher likelihood of developing both surgical and medical complications.
Also, smokers were almost twice as likely to develop wound breakdown and sepsis as non-smokers. The documented complications included wound infection, loss of implants and/or grafts, failure of wound healing which necessitated unplanned returns to the operating theatre.
Medical complications included pneumonia, heart attack, kidney failure, urinary infections, clots in the leg (deep venous thrombosis) and life-threatening clots in the lungs (pulmonary embolus)1.
Breast cancer and smoking
Interestingly, a recently published large meta-analysis of 400 944 patients with breast cancer showed that smokers were 28% more likely to die of breast cancer than patients who never smoked. Also, the likelihood of dying in breast cancer patients who gave up smoking was equal to the ones who never smoked. This indicates that breast cancer patients ceasing to smoke can dramatically lower their risk of dying from breast cancer2.
Smoking cessation strategies
The recommendation from the American College of Surgeons is to quit smoking four to six weeks before the operation and to stay smoke-free for four weeks after the operation. This can half the complication rate associated with surgery. Helpful tips on cessation of smoking can be found on www.facs.org
The effectiveness of various smoking cessation interventions was studied. It demonstrated that a smoker has a 1 in 8 chance of quitting without any additional aids. Nicotine replacement therapy can nearly double these odds, whereas smoking cessation medication can more than double them.
Nicotine replacement therapy, available in the form of gum, lozenges or patches, have been shown to decrease postoperative wound healing complications. There is no difference in efficacy of these forms of replacement so they may be used interchangeably.
Smoking cessation medications (Zyban, Chantix) reduce cravings and blunt the pleasurable effects of smoking. These medicines require a script, and should be taken under doctor supervision as they may cause serious side effects, including depression and suicidal thoughts.
Psychotherapy may be beneficial. Psychologists agree that the desire for cosmetic or other elective surgery may be a powerful motivator for smokers to quit.
A note on e-cigarettes
A case report and literature review, published in the Archives of Plastic Surgery this month, points out the risks of this new “healthier” trend. The article states, “There is a public misconception that e-cigarettes are healthier than traditional cigarettes and as such their use may go unreported by patients. Early evidence suggests e-cigarettes may induce some of the same physiologic changes as traditional cigarettes, and may have a significant deleterious effect on wound healing3.
Help patients to stop smoking
Helping patients to quit smoking is one of the most important impacts that a plastic surgeon has on a patient. It is of paramount importance to educate,support and guide patients through this life-changing endeavour.
- Goltsman et al, PRS Feb 2017
- Sollie et al, Gland Surg Aug 2017
- Fracol et al, Arch Plast Surg Oct 2017
MEET OUR EXPERT – Dr Alexandra Grubnik
Dr Alexandra Grubnik is a plastic and reconstructive surgeon with special interest in breast surgery, breast reconstruction, body contouring and cosmetic surgery. She practices at Netcare Milpark Hospital and Netcare Rosebank Hospital.