How long before surgery should a patient stop smoking or using tobacco products?

Smoking Cessation Before Surgery

Smoking cessation is strongly recommended at least 4 weeks before surgery to reduce respiratory and wound-healing complications. 1

Timing of Smoking Cessation

• Smoking cessation of 4-8 weeks before surgery is necessary to significantly reduce respiratory and wound-healing complications 1
• The risk reduction associated with cessation begins accruing after several weeks of abstinence 1
• Patients who quit smoking for more than 10 weeks before surgery can achieve complication rates similar to those who have never smoked 2
• Short-term smoking cessation (less than 4 weeks) has unclear benefits for reducing postoperative respiratory complications 1

Benefits of Preoperative Smoking Cessation

• Reduces overall postoperative complications by approximately 49% 3
• Decreases risk of specific complications:
  • Respiratory complications (pneumonia, atelectasis, respiratory distress) 2
  • Wound complications (delayed healing, infection) 1, 4
  • Air leakage and bronchopleural fistula (in lung surgery) 2
• Number needed to treat to prevent one complication is approximately 5 patients 3

Recommended Approach to Smoking Cessation

• Intensive interventions that begin 4-8 weeks before surgery show the greatest benefit 4, 5
• Effective cessation strategies include:
  • Individual counseling with weekly sessions 4
  • Nicotine replacement therapy (NRT) in addition to counseling 4, 5
  • Face-to-face or telephone counseling with written materials 1

Special Considerations for Different Surgeries

• For abdominal and pelvic surgeries, smoking cessation of at least 4 weeks is strongly recommended 1
• For liver surgery, smoking cessation should be counseled at least 4 weeks prior to hepatectomy 1
• For plastic surgery, cessation is recommended 4 weeks preoperatively and until primary healing of the operative site (approximately 2 weeks postoperatively) 6

Important Caveats

• The limitations of the evidence make it impossible to justify delaying urgent lung cancer surgery solely to pursue smoking cessation 1
• For non-urgent surgeries, the benefits of delaying surgery to achieve 4+ weeks of smoking cessation likely outweigh the risks 4, 3
• Tobacco withdrawal assistance, both counseling and pharmacotherapy, should be offered to maximize cessation success rates 6, 4
• Patients who continue to smoke have a two to threefold increase in postoperative morbidity 1

Algorithm for Smoking Cessation Before Surgery

1. Identify all smokers at initial surgical consultation
2. For elective procedures:
   • Recommend complete cessation at least 4 weeks before surgery 1
   • Provide intensive counseling and nicotine replacement therapy 4, 5
   • Consider referral to tobacco cessation specialist for heavily dependent smokers 6
3. For urgent procedures (e.g., cancer surgery):
   • Encourage immediate cessation but do not delay necessary surgery 1
   • Provide cessation support throughout the perioperative period 1
4. Continue cessation support postoperatively to promote long-term abstinence 6, 4