Should a patient remain nicotine-free before and after surgery?

Should Patients Remain Nicotine-Free Before and After Surgery?

Patients should abstain from all smoking for at least 4 weeks before surgery, but nicotine replacement therapy (NRT) can and should be used during this period to support smoking cessation without increasing surgical risk. 1, 2

The Critical Distinction: Smoking vs. Nicotine

The evidence clearly separates the harmful effects of cigarette smoking from nicotine itself:

• Smoking cessation is mandatory: Cigarette smoke causes hypoxia, tissue ischemia, and immune disorders that impair wound healing and increase respiratory complications 3
• Nicotine replacement is safe and beneficial: NRT doubles abstinence rates in the short term and does not increase healing-related or cardiovascular complications in human studies 3, 4
• The ERAS Society explicitly recommends: "Intense counselling and nicotine replacement therapy are most likely to be effective" for preoperative smoking cessation 1

Optimal Timing for Smoking Cessation

Preoperative period:

• 4-8 weeks of smoking abstinence is necessary to significantly reduce respiratory and wound-healing complications 1, 2, 5
• Cessation of less than 4 weeks shows unclear benefits and does not reduce respiratory complications 1, 5
• For wound healing specifically, at least 3-4 weeks of abstinence reduces complications (RR 0.69) 5
• In reduction mammaplasty patients, a dose-response relationship exists: those stopping >4 weeks had 33% complications vs. 68% in those who continued smoking until surgery 6

Postoperative period:

• Continue abstinence until primary wound healing is complete (approximately 2-4 weeks postoperatively) 3
• Long-term cessation provides durable benefits for decades, reducing mortality more than any other post-surgical intervention 7

Implementation Algorithm

For elective surgery:

1. Identify all smokers at initial surgical consultation 2, 7
2. Recommend complete smoking cessation at least 4 weeks before surgery 1, 2
3. Prescribe nicotine replacement therapy combined with intensive counseling 1, 4
4. Continue NRT throughout the perioperative period to maintain abstinence 4
5. Extend cessation through primary wound healing (2-4 weeks postoperatively) 3

For urgent/cancer surgery:

• Encourage immediate smoking cessation but do not delay necessary surgery to pursue cessation 2, 7
• The limitations of evidence make it impossible to justify delaying urgent lung cancer surgery solely for smoking cessation 2
• Still provide NRT and cessation support, as immediate cessation remains beneficial 7

Evidence Quality and Nuances

The guideline evidence is robust and consistent:

• The ERAS Society (2018) provides strong recommendations based on moderate-quality evidence for 4-week preoperative cessation 1
• The American College of Surgeons recommends identifying smokers and counseling cessation at least 4 weeks preoperatively 7
• Multiple meta-analyses confirm that abstinence of 4+ weeks reduces respiratory complications (RR 0.77) and 8+ weeks provides even greater benefit (RR 0.53) 5

Important caveat: One RCT found that short-term cessation (2-3 weeks) with NRT did not reduce complications in colorectal surgery 8, supporting the guideline recommendation that at least 4 weeks is necessary for meaningful risk reduction.

Common Pitfalls to Avoid

• Do not prohibit nicotine replacement therapy: There is no evidence from human studies that NRT increases surgical complications, and it significantly improves cessation success 4
• Do not accept patient self-reporting alone: More than 75% of smokers in one study denied smoking within 4 weeks of surgery when they actually continued 6
• Do not recommend cessation periods shorter than 4 weeks: Short-term cessation (<4 weeks) does not reduce respiratory complications and may have unclear effects due to temporarily increased mucous production 1, 5
• Do not delay urgent cancer surgery: For time-sensitive procedures, encourage immediate cessation but proceed with necessary surgery 2, 7

Postoperative Counseling

Continue cessation support beyond surgery:

• Counseling that begins during hospitalization and includes supportive contacts for at least 1 month after discharge increases long-term abstinence rates (OR 1.65) 7
• Intensive programs with 12-month follow-up achieve 62% abstinence rates versus 46% with minimal intervention 7
• Smoking cessation after surgery substantially reduces subsequent major adverse cardiac events, MI, and death 7