ASA NPO Guidelines for Smokeless Tobacco
The 2017 ASA guidelines do not specifically address smokeless tobacco (chewing tobacco, snuff, dip) in their preoperative fasting recommendations, as these guidelines focus on ingested substances that affect gastric contents and aspiration risk. 1
Standard NPO Guidelines Apply
Since smokeless tobacco is not ingested and does not contribute to gastric volume or acidity, patients using smokeless tobacco should follow the standard ASA preoperative fasting guidelines for healthy patients undergoing elective procedures 1:
Clear Liquids
- May be consumed up to 2 hours before surgery 1
- Acceptable clear liquids include water, fruit juices without pulp, carbonated beverages, clear tea, and black coffee 1
Solid Foods
- Light meals require 6 hours of fasting 1
- Fried or fatty foods require 8 or more hours of fasting due to prolonged gastric emptying 1
Breast Milk and Formula
- Breast milk may be ingested up to 4 hours before procedures 1
- Infant formula requires 6 hours of fasting 1
Smokeless Tobacco Cessation Recommendations
While smokeless tobacco use itself does not affect NPO status, patients should ideally cease all tobacco use (including smokeless forms) at least 4 weeks before elective surgery to reduce postoperative complications 1:
- Smoking cessation of 4-8 weeks preoperatively reduces respiratory and wound-healing complications 1
- Intense counseling and nicotine replacement therapy are most effective interventions 1
- Even shorter periods of cessation may yield some benefits, though the evidence for periods less than 4 weeks is unclear 1
Important Clinical Caveats
Smokeless tobacco does not require special NPO considerations because it is not swallowed and does not increase gastric volume, acidity, or aspiration risk 1, 2. The primary perioperative concern with tobacco use relates to cardiovascular and wound-healing complications, not aspiration 1, 3.
Patients with additional risk factors (gastroesophageal reflux disease, diabetes mellitus, difficult airway, or gastrointestinal motility disorders) may require longer fasting periods regardless of tobacco use 1.