Tobacco Use in Bariatrc Patients

*INCLUDES PATIENT HANDOUT*

by Amy K. Windover, PhD

Dr. Windover is a Psychologist at the Office of Patient Experience, The Cleveland Clinic, Cleveland, Ohio.

ABSTRACT
Tobacco use persists as the leading cause of preventable death worldwide and is prevalent among bariatric surgery candidates. Tobacco use is a well-documented surgical risk factor. This article reviews the research examining tobacco use and bariatric surgery. Based on this research, it is recommended that bariatric surgery centers establish a standard operating procedure that not only addresses the assessment of tobacco use, but also provides referrals and/or resources for the effective treatment of tobacco use and preventive intervention for those identified as at-risk for future tobacco use.

Download the patient handout that accompanies this article: Tips for Quitting Tobacco

FUNDING: No funding was provided.

DISCLOSURES: Dr. Windover reports no conflicts of interest relevant to the content of this article.

Bariatric Times. 2013;10(1):8–11.

Introduction
Tobacco use persists as the leading cause of preventable death in the United States and the world.[1, 2] According to the Centers for Disease Control and Prevention (CDC), the prevalence of smoking is currently 19.3 percent, down from 20.9 percent in 2005.[3] Prevalence of tobacco use among bariatric surgery candidates is similar to, if not greater than, the general population with estimates ranging from 12.9 to 38 percent.[3–7]

Tobacco use is a well-documented surgical risk factor.[8] Substantial research has examined the impact of tobacco use on bariatric surgery in particular. For instance, while the mortality risk associated with bariatric surgery is generally low (less than 1%),[9] death is twice as likely for active tobacco users (adjusted odds ratio [AOR] 2.05, 95% confidence interval [CI] 1.67–2.52, p<0.0001).[5]

Surgical Complications Associated with History of and/or Active Tobacco Use
A history of and/or active smoking has also been shown to increase the risk of developing postoperative complications among bariatric surgery patients.[10] Patients who smoked within one year of having bariatric surgery, compared to their nonsmoking counterparts, were 1.5 times more likely to develop any surgery-related problem within one month of having surgery (OR 1.457, 95% CI, 1.058–2.005, p<0.02),[11] including increased risk for venous thromboembolism (VTE) (OR 6.7, 95% CI, 1.9–23.57, p<0.01).[12]

In fact, research has demonstrated that the risk for VTE persists at least six months after surgery (OR 1.86, CL 1.06–3.27).[13]

Smoking can potentially disrupt breathing capacity and lung function in patients. Research reveals an association between tobacco use and respiratory complications following bariatric surgery. Patients who smoked cigarettes within one year of having bariatric surgery were at increased risk for developing pneumonia (AOR 1.56, 95% CI 1.06–2.29).[14] In a study[6] of 575 veterans who underwent bariatric surgery,[6] patients who had not smoked in the year prior to surgery, but reported a 20-pack year history were at greater risk of failing to wean from the ventilator within 48 hours of surgery compared to their counterparts with no smoking history (5.8% vs. 1.8%, respectively, p=0.0085). Patients who smoked within one year of surgery and reported a 20-pack year history demonstrated an astounding 11.1-percent failure to wean rate and an overall complication rate of 26.7 percent compared to 1.8 and 19.7 percent, respectively, for their no smoking history counterparts.[6]

Smoking, defined as smoking one or more cigarettes per day, was shown to increase the likelihood of developing marginal ulcers (AOR 30.6, 95% CI, 6.4–146, p<0.001) and wound dehiscence (OR 20.9, 95% CI 1.1–411, p<0.046) postoperatively.[15] A history of or active tobacco use was also shown to predict not only the development but also recurrence of marginal ulcers up to 12 months after bariatric surgery.[16] Slower rates of wound healing and infection have been noted more generally among surgery candidates who use tobacco.[17]

Author’s note: Though outside the scope of this article, the reader is referred to Sorenson[18,19] for a comprehensive review of the pathophysiological factors of tobacco use that contribute to delayed wound healing and infection.

With higher complication rates during and after surgery, the potential for prolonged hospitalization also increases.[14]

Preliminary research suggests patients who smoke within a month of surgery may also require higher dosing of opioid medication for postoperative pain management.[20]

Surgery-related Guidelines for Tobacco Use
In the face of these and other potential risks, many bariatric surgery-related guidelines exist for addressing tobacco use[.21–25] The latest evidence-based bariatric surgery guidelines recommend advising tobacco users to quit tobacco at least six weeks prior to bariatric surgery, as well as, provide tobacco users with the necessary support for maintaining long-term abstinence.[25] Personal motivation and confidence in one’s capacity to quit are critical for permanent tobacco cessation. Motivation for bariatric surgery combined with professional advice to quit tobacco, reduce surgical risk, and experience the health benefits of quitting can open a window of opportunity for motivating tobacco users to make a quit attempt. Providing empathy, respect, and support combined with appropriate referrals and/or resources for the effective treatment of tobacco use and relapse prevention can foster the confidence necessary for tobacco users to be successful in quitting.

Barriers to Quitting and Effective Interventions
Addressing any barriers to successful cessation is also important. One potential barrier for bariatric surgery candidates is the potential conflict between surgery-related guidelines that advocate for pre-surgical weight loss in addition to tobacco cessation. Levine et al[26] conducted a retrospective study of bariatric surgery candidates and found that patients who quit smoking reported weight gain of 28 pounds on average. Patients may fear that any weight gain associated with tobacco cessation will serve to impede their overall surgical candidacy. Assuring that patients are aware of the requirements for surgical readiness and strategies to minimize such conflicts (e.g., use of bupropion to delay any associated weight gain until after surgery) will further their long-term tobacco cessation. Many effective tobacco treatment interventions exist; however, healthcare providers often refrain from advising patients to quit tobacco due to uncertainty of how best to intervene and/or pessimism regarding patients’ willingness or capacity to quit.[27] For a succinct primer of effective tobacco treatment interventions including counseling and pharmacological intervention, the reader is referred to a brief primer by Michael Fiore, MD, and Timothy Baker, PhD.[28]

Efficacy of Tobacco Cessation among Surgical Patients
Has surgery as a window of opportunity to motivate tobacco users to quit led to successful tobacco cessation, and if so, has this impacted surgical outcome? No randomized control studies could be identified by this author specific to the efficacy of tobacco cessation interventions among bariatric surgery patients; however, such research has been done related to other types of surgical patients. Research has demonstrated that tobacco cessation interventions provided before surgery are effective in increasing abstinence rates at the time of surgery.[8,29] Furthermore, such interventions and effective cessation 6 to 8 weeks prior to surgery have been shown to reduce the risk of postoperative complications.[30,31] For example, a randomized, controlled trial of 120 patients undergoing hip or knee replacement in Denmark demonstrated that smokers who effectively quit tobacco or reduced their consumption by more than half through participation in a tobacco cessation intervention experienced an overall complication rate of 18 percent compared to 52 percent in the control group.[32] The most notable risk reductions occurred in the areas of wound healing and cardiovascular function.[32] Tobacco cessation interventions that are more intensive (e.g., 4–8 weeks) and utilize a combination of treatment modalities (e.g., counseling and nicotine replacement) appear more efficacious than less intensive or single-modality interventions.[8,31,32]

Some research has also demonstrated that, while effective in the short term, such presurgical tobacco cessation interventions may not be effective in maintaining abstinence as patients get further out from surgery.[29] A recent study examining a sample of United States service veterans found that of the nine percent who had quit smoking within six months of having bariatric surgery, all had returned to smoking when reassessed 24 months after surgery.[33] This study also noted that veterans who had bariatric surgery and resumed or started smoking experienced greater weight loss at 6 and 12 months postoperatively. However, it is important to note that this difference was not maintained at 24 months after surgery.[33] Additional research is needed to further examine long-term cessation rates. In the meantime, relapse prevention counseling and ongoing support is also recommended after surgery.

Recommendations for Healthcare Providers
In order to effectively carry out the current bariatric surgery treatment guidelines, it is recommended that bariatric surgery centers establish a standard operating procedure that not only addresses the assessment of tobacco use but also provides referrals and/or resources for the effective treatment of tobacco use and preventive intervention for those identified as at-risk for future tobacco use. All bariatric surgery candidates should be assessed for a history of or active tobacco use. If any history of or active tobacco use is acknowledged, further evaluation is necessary to determine the type of nicotine delivery (e.g., cigarettes, cigars, pipe, snuff/chew, hookah, electronic nicotine delivery devices, and nicotine replacement therapy) and quit duration, if applicable. For informed consent purposes, all pre-surgery candidates should receive verbal instruction and written documentation about the standard operating procedure prior to initiating the formal evaluation process. Surgery candidates should then be assessed for historical and active tobacco use of all types during the psychological evaluation. All active tobacco users should again be advised to stop at least 6 to 8 weeks before surgery. Next, it is recommended that tobacco users receive brief counseling on tobacco cessation, including education on the surgical risk of tobacco use and health benefits of quitting. Surgical candidates actively using tobacco should be evaluated for the potential benefit from nicotine replacement therapy and/or other tobacco cessation aids (e.g., bupropion [Wellbutrin, Zyban] and varenicline [Chantix]) or be referred to their primary care physician to explore these options. Providing additional resources to assist in quitting, such as the National Cancer Institute’s Quitline (1-800-QUIT-NOW) can also be useful in supporting patients. Lastly, nicotine/cotinine screening can be ordered for active tobacco users to verify cessation prior to surgery. Since research has not found significant risk associated with nicotine replacement therapy (NRT),[8] anabasine levels should be monitored to differentiate between smoking and NRT.  Any positive screens should result in ongoing or more intensive smoking cessation intervention.

Conclusion
Tobacco use is prevalent among bariatric surgery candidates. Active and historical tobacco use has been shown to increase risk of mortality, 30-day morbidity, venous thromboembolism (VTE), respiratory and pulmonary complications, marginal ulcers, and slowed wound healing among others. A standard operating procedure is recommended for assessing tobacco use and providing referrals and resources for the effective treatment of tobacco use and preventive intervention for those identified as at-risk for future tobacco use.

References
1.    van Meijgaard J, Fielding JE. Estimating benefits of past, current, and future reductions in smoking rates using a comprehensive model with competing causes of death. Prev Chronic Dis. 2012;9:E122.
2.    Frieden T. Center for Disease Control and Prevention Statement Regarding WHO Report on the Global Tobacco Epidemic, 2011. July 7, 2011. http://www.who.int/tobacco/global_report/2011/en_tfi_global_report_2011_cdc_statement.pdf
3.    CDC Reports Vital Information on Smoking. Centers for Disease Control and Prevention. October 22, 2012 http://www.cdc.gov/features/vitalsigns/adultsmoking/.
4.    King WC, Engel SG, Elder KA, et al. Walking capacity of bariatric surgery candidates. Surg Obes Relat Dis. 2012;8:48–61.
5.    Zhang W, Mason EE, Renquist KE, Zimmerman MB, et al. Factors influencing survival following surgical treatment of obesity. Obes Surg. 2005;15(1):43–50.
6.    Livingston EH, Arterburn D, Schifftner TL, et al. National surgical quality improvement program analysis of bariatric operations: Modifiable risk factors contribute to bariatric surgical adverse outcomes. J Am Coll Surg. 2006;203:625–633.
7.     Grace DM, Pederson L, Speechley KN, McAlpine D. A longitudinal study of smoking status and weight loss following gastroplasty in a group of morbidly obese patients. Int J Obes. 1990;14:311–317.
8.    Thomsen T, Villebro N, Moller A. Interventions for preoperative smoking cessation (Review). Cochrane Database of Systematic Reviews 2010; Issue 7, Art. No.:CD002294.
9.    Thomas H & Agrawal S. Systematic review of obesity surgery mortality risk score-preoperative risk stratification in bariatric surgery.  Obes Surg. 2012;22:1135–1140.
10.    Finks JF, Kole KL, Yenumula PR, et al.  Predicting risk for serious complications with bariatric surgery: Results from the Michigan bariatric surgery collaborative. Ann of Surg. 2011;254(4):633–640.
11.    Lautz DB, Jackson TD, Clancy KA, et al. Bariatric operations in veterans affairs and selected university medical centers: results of the patient safety in surgery study. J Am Coll Surg. 2007;204:1261–1272.
12.    Gonzalez R, Haines K, Nelson L, et al. Predictive factors of thromboembolic events in patients undergoing Roux-en-Y gastric bypass. Surg Obes Relat Dis. 2006 ;2(1):30–35; discussion 35–36.
13.    Steele K, Schweitzer M, Prokopowicz G, et al. The long-term risk of venous thromboembolism following bariatric surgery. Obes Surg. 2011;21(9):1371–1376.
14.    Gupta P, Gupta H, Kaushik M, et al. Predictors of pulmonary complications after bariatric surgery. Surg Obes Relat Dis. 2012;8(5):574–581.
15.    Wilson JA, Romagnuolo J, Byrne TK, et al. Predictors of endoscopic findings after Roux-en-Y gastric bypass. Am J Gastroent. 2006;101:2194–2199.
16.    El-Hayek K, Timratana P, Shimizu H, & Chand B. Marginal ulcer after Roux-en-Y gastric bypass: what have we really learned? Surg Endosc. 2012;26(10):2789–2796.
17.    Silverstein P. Smoking and wound healing. Am J Med. 1992;93(S1A): 22S–24S.
18.    Sorensen LT. Wound healing and infection in surgery. Arch Surg. 2012;147(4):373–383.
19.    Sorensen LT. Wound healing and infection in surgery: The pathophysiological impact of smoking, smoking cessation, and nicotine replacement therapy, a systematic review. Ann Surg. 2012;255:1069–1079.
20.    Weingarten T, Sprung J, Flores A, et al. Opioid requirements after laparoscopic bariatric surgery. Obes Surg. 2011;21(9):1407–1412.
21.    Mechanick JI, Kushner RF, Sugarman HJ, et al. American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic and Bariatric Surgery medical guidelines for clinical practice for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient. Surg Obes Relat Dis. 2008;4(5 Suppl):S109–S184.
22.    Saltzman E, Anderson W, Apovian CM, et al. Criteria for patient selection and multidisciplinary evaluation and treatment of the weight loss surgery patient. Obes Res. 2005;13(2):234–243.
23.    Schumann R, Jones S, Ortiz VE et al. Best practice recommendations for anesthetic perioperative care and pain management in weight loss surgery. Obes Res. 2005;13(2):254–266.
24.    Schumann R, Jones SB, Cooper B, et al. Update on best practice recommendations for anesthetic perioperative care and pain management in weight loss surgery, 2004–2007. Obesity (Silver Spring). 2009;17(5):889–894.
25.    Blackburn GL, Hutter MM, Harvey AM, et al. Expert panel on weight loss surgery: Executive report update. Obesity (Silver Spring). 2009;17(5):842–862.
26.    Levine MD, Kalarchian MA, Courcoulas AP, et al. History of smoking and postcessation weight gain among weight loss surgery candidates. Addict Behav. 2007;32:2365–2371.
27.    Levinson W, Cohen M, Brady D, Duffy, FD. To change or not to change. Ann Intern Med. 2001;135:386–391.
28.    Fiore MC, Baker TB. Treating smokers in the health care setting. N Engl J Med. 2011;365(13):1222–1231.
29.    Cropley M, Theadom A, Pravettoni G, Webb G. The effectiveness of smoking cessation interventions prior to surgery: A systematic review. Nicotine Tob Res. 2008;10(3):407–412.
30.    Theadom A, Cropley M. Effects of preoperative smoking cessation on the incidence and risk of intraoperative and postoperative complications in adult smokers: a systematic review. Tob Control. 2006;15(5):352–358.
31.    Thomsen T, Tønnesen H, Møller AM. Effect of preoperative smoking cessation interventions on postoperative complications and smoking cessation. Br J Surg. 2009;96(5):451–461.
32.    Moller A, Villebro N, Pedersen T, Tonnesen H. Effect of preoperative smoking intervention on postoperative complications: A randomized clinical trial. Lancet. 2002;359:114–117.
33.    Adams CE, Gabriele JM, Baillie LE, Dubbert PM. Tobacco use and substance use disorders as predictors of postoperative weight loss 2 years after bariatric surgery. J Behav Health Serv Res. 2012;39(4):462–471.

Category: Past Articles, Review