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Smoking is a known risk factor for complications following primary total joint arthroplasty (TJA). Little is known regarding the fate of patients who are asked to quit smoking before surgery. The purpose of this study was to evaluate the success of smoking cessation prior to primary TJA and the impact of smoking cessation on perioperative outcomes.
Methods
This is a retrospective review of patients who presented between 2008 and 2020 to a single academic medical center with a documented smoking history and were asked to quit smoking prior to receiving a date for primary TJA. The cohort was surveyed about smoking cessation, smoking history, use of quit aids, seeking surgery elsewhere due to the cessation policy, and postoperative complications. Descriptive statistics evaluated the relationship between demographics, smoking cessation, and postoperative complications.
Results
A total of 101 patients completed the survey with an overall response rate of 48%. Sixty-two percent of patients quit smoking before surgery, and 51% of these patients reported remaining smoke-free at 6 months postoperatively. The average time to quit before TJA was 45 days (range: 1-365 days), and 62% quit without quit aids. The wound complication/infection rate was significantly higher for patients who did not stop smoking prior to TJA (4 of 16; 27%) than for those who did quit prior to surgery (3 of 63; 5%; P = .02).
Conclusions
This study demonstrates that most patients (62%) will stop smoking, if required, prior to primary TJA. Furthermore, 51% of patients reported abstinence from smoking at 6 months following TJA. TJA appears to be an effective motivator for smoking cessation.
In the United States, tobacco use is the number 1 preventable cause of death, disease, and disability. In 2019, 34.1 million adults in the United States smoked cigarettes [
]. Most cigarette smokers (68%) desire to quit smoking, and 55% attempted to quit in the past year, but only 7.5% are successful in ceasing smoking for >6 months [
National Center for Chronic Disease Prevention and Health Promotion (US) Office on Smoking and Health The health consequences of smoking—50 years of progress: a report of the surgeon general.
Centers for Disease Control and Prevention (US),
Atlanta (GA)2014
It is well established that tobacco smokers are at an increased risk of wound complications, lower respiratory infections, myocardial infarction, and increased mortality rates following primary total hip arthroplasty and total knee arthroplasty [
Tobacco use and risk of wound complications and periprosthetic joint infection: a systematic review and meta-analysis of primary total joint arthroplasty procedures.
Tobacco use and risk of wound complications and periprosthetic joint infection: a systematic review and meta-analysis of primary total joint arthroplasty procedures.
]. Many surgeons require smoking cessation prior to indicating patients for elective, primary total joint arthroplasty (TJA). The American Academy of Orthopedic Surgeons recommends smoking cessation 4-6 weeks prior to surgical procedures [
]. At our institution, smoking cessation is required prior to scheduling an elective primary TJA, with cessation confirmed by urine screening tests. The preoperative period represents a potential target for impacting smoking cessation efforts [
Tobacco use and risk of wound complications and periprosthetic joint infection: a systematic review and meta-analysis of primary total joint arthroplasty procedures.
]. This protocol offers a tangible incentive to quit smoking (TJA surgery) with continuity of care at perioperative visits. However, smoking cessation and continued abstinence from tobacco use in the perioperative period surrounding primary TJA have proven difficult for many patients [
]. Little is known about the fate of patients who present to an arthroplasty clinic but are asked to quit smoking prior to indication for TJA. The purpose of this study was to evaluate the success of smoking cessation among TJA candidates who were required to quit smoking prior to the surgery and the impact of smoking cessation on perioperative outcomes.
Material and methods
Institutional review board approval was obtained prior to the initiation of the study. A retrospective review of a single academic medical center’s TJA clinic was performed from the year 2008 through 2020. The study period was chosen to start in 2008 to coincide with the implementation of a division-wide preoperative smoking cessation policy for elective TJA at our institution. Smoking cessation was confirmed through urine nicotine testing prior to scheduling an elective TJA.
Study cohort
Subjects were identified through retrospective review of the institution’s electronic medical record. All new patients presenting to the hip and knee arthroplasty clinic between 2008 and 2020 were identified. New patients presenting to hip and knee arthroplasty clinics completed an intake questionnaire with specific social history questions asked regarding the smoking status. The medical records of all new patients who indicated they were actively smoking were reviewed to determine if they were otherwise a candidate for primary TJA. All patients that were indicated for primary TJA but denied scheduling surgery secondary to active smoking status were included. This allowed us to capture patients who may have never proceeded with the surgery or elected to have the surgery elsewhere due to the institution’s smoking cessation policy. A survey was administered retrospectively to patients who were required to quit smoking prior to scheduling of TJA to obtain information regarding their success with smoking cessation, whether they received surgery at another institution, the length of time it took to quit smoking, smoking history (years smoking, amount), current smoking status, and whether any complications occurred in the year following TJA (Appendix 1). Surveys were administered at least 6 months after the index surgery. Smoking cessation prior to operation was confirmed with negative urine nicotine test 6 weeks prior to the surgery. The survey was administered electronically via REDCap (Research Electronic Data Capture). REDCap is a secure, Web-based application designed to support data capture and supported by thousands of consortium partner institutions [
]. The survey was distributed to 209 patients who met study inclusion criteria, and 101 patients completed the survey for a 48% response rate (Fig. 1).
Figure 1Cohorts of study participants, and outcomes of each participant.
Patient demographics, including age, sex, body mass index (BMI), total years smoking, and total pack years smoked were compared between patients who were able to successfully quit smoking prior to TJA and those who were unable to quit prior to surgery. Demographic variables were also compared to utilization rates of quit aids and rates of continued abstinence from smoking. Complications occurring within 1 year of surgery were noted and compared between patients who quit smoking prior to surgery and those who continued to smoke. Complication endpoints included any complication, any reoperation, and any wound complication or infection. Reoperation is defined as any additional surgery on the joint of interest. Wound complication/infection endpoints included periprosthetic joint infection, superficial soft tissue infection, delayed wound healing, and wound dehiscence.
Statistical analysis
Descriptive statistics were performed, and continuous variables were presented as median (interquartile range) due to nonnormal distributions while categorical variables were presented as frequencies (percentages). To evaluate the characteristics associated with smoking status and smoking cessation method, differences in continuous variables were evaluated using the Wilcoxon rank-sum test. Categorical variables and differences in complications rates were analyzed with the chi-square test. Analyses were completed using SAS statistical software version 9.4 (SAS Institute, Inc., Cary, NC). A P value <.05 was considered statistically significant.
Results
Smoking cessation, demographics, and quit methods
Of the 101 patients who completed the survey, 63 patients (62%) quit smoking prior to undergoing primary TJA. Fifteen patients (15%) underwent TJA without smoking cessation. In total, 23 patients did not undergo TJA (23%); 19 of 23 patients were unable to quit smoking and thus remained ineligible for surgery, 2 patients were able to quit smoking but were unable to achieve a goal BMI prior to surgery, and 2 patients were able to quit smoking and then deferred surgery.
The average time from being asked to stop smoking to smoking cessation for patients who quit was 45 days (range, 1 to 365 days). There were no significant differences in age, sex, BMI, total years smoking, or total pack years between patients who quit smoking prior to TJA and those who continued to smoke prior to TJA (Table 1). Of the patients who quit smoking prior to TJA, 62% did so without any form of quit aid such as medication, support group, or nicotine replacement therapy (NRT) (Table 2). For the group who used NRT to successfully quit smoking, the average years smoking (39.5 years vs 25 years, P = .007) and the pack-year history (17.5 vs 7.5, P = .0067) were significantly higher than those of the group who did not use NRT (Table 3).
Table 1Demographic comparison of quit vs did not quit smoking prior to TJA.
Did they quit smoking?
Number of participants
Variable
Median
Mean
Standard deviation
P value
No
15
Age
57.4
58.0
13.1
.6255
BMI
34.9
34.8
8.1
.3258
Female
6 (40.0%)
.5210
(n, %)
Total smoking years
30.0
28.2
12.7
.9696
Total pack years
17.5
21.8
15.6
.0973
Yes
63
Age
60.5
59.5
9.9
BMI
30.9
33.0
9.1
Female
32 (50.8%)
(n, %)
Total smoking years
28.0
28.0
13.1
Total pack years
10.0
16.1
15.7
P value, percent chance that the results are significant (alpha = 0.05).
At 6 months following TJA, 32 of 63 patients (51%) reported continued abstinence from smoking, while 31 patients (49%) had resumed smoking (Table 4). There were no significant differences in demographics or smoking history when comparing the group who quit and continued to be abstinent from smoking vs the group who quit and returned to smoking postoperatively (Table 4).
Table 4Demographics and smoking years comparison between continued cessation and returning to smoking.
Return to smoking after quitting?
Number of participants
Variable
Median
P value
No
32
Age
60.9
.4704
BMI
32.8
.1670
Female (n, %)
16 (50.0%)
.8981
Total smoking years
26.5
.3243
Total pack years
9.0
.7564
Yes
31
Age
59.2
BMI
29.5
Female (n, %)
16 (51.6%)
Total smoking years
30.0
Total pack years
10.0
P value, percent chance that the results are significant (alpha = 0.05).
Overall, 7 of 78 patients (9%) who had a TJA surgery developed a surgical complication within 1 year postoperatively. All the surgical complications that occurred were infection or wound-related complications (Table 5). Patients who did not quit smoking had a significantly higher rate of wound complications and/or infection (4 of 15, 27%) than patients who did quit smoking prior to TJA (3 of 63, 5%, P = .023). Rates of any reoperation (13% vs 5%, P = .23) were also higher in patients who did not quit smoking prior to TJA, but this difference was not statistically significant.
Table 5Postoperative complications within 1 year of surgery.
Patient
Stopped smoking prior to TJA
Postoperative complication
Reoperation
Reoperation details
Time to first reoperation
1
Yes
PJI
Yes
DAIR followed by 2-stage exchange for persistent PJI
While there have been significant reductions in the incidence and prevalence of cigarette smoking among adults in the United States since the 1960s, smoking cessation remains a difficult process [
]. In 2018, Creamer et al. found that of the 55% of smokers that attempted to quit in the year prior, only 7.5% were successful in quitting for ≥6 months [
]. A randomized control trial with 8144 subjects demonstrated that 25%-35% of smokers are able to quit for more than 6 months when using an optimal treatment such as behavioral and pharmacotherapy [
Neuropsychiatric safety and efficacy of varenicline, bupropion, and nicotine patch in smokers with and without psychiatric disorders (EAGLES): a double-blind, randomised, placebo-controlled clinical trial.
]. In the present study, 62% of patients were able to successfully quit smoking, when required to do so, prior to primary TJA. Furthermore, 51% of patients reported remaining abstinent from smoking at least 6 months following the surgery.
Reported rates of smoking cessation to achieve eligibility for arthroplasty surgery are widely variable in current literature. Hart et al. evaluated a cohort of 28,758 primary TJAs; 2514 reported smoking in the year leading up to surgery [
]. Patients in the present study were able to cease smoking relatively quickly, with a median time to cessation of 45 days (range, 1-365 days). Taken together, results from the present study and existing data in the literature suggest that while smoking cessation as a means of eligibility for TJA surgery is far from being 100% successful, patients can achieve cessation rates relatively quickly and at much higher rates than those observed in the general population.
Long-term success with smoking cessation brought about by preparation for primary TJA has varied in the literature. In the present study, approximately half of patients (51%) that had quit smoking to undergo surgery had remained abstinent from cigarettes at 6 months postoperatively. Akhavan et al. found similar results, with 64% of patients remaining abstinent from cigarettes at 6 months postoperatively [
]. At a mean time period of approximately 4 years postoperatively, 23% remained abstinent from cigarettes, and over half of the cohort (55%) relapsed and returned to cigarette use within 3 months postoperatively [
]. In the present study, there were no patient demographics or portions of smoking history (duration or volume) that were predictive of continued smoking abstinence. Hall et al. also found no difference in patient demographics or use of quit aids between patients that maintained smoking abstinence after arthroplasty surgery and patients that resumed smoking [
]. While arthroplasty surgery may represent an opportunity to achieve initial smoking cessation, most patients return to smoking over time. Further evaluation into patient and provider factors that may influence continued abstinence from smoking following TJA is necessary.
Of the patients in the present study that successfully quit smoking prior to TJA surgery, a majority (62%) did so through the use of “cold turkey” techniques, without the use of quit aids in the form of medications, support groups, or NRT. Interestingly, patients that utilized NRT to help quit smoking had a longer history of cigarette use (40 years vs 25 years, P = .007) and a higher overall volume of cigarette use (18 years vs 8 years, P = .007) relative to patients that did not use NRT to quit. Patients utilizing NRT, while they are not smoking, may still be subject to the harmful effects of nicotine in the perioperative period, such as tissue hypoxia, alterations in collagen synthesis, and immune modulation [
]. In the present study, smokers had an increased rate of any complication (27% vs 5%, P = .012) and wound complications/infection (27% vs 5%, P = .023) relative to patients who ceased smoking prior to surgery. The data from this study support the findings from other studies demonstrating that active tobacco use at the time of TJA significantly increases the risk of complications, particularly wound-related complications, following surgery.
Along with reducing postoperative wound complications, a smoking cessation protocol prior to elective TJA could aid with public health efforts to reduce smoking. Worldwide, over 7 million deaths a year are attributable to tobacco use, and this number is rising [
National Center for Chronic Disease Prevention and Health Promotion (US) Office on Smoking and Health The health consequences of smoking—50 years of progress: a report of the surgeon general.
Centers for Disease Control and Prevention (US),
Atlanta (GA)2014
]. This indicates that a there could be a large public health implication of using elective TJA surgery as an incentive for smoking cessation.
This study has limitations. Primarily, the survey responses were self-reported, so there could be reporting bias leading to discrepancies in notation of dates, complications, and so on. Second, there were multiple surgeons contributing to the care of patients in the cohort with varied documentation methods. The limitations in documentation made it difficult to determine why 10 of the 15 patients who had surgery despite reporting they continued to smoke preoperatively had the surgery at our institution while the protocol required smoking cessation. A possible explanation would include the surgeon was not aware the patient continued to smoke, surgery was allowed to proceed after discussing the risks and benefits with the patient, the patient resumed smoking after negative urine testing, and so on. This study was conducted at a single hospital, so generalization of outcomes could include population bias.
Conclusions
The data from this self-reported survey study demonstrate that most patients (62%) will quit smoking, if required to, for an elective TJA. The 6-month continued abstinence rate with TJA as the motivator appears to be significantly higher than the current national average smoking cessation rate of 7.5% at 6 months when using NRT as cited by the Centers for Disease Control and Prevention [
]. Along with long-term public health benefits of smoking cessation, the results of this study suggest that patients may be less likely to experience a wound-related complication or infection if they stop smoking prior to surgery. These data support the development of a standardized smoking cessation protocol before TJA to improve surgery outcomes and the health of individuals.
Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Author Contributions
K.P., N.O.N., T.S.B., and N.A.B. contributed to data collection. K.P. wrote the article. C.N.C. and N.A.B. provided writing assistance. All the authors contributed to proofreading the article.
Data
Available upon request.
Conflicts of interest
Dr. C. N. Carender is in the editorial board of the Journal of Arthroplasty. Dr. N. O. Noiseux is a paid consultant for MicroPort and receives research support as a principal investigator from Wright Medical, DePuy, and Smith & Nephew. Dr. J. M. Elkins receives research support as a principal investigator from DePuy/J&J and is in the editorial board of the Journal of Arthroplasty. Dr. T. S. Brown is a paid consultant for Stryker; is in the editorial board of the Journal of Arthroplasty; and is a board member in American Association of Hip and Knee Surgeons, Musculoskeletal Infection Society, and Mid-America Orthopedic Association. Dr. N. A. Bedard is a paid consultant for DePuy; is in the editorial board of the Journal of Arthroplasty; and is a board member of the American Association of Hip and Knee Surgeons. Katelyn Paulsen has no potential conflicts of interest.
For full disclosure statements refer to https://doi.org/10.1016/j.artd.2022.101087.
Tobacco use and risk of wound complications and periprosthetic joint infection: a systematic review and meta-analysis of primary total joint arthroplasty procedures.
Neuropsychiatric safety and efficacy of varenicline, bupropion, and nicotine patch in smokers with and without psychiatric disorders (EAGLES): a double-blind, randomised, placebo-controlled clinical trial.
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