In Australia and New Zealand tobacco smoking is one of the leading preventable causes of premature disease and death. Smokers also have a higher risk than non-smokers of experiencing adverse perioperative events.
Australia and New Zealand are both members to the World Health Organisation (WHO) Framework Convention on Tobacco Control. This convention requires signatories to implement measures to reduce tobacco consumption. Both countries have taken significant steps to meet their obligations under the Convention by initiating a range of measures aimed at reducing the consumption of cigarettes.
Tobacco use is known to cause certain cancers and increase the risk of other diseases and congenital abnormalities. Surgical outcomes are consistently poorer for smokers than non-smokers, with patients who smoke experiencing longer recovery times, increased risk of wound infection, and significantly increased risk for myocardial infarction and stroke. Smokers also have a higher post-surgery mortality rate than non-smokers. Smoking cessation is therefore advised to reduce the incidence and severity of diseases linked with tobacco smoking. In many cases there is evidence that smoking cessation prior to surgery also lowers the risk of postoperative wound infection, wound healing problems, respiratory complications and admissions to intensive care.
Patients may already be aware of many of the general risks associated with smoking, but may not be aware of the specific risks related to surgery. Advice on cessation that is delivered at the time a patient is booked for a surgical procedure has been associated with a higher likelihood of a patient attempting to stop. Smoking cessation up to 24 hours prior to surgery has been shown to benefit patients with these benefits increasing the earlier a patient ceases smoking. Cessation should therefore be encouraged at the earliest possible opportunity.
In New Zealand and Australia, public hospitals have widely promoted smoke free policies and smoking cessation strategies. In both countries, all new patients are required to fill out a smoking questionnaire with smokers given brief cessation advice and a quit-pack. The quit-pack, along with its associated contact phone number and website, provides information on smoking cessation including counselling options available and other cessation options such as nicotine patches and gums.
In Australia, the practice is to use “AAR”:
A=Ask patients about their smoking status. This reinforces the message that tobacco use is a significant issue.
A=Advise patients of specific perioperative risks and the risks of cancer and cardio-respiratory disease
R=Refer the patient to counselling and evidence based cessation treatment.
In New Zealand, the practice is to use “ABC”:
A=Ask all people about their smoking status and document this.
B=Provide Brief advice to stop smoking to all people who smoke, regardless of their desire or motivation to quit.
C=Make an offer of, and refer to or provide, evidence based Cessation treatment.
Smoking cessation programs have been shown to be an effective means of achieving short and long-term cessation. In practice, the level and quality of smoking cessation advice that is delivered can vary considerably. Factors such as how busy a clinic is or the relevance of smoking to the consultation may influence whether advice is given. Private hospitals are also less likely to actively promote smoking cessation, as it is not mandatory to assess the smoking status of patients. It is therefore important that hospitals, health services and medical clinics have the necessary processes in place to ensure that patients are advised of the benefits of smoking cessation.
Recommendations
In order to reduce the impact that tobacco has on surgical outcomes, and more broadly public health, RACS supports the New Zealand Government’s efforts to reduce smoking prevalence to 5% by 2025, and the Australian Government’s plan to reduce smoking to 10% by 2018.
To achieve these targets, RACS recommends and supports:
- Nationally consistent legislation across Australia
- RACS encourages national consistency, across Australia and advocates for all jurisdictions to adopt policies equivalent to the state and/or territories where the strongest legislation exists.
- Introduction of plain packaging for cigarettes in New Zealand
- RACS strongly supports the introduction of plain packaging laws in New Zealand to further limit the impact of tobacco advertising.
- Advocating the New Zealand Government to legislate against smoking in cars with children
- RACS supports the advocacy efforts of like-minded organisations in their efforts to lobby the New Zealand Government to legislate against the use of tobacco in cars with children.
- Reduce smoking uptake and inequalities in smoking rates
- RACS supports the Australian and New Zealand governments in their efforts to conduct targeted approaches aimed at assisting populations with a high prevalence of smoking to quit and to reduce overall health inequalities.
- RACS supports City Councils who have been vigilant in reducing exposure to cigarette smoke, and encourages those city councils with more relaxed policies to adopt stronger measures.
- RACS aims to continue highlighting to patients the added risk of complications during and after surgery that are faced by smokers and promotes the use of information outlining benefits of quitting prior to surgery.
- RACS encourages surgeons in both public and private practice to undertake a smoking assessment with their patients, provide brief advice on smoking cessation and offer patients appropriate information and Quit-packs. Information and resources relating to smoking cessation and quit-packs should be highly visible to patients.
- Advice on smoking cessation should be delivered as early as possible prior to a procedure so that patients have the opportunity to receive the greatest benefit from cessation.
- RACS encourages all political parties to introduce self-imposed bans on political donations from the tobacco lobby and the introduction of formal legislation preventing tobacco companies from making such donations.
- RACS encourages governments to continue using taxation as a mechanism to reduce the smoking rate.
- RACS supports further research into the effectiveness of e-cigarettes as a cessation method and their long-term health implications.
Read the full position paper (PDF 62.85KB).