Smoking and Surgery Don’t Mix

Even routine operations are riskier for smokers.

Smokers who are scheduling a medical operation might want to think seriously about quitting, once they hear the results of a new review of the impact of smoking on surgical outcomes.

A scheduled operation is the perfect incentive for smokers to quit smoking. The fact that smokers have poorer post-surgical outcomes, with longer healing times and more complications, is not a new finding. But the study by researchers from the University of California in San Francisco, and Yale University School of Medicine, published in the Journal of Neurosurgery, spells out the surgicial risks for smokers in graphic detail.

Cellular Injury

The systematic effects of nicotine and carbon monoxide in the blood of cigarette smokers result in tissue hypoxia, which is a lack of adequate blood supply caused by a shortage of oxygen.  When carbon monoxide floods the bloodstream in high concentrations, as it does in smokers, it is capable of binding with hemoglobin and thus lowering the oxygen-carrying capacity of the blood. A cascade of physiological reactions then lead to the possibility of low coagulation levels, vasoconstriction, spasms, and blood clots. 

Wound Healing and Infection

If the circulatory system is dysfunctional, healing will be impaired. “In addition,” the researchers say, “tobacco may stimulate a stress response mediated by enhanced fibroblast activity, resulting in decreased cell migration and increased cell adhesion. The net consequence is inappropriate connective tissue deposition at the surgical site, delayed wound healing, and increased risks of wound infection.”

Blood Loss

 In their review of the neurosurgical literature, the researchers found higher blood loss for smokers particularly following surgery for certain kinds of tumors and for lumbar spine injuries. Smoking causes “permanent structural changes of vessels such as vessel wall thickening,” and there is evidence that smoking is linked to “larger and more vascularized tumors, which may further contribute to intraoperative blood loss during resection.”

Cardiopulmonary Effects

Even smokers who don’t have any chronic conditions associated with smoking are at increased risk during and after surgery. Oxidative damage from smoke can cause “mucosal damage, goblet cell hyperplasia, ciliary dysfunction, and impaired bronchial function,” all of which impedes the ability to expel mucus, which increases the bacterial load, which alters the respiratory immune response, and which ultimately leads to higher rates of postoperative pneumonia in smokers.

The authors of the review note that the evidence is particularly strong in certain specialties: Cranial surgery, spine surgery, plastic surgery, and orthopedic surgery. One randomized clinical trial showed that a 4-week smoking cessation program lead to a 50 relative risk reduction for postoperative complications. Another study showed significant improvement in wound healing when patients abstained from smoking for 6 to 8 weeks prior to surgery. And a third trial of smokers cited in the study showed a major decrease in complications following surgery for the repair of acute bone fractures in patients who quit before surgery.

The authors close by suggesting that the seriousness of surgery can be used to create a “teachable moment” for patients who smoke. Other studies show consistently that “patients tend to be more likely to quit smoking after hospitalization for serious illness.” All of this makes the act of scheduling surgery a perfect point of contact with smokers in medical settings. Clinicians can neutrally lay out the facts of the matter, in a way that truly brings home the health consequences of tobacco.

Lau D., Berger M.S., Khullar D. & Maa J. (2013). The impact of smoking on neurosurgical outcomes, Journal of Neurosurgery,   1-8. DOI: 10.3171/2013.5.JNS122287

Graphics Credit:  http://www.ontarioanesthesiologists.ca/

States Quietly Defunding Anti-Smoking Programs For Kids

Only 2 cents of each tobacco settlement dollar goes to smoking prevention plans.

If there’s one thing we know about smoking, it’s that for every smoker who quits, we gain a net financial benefit. These health cost savings can be huge for states, which is why all of them have put in place smoking cessation plans and programs for their citizens. And they are able to run this programs because of the monies that come to them under the 1998 master tobacco settlement.

Perhaps it doesn’t come as a huge surprise, but it’s depressing, all the same: The Campaign for Tobacco-Free Kids estimates that states will spend less than 2 per cent of these court-mandated funds on actual programs to prevent kids from smoking. The report accuses the states of failing to reverse budget cuts to “programs that have set back the nation’s efforts to reduce tobacco use.”

The report was undertaken to access whether states have been using the estimated $246 billion over 25 years—plus cigarette taxes—to reduce tobacco use. What they found was that “states have failed to reverse deep budget cuts that reduced funding for tobacco prevention by 36 percent” from 2008 to 2012. Only North Dakota and Alaska are currently funding smoking cessation programs at the level recommended by the Centers for Disease Control and Prevention (CDC). Four states—New Hampshire, New Jersey, North Carolina, and Ohio—have allocated ZERO funds for tobacco prevention programs in FY 2013.

“Given such a strong return on investment,” the report concludes, “states are truly penny-wise and pound-foolish in shortchanging tobacco prevention and cessation programs.” The report declined to speculate on where the money actually goes, but noted that this was the “second lowest amount states have spent on tobacco prevention programs since 1999, when they first received tobacco settlement funds.”

The cries of outrage came thick and fast:

“The states have an obligation to use more of their billions in tobacco revenues to fight the tobacco problem. Their failure to do so makes no sense given the evidence that tobacco prevention programs save lives and save money by helping reduce health care costs."—Matthew L. Myers, President of the Campaign for Tobacco-Free Kids

"States with comprehensive tobacco control programs experience faster declines in cigarette sales, smoking prevalence and lung cancer incidence and mortality than states that do not invest in these programs."—John R. Seffrin, CEO of the American Cancer Society Cancer Action Network

"The paltry amount of money that states spend on tobacco prevention and cessation programs is extremely disappointing…. These programs work and it’s time for states to put more skin in the game."—Nancy Brown, CEO of the American Heart Association

"Too many states are failing their citizens by abandoning their responsibility to invest in proven programs that prevent people from smoking and help smokers quit…. Supporting these programs at recommended levels is not only the right thing to do, it's the smart thing to do — quitting smoking or never starting saves lives and saves money."—Paul G. Billings, senior vice president of Advocacy & Education at the American Lung Association

In 2007, the CDC concluded: “We know how to end the epidemic. Evidence-based, statewide tobacco control programs that are comprehensive, sustained, and accountable have been shown to reduce smoking rates, tobacco-related deaths, and diseases caused by smoking.”

Two cents on every dollar. About 20 percent of Americans smoke. “Tobacco companies spend more than $18 to market tobacco products for every one dollar the states spend to reduce tobacco use.” What’s wrong with this picture?

Photo Credit: http://www.tobaccofreekids.org

Cigarette Sadness

The chemistry of sorrow during nicotine withdrawal.

When you smoke a cigarette, nicotine pops into acetylcholine receptors in the brain, the adrenal glands, and the skeletal muscles, and you get a nicotine rush. Just like alcohol, a cigarette alters the transmission of several important chemical messengers in the brain. “These are not trivial responses,” said Professor Ovide Pomerleau of the University of Michigan Medical School. “It’s like lighting a match in a gasoline factory.”

Experiments at NIDA’s Addiction Research Center in Baltimore have confirmed that nicotine withdrawal not only makes people irritable, but also impairs intellectual performance. Logical reasoning and rapid decision-making both suffer during nicotine withdrawal. Acetylcholine appears to enhance memory, which may help explain a common lament voiced by many smokers during early withdrawal. As summarized by one ex-smoker, “I cannot think, cannot remember, cannot concentrate.”

But there is another, less widely discussed aspect of nicotine withdrawal: profound sadness. Profound enough, in many cases, to be diagnosed as clinical unipolar depression.

 Of course, people detoxing from addictive drugs like nicotine are rarely known to be happy campers. But quitting smoking, for all its other withdrawal effects, reliably evokes a sense of acute nostalgia, like saying goodbye to a lifelong friend. The very act of abstinence produces sadness, joylessness, dysphoria, melancholia—all emotional states associated with unipolar depression.

Work undertaken by Dr. Alexander Glassman and his associates at the New York State Psychiatric Institute has nailed down an unexpectedly strong relationship between prior depression and cigarette smoking, and the findings have been confirmed in other work. This sheds important light on the question of why some smokers repeatedly fail to stop smoking, regardless of the method or the motivation.  The problem, as Glassman sees it, is “an associated vulnerability between affective [mood] disorders and nicotine.”

Now a group of Canadian researchers, working out of the Centre of Addiction and Mental Health (CAMH), and the Department of Psychiatry at the University of Toronto, believe they have isolated the specific neuronal mechanisms responsible for the profound sadness of the abstinent smoker.

Writing in the Archives of General Psychiatry, the investigators, who had access to what the CAMH proudly calls the only PET scanner in the world dedicated to mental health and addiction research, gave PET scans to 24 healthy smokers and 24 healthy non-smokers. Non-smokers were scanned once, while heavy and moderate cigarette smokers were scanned after smoking a cigarette, and also after a period of acute withdrawal. Earlier research of this kind had focused on nicotine’s effect on dopamine release. But Ingrid Bacher and her coworkers in Toronto were measuring MAO-A levels in the prefrontal and anterior cingulate regions, two areas known to be involved in “affect,” or emotional responses. When patients suffering from major depressive disorders get scanned, they tend to show elevated levels of MAO-A. The so-called MAO-A inhibitors Marplan, Nardil, Emsam, and Parnate are still in use as antidepressant medications. In general, the higher the levels of MAO-A, the lower the levels of various neurotransmitters crucial to pleasure and reward. A high level of MAO-A would suggest that the enzyme was significantly altering the activity of serotonin, dopamine, and norepinephrine in brain regions involved in mood.

The researchers found that smokers in withdrawal had 25-35% more MAO-A binding activity than non-smoking controls. “This finding may explain why heavy smokers are at high risk for clinical depression," says Dr. Anthony Phillips, Scientific Director of the Canadian Institutes of Health Research's (CIHR's) Institute of Neurosciences, Mental Health and Addiction, which funded this study.

Although researchers involved in these kinds of drug studies almost always claim that the work is likely to lead to new pharmacological therapies, the plain truth is that such immediate spinouts are rare. But in this case, it does seem like the study provides a clear incentive to investigate the clinical standing of MAO-A inhibitors as an adjunct therapy in stop-smoking programs. “Understanding sadness during cigarette withdrawal is important because this sad mood makes it hard for people to quit, especially in the first few days,” said Dr. Jeffrey Meyer, one of the study authors.

As one addiction researcher noted, an associated vulnerability to depression “isn’t going to cover everybody’s problem, and it doesn’t mean that if you give up smoking, you’re automatically going to plunge into a suicidal depression. However, for people who have some problems along those lines, giving up smoking definitely complicates their lives.”


Bacher, I., Houle, S., Xu, X., Zawertailo, L., Soliman, A., Wilson, A., Selby, P., George, T., Sacher, J., Miler, L., Kish, S., Rusjan, P., & Meyer, J. (2011). Monoamine Oxidase A Binding in the Prefrontal and Anterior Cingulate Cortices During Acute Withdrawal From Heavy Cigarette Smoking Archives of General Psychiatry, 68 (8), 817-826 DOI: 10.1001/archgenpsychiatry.2011.82

Photo Credit:http://jenniferonmars.wordpress.com

Teachable Moments in the Life of a Cigarette Smoker

Child surgery makes smoking parents more likely to try quitting.

Here’s a strange one: Doctors at Mayo Clinic wanted to find out whether children undergoing surgery had any effect on the smoking behavior of their parents. And it did—but the effect appears to be short-lived.

The Mayo researchers began from the already well-tested proposition that smokers who have surgery are more likely to quit smoking. In fact, they quit at twice the rate of smokers who haven’t had surgery. Not hard to understand, intimations of mortality and all that. They pass through a teachable moment, the scientists write in Anesthesiology, defined as “an event that prompts behavioral change.” As for smokers with kids, doctors have always had recourse to two tactics for creating teachable moments for cigarette cessation. First, they could point to increased illness and asthma in the innocent children of smokers. And when that didn’t work, they could throw in the cold fact that children exposed to secondhand smoke have a higher risk of respiratory complications during and after surgical anesthesia. And in a further queasy irony, “the increased frequency of conditions such as middle ear diseases caused by secondhand smoke may also make it more likely that children will require surgery.”

For documentation, the investigators turned to the massive National Health Interview Survey (NHIS), a questionnaire served up annually to 35,000 households by personal interview. About 12% of children in the NHIS survey in 2005 were exposed to secondhand smoke. Of the thousands of children undergoing surgery, there was an increased likelihood that a parent of one of them would inaugurate a no-smoking attempt. But these quitters were no more likely to succeed in their attempt than any other quitters.

However, “parents having surgery within the previous 12 months was associated with more quit attempts, more successful attempts, and a greater intent to quit among those still smoking.” What happened to the indestructable bond between parent and child? It appears that concerns about one’s own health trump concerns about the health of offspring when it comes to quitting cigarettes. “We can only speculate about why surgery was a significant factor associated with sustained abstinence when experienced by the smoker but not the smoker’s child.”

There are plenty of limitations to these kinds of self-reported surveys, but it is hard not to speculate, along with the researchers. One obvious implication: the chances of a smoker quitting are at their maximum when parent and child both have surgeries.

“Our current findings suggest that having a child undergo surgery can serve as a teachable moment for quit attempts,” said Dr. Warner. “The scheduling of children for surgery may present us with an opportunity to provide tobacco interventions to parents, who are apparently more motivated to at least try to quit – but who need assistance to succeed.”

Shi, Y., & Warner, D. (2011). Pediatric Surgery and Parental Smoking Behavior Anesthesiology, 115 (1), 12-17 DOI: 10.1097/ALN.0b013e3182207bde

Photo Credit: http://special-needs.families.com/

Are E-Cigarettes a Good Idea or a Bad Idea?

A group of nicotine researchers argue for an alternative.

Electronic cigarettes are here to stay. If you're not familiar with them, e-cigarettes are designed to look exactly like conventional cigarettes, but they use batteries to convert liquid nicotine into a fine, heated mist that is absorbed by the lungs. Last summer, even though the FDA insisted on referring to e-cigarettes as “untested drug delivery systems,” Dr. Neal Benowitz of the University of California in San Francisco--a prominent nicotine researcher for many years--called e-cigarettes “an advancement that the field has been waiting for.” And recently, Dr. Michael Siegel of the Boston University School of Public Health wrote: “Few, if any, chemicals at levels detected in electronic cigarettes raise serious health concerns.” Furthermore, Dr. Siegel took a swipe at the opposition: “The FDA and major anti-smoking groups keep saying that we don’t know anything about what is in electronic cigarettes. The truth is, we know a lot more about what is in electronic cigarettes than regular cigarettes.”

Harm reduction advocates are ecstatic. But do e-cigarettes simply reduce harm by eliminating combustion by-products--or do they perpetuate nicotine addiction, frustrate the efforts of smoking cessation experts, and give false hope to smokers that they can have their cake and eat it, too?

Dr. Siegel conducted a survey of e-cigarette users and found that 66% reported a reduction in the number of cigarettes smoked at the six-month point. “Of respondents who were not smoking at 6 months, 34.3% were not using e-cigarettes or any nicotine-containing products at the time.” Pretty impressive--although Siegel himself refers to the findings as “suggestive, not definitive”--and seemingly a giant leap forward for harm reduction.

However, even though they have dramatically altered the harm reduction landscape, e-cigarettes will not change anything for smokers who are attempting to completely quit using nicotine. When they inhale their last e-cigarette mist, several hours later they will begin to suffer the same withdrawal pains as regular cigarette smokers: “Irritability, craving, depression, anxiety, cognitive and attention deficits, sleep disturbances, and increased appetite,” as NIDA summarizes it. Current smokers are keenly interested in the new products, partly because of health concerns, and partly, it seems safe to venture, because a new generation of nicotine-based products like e-cigarettes “will enable them to put off the need to quit smoking,” as Dr. Dorothy Hatsukami, director of the Tobacco Use Research Center at the University of Minnesota, has asserted.

Harm reduction advocates for the electronic cigarette often make it sound like once the smoker is only inhaling nicotine, his or her problems are solved. But nicotine, of course, is the addictive part. Nicotinic receptors are present in moderate to high density in the brain areas containing dopamine cell bodies--the ventral tegmental area and the nucleus accumbens—the same pattern as almost every other addictive drug.

Even that part wouldn’t be a problem if addiction to nicotine were utterly benign. But it isn’t--although you wouldn’t know it from the pro-electronic cigarette propaganda. Nicotine in the blood is correlated with increases in arterial vasoconstriction, and is strongly suspected of playing a role in arteriosclerosis and other cardiovascular diseases. Nicotine increases LDL cholesterol, causes brochoconstriction, and has been implicated in the origin of lung tumors. There are also strong suggestions of links between nicotine and low birth weights in newborns.

So, it’s important not to kid ourselves about the hazards of nicotine, even though it may also be a medicine under certain conditions, like many other addictive drugs. Nicotine, you may recall, found industrial use as a farm crop insecticide. A poison, in other words. Nonetheless, what nicotine is NOT linked to certainly matters as well. Nicotine does not cause chronic obstructive pulmonary diseases, like emphysema—a huge plus. Nicotine won’t worsen asthma, as cigarettes do. And in the form of the electronic cigarette, it won’t cause secondhand smoke—another major plus for the e-cig.

There is another approach to regulating the harm caused by cigarettes. A group of scientists has been calling for a major effort at reducing the amount of nicotine in cigarettes so that, over time, a non-addictive level of nicotine would be reached--and cigarettes would no longer be addictive. Study after study has shown that if such were the case, about 80 to 90% of smokers would quit. And teens who experimented with truly low-nicotine cigarettes wouldn’t get hooked—unlike the “light” cigarette scandal, where the supposedly safer cigarettes may actually have turned out to be more dangerous because they forced smokers to smoke more in order to get the desired effect. Dr. Hatsukami and five other prominent nicotine experts contend that extremely low-nicotine cigarettes do not cause smokers to smoke more, “because it is harder to compensate for very low nicotine intake,” according to Hatsukami. Especially if there are no high-nicotine alternatives for sale—legally, at least. Mitch Zeller, who along with Hatsukami, co-chairs the National Cancer Institute’s Tobacco Harm Reduction Network, painted this picture: “Imagine a world where the only cigarettes that kids could experiment with would neither create nor sustain addiction."

Nonsense, counters Dr. Gilbert Ross of the American Council on Science and Health. “Asserting that smokers won’t smoke more cigarettes to get the nicotine they crave is a fairy tale,” he said. “The likely result is a major increase in cigarette-related diseases.”

These are the competing visions of our nicotine-addicted future. In one scenario, smokers stay addicted to nicotine, with its accompanying heath risks and all the other negative aspects of being addicted. But the immediate harm to their health is lessened due to fewer inhaled carcinogens, and they don’t create secondhand smoke. In the opposing scenario, smokers continue to smoke, and society continues to deal with secondhand smoke through no-smoking policies, while medical research agencies, under government mandate, oversee the gradual reduction of nicotine in cigarettes to a level below what is needed for addiction.

The optimistic thought here is that either of these approaches would bring much-needed improvement to the semi-controlled anarchy and hypocrisy of the current situation.

Photo Credit: http://whyquit.com 

Top 50 Smoking Awareness Blogs

Addiction Inbox makes the cut.

Addiction Inbox is pleased to find itself listed among the "Top 50 Smoking Health Awareness Blogs" by the Pharmacy Technician Certification web site.

Here is the description included in the listing:

"An exhaustive, comprehensive, and stimulating catalogue of information pertaining to the science of substance abuse, the Addiction Inbox counts nicotine amongst its list of dangers. Expect to see articles regarding tobacco control alongside psychological studies on the physical, emotional, and mental elements of addiction."

Thanks go to Ashley M. Jones for the listing, and for bringing it to my attention.

The latest numbers on cigarette smoking from the American Heart Association show that 23.5 % of white males are smokers, with female smokers having closed the gap considerably with a smoking rate of 18.8 %.

26.1 % of black men are smokers, compared to 20.1 % of Hispanic males, and 16.8 % of Asian men. For women, blacks smoke at a rate of 18.5 %, followed by Hispanic women at 10.1 %, and non-Hispanic Asians at 4.6 %.

The tragic winners, and thus the losers, of the smoking sweepstakes are Native Americans, who show smoking rates of 35.6 % for men and 29.0 % for women.

Graphics Credit: www.chantixhome.com

addiction drugs smoking nicotine