Perioperative Smoking Cessation BUndle in a Tertiary Care Hospital - Can Turning Virtual Improve Outcomes? A Pilot Randomized Controlled Trial.

Introduction and Background Smoking continues to be a burden to the healthcare system in Canada. As of 2019, 3.7 million Canadians (12% of the population over age 15) reported being a current smoker. British Columbia's smoking rate is lower, but 10.2% of adults still regularly smoke cigarettes1. It is well-known that smokers suffer more complications and higher risk of mortality after surgery than non-smokers. Pulmonary complications, cardiovascular complications, and surgical site infections are mediators of smoking-associated mortality at 6-months and 1-year after elective surgery.

Although there have been a handful of studies that have demonstrated dramatic reductions in postoperative complications with well-timed smoking cessation interventions in the preoperative period, these results have not translated into widespread clinical practice in delaying surgery for the purpose of achieving smoking cessation. In addition, most of these studies took place in Europe, where smokers may behave differently than in the Canadian setting.

A systematic review recommended at least 4 weeks of smoking cessation in order to reduce postoperative complications6. Several European studies have shown dramatic reductions in complications (up to 30% absolute risk reductions) when smoking cessation interventions have been implemented 4-8 weeks preoperatively. One Canadian editorial even suggested new policies be put into place to delay elective surgeries in smokers until a trial of cessation for 6 weeks had taken place.

Implementation of smoking cessation programs preoperatively have the potential to reduce morbidity and mortality. A Cochrane systematic review has shown that preoperative smoking cessation therapy improves both short and long-term smoking cessation. In fact, a surgical encounter with the healthcare system has been described as a "teachable moment" that provides motivation for patients to permanently stop smoking. Despite this information, most anesthesiologists do not routinely offer smoking cessation advice to their patients and advice, counselling, and pharmacotherapy for smoking cessation is not routine in pre-admission clinics across Canada and the United States.

Several small trials have shown that smoking cessation interventions can increase smoking cessation and reduce postoperative complications, particularly wound-healing complications, which can have an absolute risk reduction of up to 25%. Prior work by one of the co-investigators showed that a simple intervention in the pre-admission clinic was able to increase the abstinence rate from 3.6% to 14.3% on the day of surgery. Smoking cessation initiated in the perioperative period can also promote long-term smoking cessation.