Behavior, knowledge, and attitude of surgeons and patients toward preoperative smoking cessation

Tobacco smoking remains the leading cause of preventable death all over the world.[¹] Current statistics shows that it will not be possible to reduce tobacco-related deaths over the next 30–50 years, unless tobacco users are encouraged to quit.[²] Tobacco smoking also is a well-known risk factor for postoperative complications, such as postoperative infections and impaired wound healing,[³] and tobacco smokers have higher prevalence of respiratory complications during anesthesia and an increased risk of postoperative cardio-pulmonary complications.[⁴]

In addition, smokers have a greater risk of postoperative intensive care admission. However, some of the studies have shown that the brief cessation from tobacco smoking might reduce the risk of these complications and improve the surgical outcome.[⁵⁶]

The level of smoking-related surgical complications awareness among patients is low, whereas 25% of surgical patients are unlikely to be informed about it by their surgeons. However, patient compliance comprises only 40% of those advised.[⁴⁵]

Scheduling of smoker patients for surgery is a point of controversy that is currently not being exploited systematically for this purpose.[⁵] Evidence demonstrates that even a brief preoperative clinical intervention can significantly increase abstinence rates in a variety of settings.[⁷] Many health-care environments, including hospitals/and surgical clinics, have implemented no-smoking policies. As a result of this, in-patients are ideally placed to receive smoking cessation advice and counseling. However, little attention has been paid to the role of surgeons in addressing tobacco use. Indeed, many surgical specialists recognize the adverse effects of smoking both on short- and long-term outcomes. Each year, millions of cigarette smokers require surgery, so surgeons can play an important role in tobacco control and prevention of deaths due to cigarette smoking. Recently, many studies have shown the benefits of preoperative and long-term postoperative smoking cessation in patients.[⁸] In addition, it has been well documented that smoking cessation has significant benefits on morbidity and mortality.[⁹] However, many smokers never considered quitting from smoking until a health problem occurs. There is strong evidence that hospitalized patients who have concern for smoking cessation are associated with increased rates of spontaneous smoking cessation compared with the general population. Among these patients, it appears that the chances of quitting increase with the intensity of medical interventions.[⁵]

In most recent report statistics, 22.6% of the Saudi adult populations are active smokers which suggest that this percentage is considered a high prevalence.[¹⁰¹¹] However, most of the hospitals in Riyadh offer smoking cessation programs that are either weak or not fully functional; this directly affects smoker's health. The need for this investigatory mission originated from the fact that King Khalid University Hospital (KKUH) is one of the largest tertiary healthcare centers and serves large number of surgical patients from Riyadh and other nearby areas, but KKUH does not have any smoking cessation program for pre and postoperative surgical patients.

The aim of the study is to determine the number of surgical patients who received education about the magnitude of smoking cessation prior to surgery by their treating surgeons, and to determine the number of surgeons who preoperatively inform their patients about the risk of smoking on the surgical outcomes. In addition, to assess the number of patients who agreed to quit smoking completely after surgery by evaluating patients' compliance with smoking cessation advise.

Methods

This is a descriptive, comparative cross-sectional quantitative study conducted on outpatients, inpatients, and treating surgeons at KKUH during January 2013. The research team distributed self-administered anonymous questionnaires to eligible subjects.

The research tool used is a survey using self-administered anonymous questionnaires to eligible subjects. Two surveys were conducted: (1) Patients' survey comprised 23 questions including patients' demographics, smoking habits, kind of surgery, smoking cessation, and doctor's recommendation to quit smoking and (2) surgeon's survey comprised 12 questions including type of surgery, smoking status, smoking duration, frequency of smoking, frequency of attending to smokers, and how these surgeons addressed smoking and quitting smoking [Appendixs 1 and 2].

The KKUH in Riyadh, Saudi Arabia, is an 800-bed facility that includes both inpatient and outpatient care facilities. There are over 20 well-functioning operation rooms, a fully staffed laboratory, radiology and pharmacy services, and other supporting services. This hospital provides primary and secondary care services for patients that are limited to the northern region of Riyadh. Tertiary care services are provided to all citizens on referral bases. Everyone in Saudi Arabia can use its services free of cost, without restriction to a specific catchment area. Surgical Service Department provides services for operative and other invasive procedures and immediate postoperative care on a 24-h basis. All surgical subspecialties are performed at KKUH, and this center was chosen for this study due to the variety of socioeconomic classes of patients who are visiting here for their treatment.[¹²]

All adult patients (18 years old and more than 18 years old) who were visiting KKUH for surgical and nonsurgical reasons were included in this study. Smoking status was used to describe as either currently regular smokers, ex-smokers (patients who have smoked at least 100 cigarettes in their lives and have stopped smoking completely more than 12 months ago), passive smokers, or nonsmokers.[¹³¹⁴]

Vascular surgery clinic visitors were excluded due to involvement of smoking in the pathogenesis of atherosclerosis and the treatment. Patients who will be visiting surgery clinic for the mere purpose of consultation without determining the need for surgery were also excluded. The study included addressed consultant surgeons, senior registrars, and residents in KKUH. Pediatric surgeons were excluded from the sample due to their minimal contact with smoking patients. Furthermore, vascular surgeons were excluded too from our sample in this study for the above-mentioned purposes.[¹⁵]

Data collection was conducted from January to March 2013. Data collection was held three times a week for 3 months. Information was gathered through structured, validated questionnaires. A research member was available to assist the participant to clarify the questions when needed. The questionnaire included the following elements: Demographic features, type of surgery, smoking cessation advice by surgeons, and patient behavior toward preoperative smoking cessation [Appendix 1]. A self-administered online questionnaire, sent to surgeon's office e-mails by the research team members, was randomly distributed among consultants of Surgery Department in KKUH. Questionnaires contained smoking status of the surgeon, whether they advise their patients to stop smoking prior to surgery, and their views on the importance and appropriate time of preoperative smoking cessation [Appendix 2].

Based on previous literature, the percentage of surgical patients who were advised about smoking cessation was about 39%,[¹⁶] with a significance level (α) of 5% and a confidence interval 95%, the minimum sample size required to correctly reject the null hypothesis is 366 patients. Cluster sampling technique was used to divide the hospital into three clusters: Academic facilities, outpatients' clinics, and inpatients' wards. Surveys were distributed among eligible participants and underwent further assessment and filtration based on the systematic randomization method to minimize the selection bias. Since 290 surgeons operate the Department of Surgery in KKUH, a convenient sample was used with the exclusion of pediatric and vascular surgeons.

A pilot study for validation has been conducted in the surgical clinic in KKUH, as the Arabic version of the questionnaires given to the participants and then modulated by the research team. Questionnaires were distributed also to the vascular and pediatric surgeons independently from our sample to gather feedback on the clarity of the questions.

The collected data were tabulated and analyzed using SPSS Software version 21 (SPSS Inc., Chicago, IL, USA). The effectiveness of the smoking cessation advice will be determined by comparing outcome measures. Numerical variables are reported as the mean standard deviation. The statistical significance was defined as P < 0.05.

Results

A total of 795 patients were included during this study, among which 108 (13.5%) had surgery and 687 (86.4%) were nonsurgical patients. Two groups were compared according to potential categorical variables, including age, sex, marital status, schooling, occupation, smoking history, and knowledge and behavior about smoking [Table 1]. There was significant difference in the mean age between the surgical (31.16 ± 16.38 years) and nonsurgical patients (23.69 ± 10.72, nonsurgery) (P = 0.001). Males outnumbered in surgery group, whereas females were more in nonsurgery group (P = 0.001).

Percentage of male was higher in surgery, whereas percentage of female was more in nonsurgery patients (P = 0.001). Compared with the marital status, married persons have higher risk of surgery (P = 0.001). Similarly, frequency of college education was higher (43.5%) in surgery patients (P = 0.001), and unemployed (49.9%) and students (32%) were more in nonsurgery patients. Distribution of income frequency did not indicate any statistical difference. When compared with nonsmokers (41.7%), current smokers (37.5%), ex-smokers (12.5%), and passive smokers (8.3%) were more dominant and demonstrated increased risk (P = 0.001) of surgery. On a more detailed inquest, that involved asking the patients about the importance of quitting smoking for better health, the response was (95.4%) of the surgical patients agreed to quit smoking before surgery, while (4.6%) disagreed. In addition, the same question was raised to nonsurgical patients, for which 94% answered “yes.” When asked to respond about the knowledge of the harmful effects of smoking on the surgery, more than half (66.7%) of surgery group and 73.1% of nonsurgery patients were unaware of the harmful effects of smoking.

In this study, 108 surgical patients (already had different type surgery in the past 6 months) were recruited from 12 different types of surgical departments [Table 2]. Table 2 provides patient distribution according to the specialties involved. Of the total surveyed subjects, major number of surgery patients was 23.3% from the general category and 23.3% from the Orthopedic Department whereas 8.7% from Cardiology Department, and 7.8% from Ophthalmology and Plastic Surgery Department. The least percentage of patients was from Trauma, Neurosurgery and Cardiothoracic surgery with a percentage of 1.9%, 1.9%, and 1%, respectively, whereas the rest of the surgery patients were from bariatric (4.9%), endocrinology (4.9%), and Ob/gynecology and urology (5.8%). Regarding the smoking habit among these patients, most of them smoked cigarettes (79.4%) compared to hookah (17.7%) and cigars (2.9%). Majority of smokers (55.9%) smoked 11–20 cigarettes daily for more than 4 years (76.5%). Nearly 26.5% of patients were chain smokers, who smoked more than 20 cigarettes per day. Further, higher percentage of smoker patients (55.9%) daily smoke 11–20 cigarettes daily, and regarding the duration of smoking (76.5%) of the smokers in general smoked for more than four years, (20.6%) for 3-4 years, and (2.9%) for less than 2 year.

Further, all 108 surgery patients were enquired, whether they were advised to stop smoking before and/or after surgery by their treating surgeons, 58.8% patients declared that they were advised to stop smoking before surgery and 51.4% patients were advised to stop smoking after surgery. Out of 58.8% patients who were counseled to stop smoking before surgery, 41.2% patients were advised to quit smoking for less than 1 week, 35.3% for 1–2 weeks, 5.9% for 3–4 weeks, and 17.6% for more than 4 weeks before surgery. Among patients advised to quit smoking after surgery, 51.4% patients were advised to quit smoking after surgery, 50% patients were recommended to stop smoking more than 4 weeks for better health. Finally, smoker patients were also asked about their behavior toward quitting, and 70.6% of patients were willing to quit smoking after the surgery.

In the present study, questionnaire sent to surgeons contained eight questions concerning gender, profession, smoking habits, and behavior and attitude toward addressing their patients to stop smoking [Table 3]. Responses from doctors are tabulated in Tables 4 and 5. A total of 66 surgeons (nonvascular and nonpediatric), majority of them male (88.4%), responded to the questionnaire (response rate: 22.83%). Out of those, 32 (46.4%) were specialized in general surgery, 7 (10.1%) in bariatric surgery, whereas the cardiac, cardiothoracic, and plastic surgery accounted for 7.2% each.

The study population comprised more male (88.4%) surgeons rather than female (11.6%) surgeons. Majority of the surgeons had never smoked (69.6%), 21.7% were current smokers, and 21.7% were ex-smokers. Most of the surgeons were interacting with smoker patients (60.9%) and frequency of seeing passive smoker was 47.8%. Majority of surgeons (69.6%) have advised patients to stop smoking more than 2 weeks before surgery. More than half of the surgeons (53.6%) believed that preoperative smoking cessation sometimes reduced postoperative complications and 40.6% surgeons reported this habit will reduce surgical complications after surgery. On asking about how often patients quit smoking after being advised, majority of surgeons (59.4%) said that the patients completely stopped, whereas 34.8% believed that patients sometimes took the advice and stop smoking and 4.3% surgeons responded that patients never stopped smoking.

Discussion

The range of adverse health consequences of tobacco use is well documented and widely acknowledged. The overall adverse health impact of smoking offers a sobering prognosis for the long-time smoker: An estimated 50% of current smokers will die of smoking complication, and these current smokers enter a medical encounter with smoking-related disease if they do not quit. Accumulations of research showed that prolonged cigarette use from early adult life triples age-specific mortality rates, which are fully normalized only through smoking cessation provided in medical context.[⁹] The present study attempts to determine patients smoking knowledge and behavior and explore the attitude of the surgeons whether they are advising their patients regarding smoking cessation during pre and postoperative surgery.

Results have indicated that current, ex- and passive smokers are more prevalent in surgery group, which reflected the harm effect of smoking. The majority of patients who underwent surgeries were aware of the smoking complications during pre- and post-effects of surgery, whereas a large portion of nonsurgery patients also accepted quitting smoking prior to surgery is of importance. Hospital-based cessation has been linked to a substantial reduction in the risk of all-cause of surgeries and mortality among patients.[¹⁷] The effectiveness of this cessation approach may be attributable to the fact that hospitalizations represent a “window of opportunity” during which patients are particularly motivated to quit smoking. Indeed, patients highly respect their surgeons' opinions and recommendations, and they enter a medical encounter with a focus on their health and a readiness to engage in actions relevant to improving their well-being, such as quitting smoking.[¹⁸] However, results demonstrated that most of the patients were advised to quit smoking before (58.8%) and after (51.4%) surgery by their treating surgeons. Highest percentages of surgeons are advising their patients to quit smoking less than 1 week before surgery, which is not the optimal duration for reducing the postoperative complication. This study has suggested that preoperative smoking cessation is a short-term goal and needs abstinence of 6 weeks for benefit of postoperative complication.[¹⁵] According to the new KKUH policies, smoking inside the hospital buildings is strictly prohibited, and there are penalties recorded against whoever violates this law.[¹²] This facilitates postoperative smoking cessation.

It has been documented that 64.9% smoker patients stopped smoking before undergoing surgery, and this might be because scheduling of patients for surgery is an appropriate time point to reduce the pre and postoperative complications. Thus, surgery can serve as a teachable moment as defined. Raw et al. have found that 3 min of advice in the clinic increased the patient's chance of quitting by 2%, thus more intensive interventions are even more effective.[¹⁹] A recent study has also shown benefit of preoperative and long-term postoperative smoking cessation.[⁸] Simon et al. have conducted randomized trial on 324 noncardiac surgery patients at the Veterans Affairs Medical Center, San Francisco, and found that, smoking cessation intervention targeted at hospitalized smokers can increase long-term quit rates.[²⁰] Similarly, Ratner et al. tested a smoking intervention on 237 presurgical patients and suggested that encouraging patients to abstain from smoking before surgery and postoperative support are efficacious ways to reduce preoperative and immediate postoperative tobacco use.[²¹]

Based on this present survey, more than 70% of surgical patients are willing to quit smoking after surgery, as a consequence, all health professionals should make every effort to encourage patients to quit smoking, since smokers who are well motivated are more likely to be successful than those who are not.

A surgeon's role and attitude while treating a smoker patient is threefold: To advise patients to stop smoking prior to surgery, to provide guidance on the appropriate period of cessation, and to advise them to stop smoking postoperatively. Results of this survey revealed that the majority of surgeons reported that they advised their patients for smoking cessation during presurgery. Smokers may be at a greater risk of postoperative complications such as delayed wound healing, pulmonary complications (atelectasis), more pain, and mortality, hence preoperative smoking cessation seems to offer important benefits in reducing these complications.[²²] Most of the surgeons (40.6%) have advised patients to quit smoking for more than 2 weeks before surgery, whereas study showed that when patients stopped smoking 3–4 weeks before surgery they had significantly reduced surgical complications.[²³] In this study, patients were not getting proper time duration advice. This behavior and attitude of the surgeons reflects lack of knowledge and skills in smoking cessation and needs training in smoking cessation and knowledge of its effect. Health-care professionals have a certain responsibility as being role models for patients with regard to healthy behavior.[²⁴] After advising their patients, 59.4% of surgeons believe that patients quit smoking after they were counseled to do so.

This study has some limitations. The primary limitation is whether this sample is representative of Saudi surgeons. Second is the question whether the patients have continued smoking after the operation or not, possibly some patients would not answer “yes,” because they thought they would be labeled as patients who did not have enough time to stop smoking or they will be regarded as patients unable to stop smoking. Third, the results are based on patient self-report; therefore, they may be inaccurate and do not demonstrate the actual rate of advice and questioning. Recall bias of the patients was greatly minimized by asking about the surgeries that were done in the previous 6 months.

Recommendations

A well-equipped center should be warranted in KKUH to provide smoking cessation programs and services for patients who seek help, to guide them through the process of smoking cessation and audit their effectiveness. Well-organized multidisciplinary approach must be directed to surgical patients, offering simple interventions in general practice, outpatients, or at preoperative assessment clinics, more patients could be encouraged and assisted to quit smoking and as a result benefit from reduced postoperative complications and length of stay. Future research should look into the effectiveness of smoking cessation advice that is given by a health-care provider to patients, and the reasons why surgeons fail to deliver such advice.

Conclusion

The surgeons and patients who participated in the questionnaire were aware that smoking cessation improves outcomes, but most of the surgeons did not provide brief advice about time duration to stop smoking. Surgeons should actively participate in tobacco control training and education to improve their knowledge and behavior toward smoking. This will lead to improvements in knowledge, as well as the frequency with which they inquire about patients' smoking status and encouraging patients to quit smoking.

Financial support and sponsorship

This study was supported by College of Medicine Research Center, Deanship of Scientific Research, King Saud University, Riyadh, Saudi Arabia.

Conflicts of interest

There are no conflicts of interest.

Acknowledgment

This study was supported by The College of Medicine Research Center, Deanship of Scientific Research, King Saud University, Riyadh, Saudi Arabia.