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ECONOMICS, EDUCATION, AND HEALTH SYSTEMS RESEARCH

Anesthesiologists, General Surgeons, and Tobacco Interventions in the Perioperative Period

David O. Warner, MD^*, Michael G. Sarr, MD, Kenneth P. Offord, MS, and Lowell C. Dale, MD

Departments of *Anesthesiology, Surgery, Medicine, and Health Sciences Research, Mayo Clinic, Rochester, Minnesota

Address correspondence and reprint requests to David O. Warner, MD, Department of Anesthesiology, Mayo Clinic, 200 First St. S.W., Rochester, MN 55905. Address e-mail to warner.david{at}mayo.edu

	Abstract

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Surgery presents an opportunity for interventions in cigarette smokers that will facilitate abstinence from tobacco. However, little attention has been paid to the role of anesthesiologists and surgeons in addressing tobacco use. To determine the practices and attitudes of these physicians regarding this issue, we sent a postal mail survey to a national random sampling of anesthesiologists and general surgeons engaged in active practice within the United States (1000 in each group). Response rates were 33% and 31% for anesthesiologists and surgeons, respectively. More than 90% of both groups almost always ask their patients about tobacco use, and almost all respondents believed that surgical patients should maintain abstinence after surgery. Most believed that it was their responsibility to advise their patients to quit smoking, but only 30% of anesthesiologists and 58% of surgeons routinely do so. Nonetheless, approximately 70% of both groups would be willing to spend an extra 5 min before surgery to help their patients quit. Barriers to intervention included a lack of training regarding intervention techniques, a perceived lack of effective interventions, and insufficient time to intervene. Intervention opportunities are not exploited consistently in the surgical population; educational efforts directed at physicians in surgical specialties are indicated.

IMPLICATIONS: Although most surgeons and anesthesiologists believe that it is important for their patients to stop smoking at the time of surgery, most do not have the knowledge or experience to help them achieve this goal.

	Introduction

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Many cigarette smokers require surgery and anesthesia. Current policies in many US health care facilities require temporary forced abstinence in the buildings and on the grounds of the facility. Abstinence not only may decrease the frequency of postoperative complications (1,2), but also may present a "teachable moment" that encourages smokers to stop (3). The illness that makes surgery necessary may highlight personal vulnerability to health risks, especially if the illness is directly related to smoking (3). Communicating this relationship to the patient may improve the effectiveness of interventions for tobacco use. At the very least, the scheduling of surgery, no matter how minor, brings patients into contact with the health care system and provides a unique opportunity for intervention.

A primary recommendation of the US Public Health Service guidelines on tobacco use and dependence (4) is to systematically identify all tobacco users who come into contact with the health care system, strongly urge them to stop, and aid them in doing so. The guideline goes on to say that "...all physicians should strongly advise every patient who smokes to quit because evidence shows that physician advice to quit smoking increases abstinence rates" (4). The scheduling of patients for surgery represents a point of contact that is currently not being exploited systematically for this purpose. Evidence demonstrates that even brief clinical interventions can significantly increase abstinence in a variety of settings (5). More intensive services, initiated by physicians and fully implemented by other providers, are even more effective (5). However, little attention has been paid to the role of anesthesiologists and surgeons in addressing tobacco use.

There may be several barriers to physician intervention in the perioperative period. Surgeons and anesthesiologists may not fully appreciate the risks of smoking in the immediate perioperative period. They may not view interventions as being part of their responsibilities, may not believe that interventions are effective, or may not believe that they have time to intervene. Few have had training in providing such interventions or have ready access to relevant educational materials. Many may not be aware of how to refer patients for more intensive interventions by specialists.

Our study examined the reported practices and attitudes of anesthesiologists and general surgeons regarding cigarette smoking intervention in the perioperative period. This information is a first step toward developing a research agenda and educational efforts directed toward these groups as part of a comprehensive strategy to promote tobacco abstinence in surgical patients.

	Methods

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The study was approved by the Mayo Foundation IRB. A list of active members (resident, affiliate, honorary, and retired members were excluded) was generated by the American Society of Anesthesiologists and the American College of Surgeons. Questionnaires were mailed to 1000 active American Society of Anesthesiologists members and 1000 active general surgeon members of the American College of Surgeons by the Survey Research Center at Mayo Clinic Rochester. Two survey packets with the cover letter, survey instrument, and postage-paid return envelope were prepared specific to each group. Responses were anonymous, so there was one mailing, with no follow-up of nonresponders. To allow identification of actively practicing physicians, a screening question asked whether they were currently engaged in active practice.

Questionnaires included the following items:

1. Current practices: these items related to the current practices of these physicians regarding smoking interventions and included the frequency with which intervention components are applied.
   
2. Attitudes and beliefs: these items queried the attitudes toward and beliefs regarding smoking interventions. They were categorized into questions related to 1) perceptions of risks and benefits of perioperative smoking abstinence; 2) perceptions of physician responsibility for intervention; 3) knowledge of issues associated with intervention; 4) perceptions of barriers to intervention; and 5) a survey of interest in learning more about how to intervene.
   
3. Demographics: these items included information regarding practice environment, access to patients before and after surgery, and personal characteristics.
   

Summary statistics of responses were prepared and represent the primary focus of this report. We also compared the responses of anesthesiologists and general surgeons to determine how their attitudes might differ. The two groups were compared by using nonparametric tests for each of the demographic variables, by using a ranked sum test taking into account tied rankings for the continuous variables (age and years of practice), and by using Fisher’s exact test for categorical variables. Respondents could indicate more than one practice environment, so for statistical comparisons, those with multiple practice environments were included in the "other" category. The questions regarding the practitioners’ current practices had four options ranging from "never" to "almost always (over 75% of the time)." The distribution of these ordinal responses in the two groups was compared by using a ranked sum test. For items accessing the respondent’s attitudes/beliefs and interest in learning about interventions, there were five levels of agreement ranging from "strongly agree" to "strongly disagree" and a "don’t know" option. Some items had a "not applicable" option; these responses were excluded from comparisons. Seven of the items had more than 3% of the respondents in one or both groups selecting the "don’t know" option. For these seven items, comparisons were made with a ² test. Otherwise, a ranked sum test was performed that compared the distribution of the five levels of agreement in the two groups, taking into account tied rankings. For these items, the "don’t know" responses were combined with the "neutral" option before statistical comparisons were performed. The proportion of usable completed surveys (i.e., response rate) in each group was compared by using a ² test. In all cases, P values >0.050 were considered not significant.

	Results

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Response rates were not significantly different between groups (Table 1). Seven anesthesiologist surveys and 60 surgeon surveys were excluded because the respondents indicated that they were no longer engaged in active clinical practice. The demographics of respondents in active practice are shown in Table 2 and form the basis for this report. Surgeons were older, longer in practice, and more likely to be male (P < 0.01 for each). Most respondents were never smokers, and only 1% were current smokers.

Only approximately 40% of respondents knew that nicotine patches are available without a prescription or that there are nonnicotine medications available to assist with quitting (Table 5). Approximately 35% agreed that nicotine-replacement therapy was safe to use during surgery; approximately 60% agreed that it was safe to use after surgery. Most did not know whether physician reimbursement was available for tobacco-use intervention in these patients.

Considerable numbers of both groups reported deficits in knowledge regarding how to help their patients achieve tobacco abstinence (Table 6). Approximately half of respondents expressed interest in learning more about interventions, and approximately 40% would be willing to attend a workshop to do so. Most would spend an extra 5 min before surgery to deliver an effective intervention, and almost all would refer smokers to an effective intervention service if it were readily available in their practice setting.

	Discussion

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Almost all survey respondents reported asking their patients whether they smoked cigarettes—this is similar to the reported practices of primary care physicians such as general internists and family practitio-ners (6). However, relatively few consistently counseled patients about how to stop. The reported frequency of counseling was less than noted in prior surveys of primary care physicians (6). Other studies have also noted that the frequency of counseling is less in surgical subspecialists compared with primary care physicians (7,8). Although most general surgeons believed that intervention was their responsibility, few anesthesiologists agreed. This belief persisted despite recognition of the adverse effects of smoking on perioperative outcome and the acknowledgment that the perioperative period is an opportune time to promote permanent smoking abstinence. A similar dichotomy between beliefs and practice has been noted in other studies of physician interventions for tobacco use (9).

Given the demonstrated effectiveness of even brief physician intervention in promoting smoking abstinence (5), considerable attention has been directed toward encouraging primary care physicians to provide such interventions, given their frequent contact with smokers (4). However, smokers also have contact with other physicians in diverse settings. In 1996, approximately 40 million visits occurred for surgical and diagnostic procedures in the United States (10). Al-though surgical rates in cigarette smokers are not known, simple estimates suggest that millions of smokers undergo surgical procedures annually. There is currently no consistent approach to helping surgical patients manage their tobacco dependence, and formal intervention programs for smoking are usually not part of standard surgical care. Our data suggest several reasons for this relatively infrequent intervention by anesthesiologists and surgeons, as well as possible steps to improve it.

First, physicians are more likely to address smoking behaviors when patients are seen for an illness recognized as related to smoking (11,12). Although the need for a surgical procedure is often linked to chronic tobacco use, there may not be a direct connection, or it may not be appreciated in many patients. Although most physicians recognize the long-term health benefits of smoking cessation, the effects of smoking on immediate postoperative outcomes may not be as well appreciated. This may affect the physician’s motivation to intervene. This study demonstrated that appreciation for the perioperative risks of smoking was greater in general surgeons than anesthesiologists, and general surgeons were more likely to report providing interventions. It is probably not coincidental that the volume of published surgical literature regarding tobacco use is largest for the subspecialties of reconstructive orthopedic, plastic, cardiac, and oral surgery, in which the consequences of continued smoking on surgical outcome are perhaps best recognized (2,13,14). Further research on postoperative morbidity directly related to smoking could increase physician motivation to intervene.

Second, the duration of preoperative abstinence needed to affect postoperative outcomes is often unclear. For example, some have interpreted a prior study by Warner et al. (15) as suggesting that the rate of postoperative pulmonary complications is increased in patients who quit smoking within eight weeks of cardiac surgery compared with those who continue smoking. However, this difference was not statistically significant, and these authors did not conclude that recent preoperative abstinence increased risk, but rather that the full benefits of smoking cessation may require longer periods than previously reported (15). This study may contribute to the uncertainty regarding the efficacy of short-term abstinence expressed by the anesthesiologists, although we agree with a review of postoperative pulmonary complications that recommends preoperative abstinence regardless of timing (16). Better studies defining the optimal duration of preoperative abstinence necessary to achieve improved early postoperative outcomes may strengthen the motivation to intervene if relatively brief abstinence improves postoperative outcomes.

Third, physicians who believe that smoking interventions can be effective will be more likely to offer such interventions (17). Consistent with this idea, anesthesiologists were more likely to believe that interventions would not be effective and were less likely to offer them compared with surgeons. Although overwhelming evidence shows that interventions are effective in multiple settings (5), relatively few efforts have been targeted to the hospitalized surgical patient (18) (compared with hospitalized patients in general) (17). No studies have addressed patients undergoing ambulatory surgery. Some studies have questioned the safety of nicotine-replacement therapy in the perioperative period, on the basis of the effects of nicotine (given in doses far larger than those achieved with nicotine-replacement therapy) on wound and bone healing in animal models (19,20). Although counterbalancing clinical data suggest the safety of nicotine replacement in this setting (21), the issue may not be resolved in the minds of many physicians. Further studies confirming the safety and effectiveness of pharmacologic interventions such as nicotine-replacement therapy in the perioperative period need to be performed. Designing strategies tailored to the surgical patient and demonstrating their efficacy could increase enthusiasm for offering such interventions.

Finally, it is apparent that many respondents are not familiar with available interventions (4). For example, a minority of respondents knew that nicotine patches are available without a prescription. Many respondents indicated that they do not know how to intervene effectively with tobacco users. This knowledge deficit may reflect a lack of training, because issues of tobacco use are still largely ignored in medical schools and in residency programs for these specialists. In addition, no formal requirements or suggested policies related to tobacco intervention are mandated by national educational regulatory committees for these specialties.

We also identified factors that auger well for future involvement of general surgeons and anesthesiologists in tobacco interventions. Few respondents were current smokers, and this is consistent with trends in physician smoking behavior in the United States (22). This factor, which is an important determinant of intervention implementation in other countries with more frequent rates of physician smoking (23), should not impede smoking interventions in this country. Many respondents indicated a willingness both to learn more about intervention strategies and to implement them in their practices if such interventions were relatively brief. This interest was not limited to physicians at any particular stage of their careers, because responses were similar regardless of the number of years in practice. Surgeons in general reported more concern with issues related to smoking compared with anesthesiologists. Several factors may contribute to this difference, including 1) the more direct concern of surgeons regarding how smoking affects their handiwork, 2) more patient contact before and after surgery that may permit more time to address tobacco-related issues, and 3) the role that many surgeons play in providing some aspects of primary care to their patients, a role not shared by most anesthesiologists.

Educating surgical subspecialists is only one component of a strategy to provide tobacco interventions to surgical patients. There is strong evidence that provider education, combined with health system changes such as provider reminder systems, are highly effective in increasing the rates of intervention and cessation (5). Such systems can be as simple as adding stickers to patient charts to ensure that smoking status is documented. Given the time pressures associated with modern practice and the trend toward ambulatory surgery, which is often associated with limited preoperative patient contact by anesthesiologists, there are very real challenges in implementing tobacco interventions. Ideally, interventions performed by surgeons and anesthesiologists should be one component of a comprehensive approach that includes collaborations with other health care providers. However, if such health system changes are to be implemented, surgical specialists must understand the relevance to their practice and must be enthusiastic proponents of and participants in the system change.

Surveys have important limitations. Survey response rates have been declining over time, and our response rate was within the range reported in other recent physician surveys (24), including those of anesthesiologists (25). However, this relatively small response rate introduces the possibility of response bias if those physicians most interested in tobacco use issues were more likely to respond. Thus, the survey may actually overestimate such interest in a general population of these specialists. There also may be recall bias on the part of the respondents. For example, although surveys indicate that up to 98% of physicians report routinely recording smoking status (6) and although most report routinely counseling patients to quit, actual contemporaneous assessment of practice shows that only approximately two thirds of primary care physicians identify patients’ smoking status and that only approximately one quarter actually provide counseling (11). Thus, physicians may overestimate the actual frequency of their implementation efforts. If our observations represent an overestimate of physician interest and recall, then our conclusion that there is a major opportunity for improving smoking cessation interventions in this practice setting is further strengthened.

In summary, the results of this survey can provide guidance in establishing critical research and education agendas that could improve the delivery of tobacco interventions in the surgical patient. Evidence-based educational programs need to be implemented that address the gaps in knowledge and skills identified in this survey. Combining education with changes in health care systems that promote tobacco interventions could have a major effect on both immediate perioperative morbidity and the long-term health of a large and currently undertreated population of tobacco users.

	Acknowledgments

 
Supported by funds from Mayo Foundation, the Minnesota Partnership for Action Against Tobacco (DOW), and National Institutes of Health Grant R25 CA086421 (LCD).

The authors acknowledge Susanna Stevens for her excellent assistance with statistical analysis and Janet Beckman for her superb secretarial help.

	References

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Anesthesia & Analgesia® is published for the International Anesthesia Research Society® by Lippincott Williams & Wilkins with the assistance of Stanford University Libraries' HighWire Press®. Copyright 2006 by the International Anesthesia Research Society. Online ISSN: 1526-7598   Print ISSN: 0003-2999