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Invited Critique
Apr 2012

Kicking Society's Tobacco HabitComment on “The Clinical Effect of Smoking and Smoking Cessation on Wound Healing and Infection in Surgery”

Author Affiliations

Author Affiliation: Institute for Clinical Outcomes Research and Education, St Vincent's University Hospital, Dublin, Ireland.

Arch Surg. 2012;147(4):383. doi:10.1001/archsurg.2012.43

An astonishing 1 in 5 US adults are current smokers (≥100 lifetime cigarettes and regular consumption).1 Although this figure has declined a little recently, the overhanging health issues will persist for some time. The current findings of adverse effects on surgical site infections and reparative processes are less surprising.2 However, can we confidently determine inhaled tobacco smoke as an isolated risk factor with the current study design? There are far too many covariables to digest. Smokers tend to be in lower socioeconomic groups, be more sedentary, drink more alcohol, and have more comorbidities than current nonsmokers (ex-smokers) and never (life-long tobacco-free) smokers. The inadequate power of the studies, the well-recognized inaccuracy with which patients report their smoking habits, and the haziness of wound-healing definition (eg, rate of healing, time to complete closure, patient satisfaction, self-assessed or surgical scores?) are prohibitive impediments to present data interpretation and the call for future trials.

A more pragmatic position for the surgical community to maintain is a consistent antitobacco attitude, encouraging and strongly recommending cessation (whether or not it is in advance of an operation). This moral imperative helps reduce direct and related health care costs and so benefits the patient and society as a whole. Sustained comprehensive tobacco control programs that include patient information, support programs, health warnings, media campaigns, and smoke-free policies work. California, Washington, Maine, and New York saw their smoking prevalence fall by 40% or more in the past decade by implementing these programs. The question is not at what cost this is achieved. Federal and state government must support health care reform that embraces tobacco control or risk being the butt of society's smoke.

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Article Information

Correspondence: Dr Winter, Institute for Clinical Outcomes Research and Education, St Vincent's University Hospital, Elm Park, Dublin 00004, Ireland (des.winter@gmail.com).

Financial Disclosure: None reported.

Centers for Disease Control and Prevention.  Smoking & tobacco use. http://www.cdc.gov/tobacco. Accessed November 30, 2011
Sørensen LT. Wound healing and infection in surgery: the clinical impact of smoking and smoking cessation: a systematic review and meta-analysis.  Arch Surg. 2012;147(4):srv120001373-383Article