Smoking - NYSORA

Explore NYSORA knowledge base for free:


Learning objectives

  • Describe the perioperative complications associated with smoking
  • Manage smoking patients scheduled for anesthesia


  • Cigarette smoking is one of the primary causes of preventable illness and premature death
  • Quitting smoking before surgery leads to a reduced incidence of postoperative complications
  • The longer the period of cessation before surgery, the greater the benefit

Perioperative complications associated with smoking

  • There is a clear dose-response relationship between the amount smoked and perioperative morbidity
  • Possible complications:
IntraoperativeReintubation after planned extubation
Hypoventilation and hypoxemia
PostoperativeIncreased mortality
Unplanned intubation
Mechanical ventilation
Cardiac arrest
Myocardial infarction
Superficial wound infection
Deep wound infection
Organ space infection
Septic shock


  • Education regarding the benefits of pre-operative smoking cessation when possible
  • Ideally, smoking is stopped 8 weeks before surgery
  • Stop smoking 24h before surgery to negate the effects of nicotine and COHb
  • Effects of smoking cessation:
    • Symptoms of cough and wheeze decrease within weeks
    • Mucociliary clearance starts to improve after a week 
    • Lung inflammation takes much longer to subside
    • Goblet cell hyperplasia regresses and alveolar macrophages decrease
    • Decrease in all-cause mortality in patients with coronary artery disease by approximately 33%
    • Risk of coronary heart disease and cerebrovascular disease approaches the risk of never-smokers within 10-15 years
  • Guidance
    • Patients who smoke are more likely to quit if they are offered a combination of interventions
    • Ask and record smoking history (pack-years)
    • Advise that the most effective way to quit is with a combination of medication and specialist support
  • Pharmacological aid
    • Nicotine replacement therapy (patches, lozenges, chewing gum, or nasal sprays.)
    • Oral bupropion 
    • Oral varenicline

Suggested reading

  • Carrick MA, Robson JM, Thomas C. Smoking and anaesthesia. BJA Educ. 2019;19(1):1-6.

We would love to hear from you. If you should detect any errors, email us