Tobacco Use: What Anaesthetists Can Do About It.

Summarised by Ms Sz-Ying and Mr John Tsao. Medical Students, YLLSoM, NUS

Further Reading: David O. Warner; Anesthesiologists and the Other Pandemic: Tobacco Use. Anesthesiology 2022; 137:484–508

This article highlights the importance of multimodal perianaesthesia tobacco treatment for the management of tobacco use disorder.

1. Tobacco use disorder

a. What is it?

i. Tobacco use has a long history. Several developments in the early 20th century led to a marked increase in tobacco use in the USA, followed by the rest of the world. These included  technological advances in tobacco product design and manufacture, sophisticated marketing campaigns by tobacco companies, and the high addiction potential of nicotine. Criteria for Tobacco Use Disorder are well defined. They include an increasing use of tobacco, craving phenomenon, tolerance, and withdrawal symptoms. 

b. Pathophysiology

i. Nicotine’s strong addictive potential is caused by its agonist effect at nicotinic ACh receptors. Dopamine release leads to pleasure, elevated mood and stimulation. At the same time, desensitisation of these receptors lead to tolerance. Withdrawal occurs when the receptors are no longer stimulated by nicotine. The short half life of nicotine further increases it’s addictive potential.

ii. Nicotine feeds into the reward and reinforcement system in the brain. Overtime, neuroplastic changes develop, resulting in addiction and an inability to quit tobacco.

iii. When it comes to quitting, sustained exposure of the brain to nicotine makes this a difficult task. Only 1 in 20 unassissted attempts at quiting results in success. The number of previous attempts and motivation to quit are some of the factors that predict success. Those who quit spontaneously or unplanned tend to succeed more. 

Reference: David O'Warner. Anesthesiologists and the other pandemic: Tobacco use. Anesthesiology 2022

2. Emergance of E-cigarettes and pandemic

a. E-cigarrettes – are they safer?

i. E-cigarette use is increasing especially in young adults due to media rebranding and flavouring. They now play an important role in initiating ans sustaining nicotine use.

ii. E-cigarettes are potentially less harmful compared to conventional cigarettes. They have been studies for use in assissting smokers to quit tobacco perioperatively, but results are inconclusive.

iii. Studies have also shown potential adverse effects of E-cigarettes perioperatively. These include new onset asthma, increased cardiovascular risk & poor wound healing. 

3. Surgery – a powerful stimulus to quit tobacco

a. Among various moments of spontaneous quitting, receiving surgical procedure demonstrates increased long-term quit rate even without smoking cessation treatment, especially when the surgery is for a smoking-caused diseases. The psychophysiology of this is still unclear, but it is considered to be a ‘teachable moment’. These refer to health events that motivate a person to spontaneously adopt health changing behaviours without external intervention.

b. Smoking is a known perioperative risk factor contributing to perioperative and post-operative complications. Trials demonstrates that stopping smoking at any time before surgery and briefly post-operatively can reduce complications and healthcare cost.

c. In addition, evidence shows that patients would like to be advised on the risk of smoking before and after surgical procedures. This suggests an important role for anaesthesiologists to address quitting tobacco perioperatively.

Reference: David O'Warner. Anesthesiologists and the other pandemic: Tobacco use. Anesthesiology 2022

4. Multimodal perianaesthesia tobacco treatment and role of anaesthegiolosits

a. Similar to multimodal analgesia, tobacco treatment has four core components (documentation of tobacco use, advice to quit, access to nicotine replacement therapy or other pharmacotherapy and referral to counselling resources. The figure above from the article summarises this.

b. Evidences has shown successes in these methods especially when physicians are actively involved in the process.

c. Methods on how to start the conversation is explained in the article with various forms of tactics suggested. All put an emphasis on commitment.

5. Integrating perianaesthesia component to tobacco treatment

a. Tobacco treatment involves counseling and medication. Various medications and counselling strategies are discussed in the article, including the “5As” approach.

If you would like to be notified via email on updates and news surrounding SSA and other related conferences & workshops, please enter your details below.

Kindly provide your non-corporate email address if you suspect that you may not be able to view or access our newsletters due to your company’s firewall configuration

Your email will always remain private and confidential and will only be used for these conference updates.