Version July 2025
INTRODUCTION —
Cigarette smoking is a risk factor for perioperative pulmonary, cardiovascular, bleeding, and wound healing complications. Limited evidence suggests that some risk may also be associated with "vaping" (ie, use of electronic cigarettes [e-cigarettes]) as a method for consumption of nicotine (or other substances such as cannabis).
This topic will discuss adverse effects of smoking or vaping on perioperative outcomes, and the role of anesthesia care providers together with other health care professionals in managing these risks.
Detailed discussions of the risks of smoking, the benefits of smoking cessation, and management strategies to achieve this goal are available in other topics:
●(See "Cardiovascular risk of smoking and benefits of smoking cessation".)
Further discussions of the risks of vaping nicotine or other substances using e-cigarettes, and management strategies to achieve vaping cessation are available in separate topics:
●(See "Vaping and e-cigarettes".)
●(See "E-cigarette or vaping product use-associated lung injury (EVALI)".)
●(See "Management of smoking and vaping cessation in adolescents".)
PERIOPERATIVE RISKS OF SMOKING
Cigarette smoking — Cigarette smoking harms surgical patients. Perioperative pulmonary, wound healing, cardiovascular, and other complications are more likely in patients who continue to smoke up until the time of surgery [1-4]. A 2014 meta-analysis found an increased risk of pulmonary complications (relative risk [RR] 1.73, 95% CI 1.35-2.23) and wound-related complications (RR 2.15, 95% CI 1.87-2.49) for patients who currently smoke, compared with those who do not [5]. A subsequent observational study of patients undergoing elective surgery also noted an association between surgical site infection and smoking (odds ratio [OR] 1.51, 95% CI 1.20-1.90), particularly if smoking occurred on the day of surgery (OR 1.96, 95% CI 1.23-3.13) [6]. Also, perioperative cardiovascular complications are more frequent in patients who smoke [1,2].
Furthermore, the surgery itself may be affected by smoking. A 2020 study of nearly 5.5 million cases in the American College of Surgeons National Surgical Quality Improvement Program database noted a higher risk for transfusion of blood products (OR 1.06, 95% CI 1.05-1.07) and need for reoperation (OR 1.28, 95% CI 1.27-1.31) in the 19 percent of patients who smoked compared with those who did not smoke [7].
Even exposure to secondhand smoke in nonsmoking patients is associated with adverse effects. In children exposed to secondhand smoke, the risk of airway complications such as laryngospasm is more than doubled [8]. In one study of 60 nonsmoking adults undergoing one-lung ventilation for lobectomy, those exposed to secondhand smoke had lower partial pressure of arterial oxygen and higher partial pressure of carbon dioxide compared to those not exposed [9]. Exposure to secondhand smoke was also associated with higher postoperative morphine consumption, and similar observations have been reported by others [9-11].
Detailed discussions of the adverse effects of smoking are available in other topics:
●(See "Cardiovascular risk of smoking and benefits of smoking cessation".)
Cannabis smoking — All surgical patients should receive routine perioperative screening for substance use, including cannabis or synthetic cannabinoids. There are potential pulmonary, cardiovascular, neuropsychiatric, and gastrointestinal adverse effects of smoking synthetic tetrahydrocannabinol (THC) products or cannabis (marijuana), which may affect anesthetic risk. Furthermore, co-use of cannabis and tobacco is associated with greater risk of adverse postoperative complications compared with use of cannabis alone [12].
Elective surgery should be delayed for patients who are acutely intoxicated. Management of elective surgery in chronic users or emergency surgery in an acutely intoxicated patient is discussed in a separate topic. (See "Anesthetic considerations for adults with substance use disorder or acute intoxication", section on 'Cannabinoids'.)
PERIOPERATIVE RISKS OF VAPING
Vaping nicotine — Electronic cigarette (e-cigarette) aerosols may harm surgical patients, although data are scant. Nicotine is the active ingredient in e-cigarettes, but the aerosolization process also produces other pharmacologically active compounds. Constituents of commonly vaporized liquids include a variety of preservatives, solubilizing agents, and flavors. Likely harmful compounds include propylene glycol, formaldehyde, acrolein, vegetable glycerin, aldehydes, carcinogenic nitrosamines, polycyclic aromatic, hydrocarbons, and heavy metals such as lead [13,14]. However, the identity and potential effects of each of these additives have not been thoroughly studied. (See "Vaping and e-cigarettes".)
A new type of device uses a different technology to heat-not-burn (HNB) tobacco leaf to produce a nicotine-containing aerosol. These newer devices expose users and bystanders to many of the same chemicals as tobacco smoke, but at substantially lower levels than conventional cigarettes [15]. HNB products are described in detail separately. (See "Patterns of tobacco use", section on 'Heated tobacco products'.)
Potential adverse perioperative effects of vaping nicotine and the various additive agents in e-cigarettes include:
●Pulmonary effects, including direct cytotoxic effects of electronic cigarette fluids, aerosols and solvents on lung cells [16], exacerbations of asthma, and increased lung inflammation [13].
●Cardiovascular effects, such as sympathetic activation and increased circulating catecholamines, vascular oxidative stress, inflammation, and thrombogenesis [17-20].
●Theoretical concern regarding wound healing. In two studies in rats, rates of necrosis of skin flaps were higher in those exposed to e-cigarette aerosol or conventional cigarette smoke, compared with unexposed rats [21,22]. There is scant evidence in humans suggesting that nicotine can increase risk of wound infections [23]. One propensity-matched retrospective analysis of patients undergoing shoulder arthroplasty noted higher rates of sepsis, surgical site infections, wound disruptions, readmissions, mechanical loosening of prostheses, and prosthetic joint infections in those using non-tobacco nicotine products such as e-cigarettes compared with those who were not exposed to nicotine [24].
Vaping other substances — Other products consumed via vaping include synthetic tetrahydrocannabinol (THC) products or cannabis (marijuana) (see "Anesthetic considerations for adults with substance use disorder or acute intoxication", section on 'Cannabinoids'), together with additive substances, such as the solvent vitamin E acetate [25-31]. Compared with inhaling nicotine, patients inhaling other substances are at greater risk for development of perioperative lung injury [31].
However, the potential for adverse effects has been highlighted by the onset of acute e-cigarette or vaping product use-associated lung injury (EVALI) in some patients in the United States [19,20,31-34]. Severity of symptoms and physiologic derangements can range from mild (not requiring hospitalization) to severe (requiring noninvasive ventilation, endotracheal intubation with mechanical ventilation, or extracorporeal membrane oxygenation [ECMO]) [31,35,36]. Although the cause is not completely understood, most cases are associated with vaping THC together with the additive vitamin E acetate. (See "E-cigarette or vaping product use-associated lung injury (EVALI)".)
TREATMENT OF SMOKING IN THE PERIOPERATIVE PERIOD
Rationale — There are two compelling reasons to help perioperative patients quit smoking.
First, randomized trials and meta-analyses suggest that tobacco treatment (also known as tobacco use intervention) in the perioperative period, including counseling and nicotine replacement therapy (NRT), is effective and reduces the risk of complications [37-39] (see "Evaluation of perioperative pulmonary risk"). A 2023 systematic review that included 38 trials with 7310 participants noted that perioperative tobacco treatment increased successful abstinence at the time of surgery (risk ratio [RR] 1.48, 95% CI 1.20-1.83) and 12 months after surgery (RR 1.62, 95% CI 1.29-2.03), compared with no intervention [37]. A 2014 meta-analysis that included 13 trials of perioperative tobacco treatment (2010 participants) noted a reduction in the incidence of any postoperative complication (RR 0.42, 95% CI 0.27-0.65), as well as the incidence of wound-related complications (RR 0.31, 95% CI 0.16-0.62), compared with no treatment [39].
Second, the perioperative period provide a “teachable moment” for interventions to achieve smoking cessation. Even in the absence of a perioperative treatment intervention, patients are more likely to succeed if they attempt to quit smoking in the perioperative period before and/or after a surgical procedure [40]. For example, even having a relatively minor outpatient surgery increases the chances of successful quitting by about 30 percent. Interventions can leverage this “teachable moment” so that even more patients will quit for good, which can have lasting health benefits [41-43].
Timing of interventions — There is likely at least some benefit from smoking cessation of any duration prior to surgery, so all patients who smoke should be advised to quit throughout the pre-operative period. Abstinence engenders cumulative physiologic benefits during recovery from the effects of smoking and leads to reduced risks of several perioperative complications [1,42]. We agree with the recommendations of the Society of Perioperative Assessment and Quality Improvement (SPAQI) regarding the benefits of early and frequent preoperative smoking counseling [3]. (See 'Perioperative risks of smoking' above.)
The duration of abstinence necessary to achieve perioperative benefit is not known. A 2011 meta-analysis of observational studies noted that the longer the period of abstinence, the greater the reduction in risk for complications [44]. Although patients should quit for as long as possible before the date of surgery, limited data suggest that even brief preoperative abstinence (such as not smoking the morning of surgery) may have benefits [3]. For example, in one study in patients undergoing vascular surgery, abstinence shortly before surgery resulted in lower levels of exhaled carbon monoxide and fewer episodes of cardiac ischemia related to increased heart rate and blood pressure compared with those who smoked on the morning of surgery [45]. In an observational study of patients using cigarettes before elective surgery, the risk of a surgical site infection nearly doubled for patients who smoked on the day of surgery compared with those who did not smoke on that day (odds ratio [OR] 1.96, 95% CI 1.23-3.13; 6919 patients) [6].
Components of tobacco treatment
●Standard components – We agree with guidelines from the United States Public Health Service for tobacco treatment in healthcare settings, which state that patients who smoke should receive treatment that includes both counseling and pharmacotherapy [46].
●Counseling – Counseling (either in-person or remote) can range from brief discussions with physicians to multiple sessions provided by trained tobacco treatment specialists (see "Behavioral approaches to smoking cessation"). For practices in the United States without access to such specialists, the National Cancer Institute sponsors a single toll-free number (1-800-QUITNOW) that provides free state-sponsored “quit-line” telephone counseling services. Similar services are available in many other countries. Web-based counseling resources are also available (see Quit For Surgery for listing).
●Pharmacotherapy – Pharmacotherapy significantly increases the chances of successful quitting. The most popular US Food and Drug Administration (FDA)-approved medications include various formulations of NRT (with patches, gum, and lozenges available without prescriptions) and varenicline, which acts as a partial agonist at the alpha-4 beta-2 nicotinic receptor, blocking nicotine from binding to the receptor and interrupting the reinforcing effects of nicotine that lead to nicotine dependence. Notably, evidence does not support an older concern that NRT could theoretically impair wound healing due to vasoconstriction. Surgical patients using NRT to maintain abstinence from tobacco do not have increased risk for wound-related or other perioperative complications [23,47,48]. Thus, the preponderance of available evidence shows that NRT is safe to use in surgical patients. (See "Pharmacotherapy for smoking cessation in adults".)
Typically, strategies that combine counseling and pharmacotherapy are employed, and evidence shows that they are effective [49]. In one study, a perioperative smoking cessation intervention included varenicline, one counseling session, and provider referral to a quit-line; this was implemented in the preoperative clinic between 7 and 60 days before elective surgery [50]. In this study, abstinence increased by 62 percent compared with brief counseling and self-referral to a quit-line. In another example, a preoperative intervention consisting of a brief (less than five minutes) counseling session by a trained preadmission nurse, stop-smoking brochures, referral to a telephone counseling service, and a free six-week supply of nicotine patches increased both short-term (30 day) abstinence (RR 4.0, 95% CI 1.2-13.7) and long-term (one year) abstinence (RR 3.0, 95% CI 1.2-7.8) [51,52].
●Use of e-cigarettes – E-cigarettes have been explored to help patients quit smoking, with limited evidence suggesting that counseling the use of e-cigarettes may reduce or eliminate exposure to tobacco smoking in the perioperative period [53-57]. However, unless the alternative is relapse to smoking conventional cigarettes, we do not recommend e-cigarettes as a form of NRT in the perioperative period due to the potential deleterious effects of e-cigarette aerosol (see 'Perioperative risks of vaping' above and "E-cigarette or vaping product use-associated lung injury (EVALI)"). The efficacy and safety of other tobacco treatment interventions are supported by evidence. (See "Overview of smoking cessation management in adults".)
Our approach to perioperative tobacco treatment — Our approach to treating surgical patients who smoke can be summarized as "Ask, Advise, and Refer" [3,58] (see "Overview of smoking cessation management in adults"):
●Ask – All surgical patients should be asked whether they smoke (or use electronic cigarettes [e-cigarettes]), even if their tobacco status has already been documented in the health record [46]. Asking this question confirms the accuracy of previously recorded information and reinforces the message that tobacco use incurs some risk during and after surgery.
●Advise – All patients should be strongly advised to quit smoking for as long as possible before and after surgery, and that this will help them achieve the best possible outcome after their surgery [41]. Patients who do not want to quit in the long term can be advised to at least "quit for a bit" (ie, abstain from smoking from at least the morning of surgery until one week after surgery) [59]. Patients who are unwilling to "quit for a bit" should be advised to avoid smoking on the morning of surgery. This advice is particularly effective when delivered in person by the surgeon, anesthesia provider, or primary care provider.
●Refer – All patients should be referred to available resources to help them quit, which may include [3,41]:
•Online resources (see Quit For Surgery for listing) [60].
•In-person tobacco treatment services. (See "Behavioral approaches to smoking cessation" and "Overview of smoking cessation management in adults" and "Pharmacotherapy for smoking cessation in adults".)
•Telephone counseling ("quit-lines") that provide ongoing support available in the United States via a single toll-free telephone number (1-800-QUIT-NOW) [61].
The main challenge for the treatment of tobacco use in surgical patients who smoke is not a lack of effective interventions, but rather the practical difficulties of consistently applying these interventions in busy perioperative practices. Principles of implementation science can guide efforts to incorporate tobacco treatment as a routine part of surgical care, although widespread implementation of such efforts is challenging [62].
We agree with the concept of “multimodal perianesthesia tobacco treatment,” which includes four main components, and is most effective when all four are combined [41]:
●Consistent ascertainment and documentation of tobacco use
●Advice to quit provided by anesthesia providers and other clinicians
●Pharmacotherapy
●Referral to counseling
Institutional programs — Examples of institutional efforts to provide such an integrated systematic approach to perioperative tobacco treatment include [3,41,59,63,64]:
●Ensuring that screening and documentation of patients' smoking status are consistently implemented in preoperative clinic settings, and are supported by current electronic medical record (EMR) systems
●Educating surgeons, anesthesia providers, and other personnel who provide perioperative care about how best to provide advice and assistance
●Creating robust decision-support systems such as decision aids to support clinician advice and assistance in the preoperative clinic
●Implementing EMR-based systems to easily refer patients to services that provide counseling and pharmacotherapy
●Supplying material regarding how to quit smoking in patient preoperative education programs (eg, patient portal messages, telehealth visits)
●Measuring the delivery and results of tobacco treatments including clinic screening rates, referral rates to smoking cessation programs, pharmacotherapy prescriptions, quit rates on the morning of surgery, and postoperative abstinence
These and other options can be customized to the needs of an institution or a surgical practice. For example, one pilot program that included 276 patients in a surgical practice established a screening system to consistently ascertain tobacco use, and also trained surgeons to provide brief counseling (facilitated by a decision aid) and ensure referral to counseling services [63]. This intervention required less than five minutes. Referral rates to counseling increased from 3 to 28 percent, actual counseling increased from 5 to 12 percent, and continuous abstinence at 30 postoperative days increased from 18 to 39 percent [63].
In the United States, tobacco treatment for surgical patients is reimbursed by Medicare and Medicaid, as well as most private insurers (separately from anesthesia services) [41]. The outcome of perioperative tobacco treatment (eg, abstinence on the morning of surgery) is also a nationally recognized quality measure.
TREATMENT OF VAPING IN THE PERIOPERATIVE PERIOD —
Similar to asking all surgical patients whether they smoke tobacco, all patients should also be asked whether they use e-cigarettes (ie, whether they vape) [65]. It is also important to ask adolescent surgical patients about their use of these devices since about 8 percent of high school students report current use of e-cigarettes [66,67]. Even though nicotine-containing e-cigarettes are classified as tobacco products, many patients do not realize this. Although there are many different terms used to describe these devices, most patients of all ages will recognize the terms "electronic cigarettes" or "vape." (See "Vaping and e-cigarettes".)
Those who indicate that they use e-cigarettes or vape should be asked specifically what substances they vape, with the question best phrased as "nicotine or something else" [68]. It is important to make this distinction because those inhaling substances other than nicotine (eg, delta-9 tetrahydrocannabinol [THC] products) may be at greater risk for the development of perioperative lung injury [31]. Notably, there is an ever-changing variety of products that can be vaped, and systems are used by individuals to "mix their own" vaping liquid. (See 'Perioperative risks of vaping' above and "E-cigarette or vaping product use-associated lung injury (EVALI)".)
Although specific perioperative effects of various types of e-cigarette aerosol are largely unknown, we use the following approach for patients who vape:
●Counseling with the explanation that although the effects of vaping on perioperative complications are unclear, there are reasons for concern regarding short-term and long-term effects [25,54,69-72]. Thus, we advise patients to abstain from vaping for as long as possible before and after surgery, similar to abstaining from conventional cigarette smoking. This recommendation is particularly strong for those who vape substances other than nicotine. The only exception to this advice would be for patients who depend on e-cigarettes to maintain abstinence from conventional cigarettes and who may relapse if not vaping. . Eventual cessation of all tobacco products, including e-cigarettes, is recommended. (See "Vaping and e-cigarettes".)
●Similar to patients who smoke, patients who vape should be referred to resources that can aid with abstinence. (See 'Treatment of smoking in the perioperative period' above and "Management of smoking and vaping cessation in adolescents".)
SOCIETY GUIDELINE LINKS —
Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Smoking cessation, e-cigarettes, and tobacco control".)
SUMMARY AND RECOMMENDATIONS
●Perioperative risks of smoking
•Cigarette smoking – Cigarette smoking increases the risk of perioperative pulmonary, cardiovascular, and wound healing (eg, surgical site infection) complications. (See 'Cigarette smoking' above.)
•Cannabis smoking – Potential adverse perioperative effects of smoking synthetic tetrahydrocannabinol (THC) products or cannabis (marijuana) include pulmonary, cardiovascular neuropsychiatric, and gastrointestinal effects. (See 'Cannabis smoking' above.)
●Perioperative risks of vaping – Vaping nicotine and the various additive agents in electronic cigarettes (e-cigarettes) such as THC or the solvent vitamin E acetate has potential adverse pulmonary, cardiovascular, and wound-related effects. (See 'Vaping nicotine' above and 'Vaping other substances' above.)
In some cases, vaping may cause acute e-cigarette or vaping product use-associated lung injury (EVALI), with severity ranging from mild (not requiring hospitalization) to severe (requiring noninvasive ventilation or endotracheal intubation with mechanical ventilation), as discussed in a separate topic. (See "E-cigarette or vaping product use-associated lung injury (EVALI)".)
●Treatment of smoking in the perioperative period
•Rationale – Quitting smoking reduces perioperative risks, and tobacco treatment interventions for surgical patients who smoke reduce complication rates and increase the rates of long-term postoperative abstinence. (See 'Rationale' above.)
•Timing of interventions – Although patients should quit for as long as possible before the date of surgery (ideally more than four weeks preoperatively), even brief preoperative abstinence (such as not smoking the morning of surgery) may have benefits. (See 'Timing of interventions' above.)
•Components of tobacco treatment – Treatment should include both pharmacotherapy (eg, nicotine replacement therapy [NRT] or varenicline) and counseling (either in-person or remote). Pharmacotherapy, including NRT, is safe and effective in the perioperative period. (See 'Components of tobacco treatment' above and "Overview of smoking cessation management in adults", section on 'Combined behavioral treatment and pharmacotherapy preferred'.)
•Our approach – Clinicians evaluating perioperative patients should “Ask, Advise, and Refer” (see 'Our approach to perioperative tobacco treatment' above):
-Ask every patient about tobacco use and document their use.
-Advise every patient who uses tobacco to quit smoking for as long as possible before and after surgery.
-Refer patients to available tobacco treatment resources, such as tobacco treatment services and telephone counseling (1-800-QUITNOW).
We agree with the concept of “multimodal perianesthesia tobacco treatment,” which includes:
-Consistent ascertainment and documentation of tobacco use
-Advice to quit provided by anesthesia providers and other clinicians
-Pharmacotherapy
-Referral to counseling
•Institutional programs – Examples of institutional efforts to provide such an integrated systematic approach to perioperative tobacco treatment include (see 'Institutional programs' above):
-Ensuring that screening and documentation of patients' smoking status are consistently implemented in preoperative clinic settings, and supported by current electronic medical record (EMR) systems
-Educating surgeons, anesthesia providers, and other perioperative personnel about providing advice and assistance
-Using decision-support systems such as decision aids
-Implementing EMR-based systems to easily refer patients to services that provide counseling and pharmacotherapy
-Supplying material for preoperative education programs (eg, patient portal messages, telehealth visits)
-Measuring the delivery and results of tobacco treatments including clinic screening rates, referral rates to tobacco treatment programs, pharmacotherapy prescriptions, quit rates on the morning of surgery, and postoperative abstinence
•Treatment of vaping in the perioperative period – All patients should also be asked whether they use e-cigarettes or vape, and what specific substances they vape. Similar to smoking conventional cigarettes, we advise patients to quit vaping nicotine and other substances for as long as possible before and after a surgical procedure. Counseling and referral to resources promoting abstinence are offered. (See 'Treatment of vaping in the perioperative period' above.)
