A Perioperative Smoking Cessation Intervention with Varenicline, Counseling, and Fax Referral to a Telephone Quitline Versus a Brief Intervention: A Randomized Controlled Trial
Anesthesia & Analgesia 2017;125(2):571-579 doi:10.1213/ANE.0000000000001894
Presented by Dr T. Sheppard
Background
- Smoking is addictive
- High health burden with smoking-related diseases (but also high tax revenue)
- Increased incidence of surgical complications associated with smoking
- Wound
- Pulmonary
- Infection
- Treatment with chemical & behavioural interventions is effective in reducing smoking in surgical patients – but has not been tested in a pre-op assessment clinic setting
- Varenicline (Champix®) is effective in increasing abstinence in both surgical & non-surgical patients
Design & Setting
- RCT
- Open label
- Prospective
- Pre-op assessment clinic with 6 anaesthetists and 1 pharmacist delivering BOTH interventions
Subjects
- Elective ambulatory and inpatient surgery
- Preoperative surgical clinics: general surgery, orthopaedics, urology, plastic surgery, vascular surgery, otolaryngology, ophthalmology, and neurosurgery
- Smokers of at least 10/day with no abstinence for 3 months in past year
- Equal proportions based on “Stage of Change” i.e. readiness to quit smoking
Exclusions:
- Patients with contraindications to varenicline (Champix®), pregnancy or breastfeeding, use of nicotine replacement therapy in last 3 months, use of tobacco products other than cigarettes
Intervention
Randomised to either;
A 10- to 15-minute structured preoperative counselling session
and
Pharmacotherapy with a free 3-month supply of varenicline
and
An educational pamphlet
and
A fax referral to a quitline for proactive telephone counselling and follow-up
or
Control group that received brief advice regarding smoking cessation and quitline information for self-referral
Outcomes
Primary
- 7-day point prevalence (PP) abstinence at 12 months after surgery
Secondary
- Abstinence at 1, 3, and 6 months
- Measurement of urinary cotinine (metabolite of nicotine) levels and expired-air carbon monoxide levels used to prove smoking cessation
Results
- 18-month period
- 296 patients randomised (8570 pts screened, 1024 smokers, 788 excluded)
- Significant increase in smoking abstinence in intervention group vs control (42.4% vs 26.2% (RR, 1.62; 95% CI, 1.16–2.25; P = .003))
- Significant increase in PP of secondary outcome measures;
- 1 month: 45.7% vs 25.5% (RR, 1.79; 95% CI, 1.29–2.49; P < .001)
- 3 months: 46.4% vs 26.9% (RR, 1.72; 95% CI, 1.25–2.37; P ≤ .001)
- 6 months: 45.0% vs 26.2% (RR, 1.72; 95% CI, 1.24–2.38; P < .001)
Conclusions
- Smoking abstinence significantly increased in intervention group and was also sustained for a longer period
- Increased nausea reported in the intervention group, but other complications were no different
- Significantly greater effect on in-patients than day-surgery
Strengths
- Significant reduction in short-term and long-term smoking habits
- Representative cohort of surgical patients
Weaknesses
- Observer bias – advice given by anaesthetists & pharmacist as opposed to independent researcher
- Details of surgery were not explored
- Malignancy
- Prolonged in-patient stay
- ITU stay
- Open label – significant reductions in smoking in both groups
- Multiple interventions in the intervention group
- Which part had the biggest impact?
- Free prescription of Champix® – would otherwise have to be paid for
Implications
- The smoking cessation methods on display in this trial were very effective
- Unclear what the potential for long-term outcomes would be compared with a “control” population re: wound healing, pulmonary complications
Potential for impact
- Some form of smoking cessation advice for surgical patients would likely lead to some reduction in smoking habits
- With the move to day-of-surgery-admissions it is difficult to find an appropriate time for discussion about smoking cessation
- Pre-op clinics themselves are extremely busy and with all the other important pieces of information, would smoking cessation be lost in a cloud of do’s and don’ts before surgery?
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