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?