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Patient Perceptions and
Willingness to Stop Smoking
Prior to Foot and Ankle
Surgery
Adam Baker MD, Susan N. Ishikawa MD, G. Andrew Murphy MD, Benjamin J. Grear MD, David R. Richardson MD, Erin Dean MD
University of Tennessee-Campbell Clinic Department of Orthopaedic Surgery & Biomedical Engineering
Memphis, Tennessee
Disclosures Title
Patient Perceptions and Willingness to Stop Smoking Prior to Foot and Ankle
Surgery
Authors
Adam Baker MD, Susan N. Ishikawa MD, G. Andrew Murphy MD, Benjamin J. Grear
MD, David R. Richardson MD, Erin Dean MD
Authors have no conflicts of interest to disclose.
No funds were received in support of this study.
Disclosures are in the Final AOFAS Mobile App
Background F&A Risk Estimated 1.3 billion
smokers in the world1
Approx. 42.1 million in the
US (18% of population)2
Leading cause of
preventable death in the
US3
Much of population is
unaware of the effects
smoking has on
cardiovascular health4
Even fewer are aware of
effects on bone healing and
wound healing5
Smokers 6 times more likely to develop infection after foot and ankle surgery6
Bone healing delayed after bunion surgery in smokers7
Risk of developing nonunion 3 times higher in smokers undergoing hindfoot fusions8
Smoking Cessation Meta-analysis consisting of RCT found that preoperative
smoking cessation reduced risk of complications by 41%12
Difficult – only 4% to 7% of smokers able to quit without
medication or other help9
Relapse at 6 months ~ 80%10
Nicotine replacements and other medications can increase
quit rate to 25%9
Addition of smoking cessation aids with doctor’s advice
increases likelihood of success (self-help hotline, internet
resources, and access to NRT)11
Study Goals
Determine patient awareness of smoking’s effects on
orthopaedics
Determine patient willingness to quit smoking before
foot/ ankle surgery
Methods
Over a 6-month period, new foot/ankle patients who
reported cigarette usage were given a short, 5-
question survey
Prior to the survey, a brief explanation of the
deleterious effects of smoking on bone, soft-tissue,
and wound healing was given
Additional information was gathered on years of
smoking and number of cigarettes smoked per day
Survey 1. Prior to reading this information, were you aware that
smoking can slow bone and soft-tissue healing and can
lead to poorer results?
2. Knowing this information, are you more likely to attempt to
stop smoking to aid in the healing of your foot or ankle
condition?
3. If surgery is not required for your condition, would you be
agreeable to a supervised smoking cessation program?
4. If surgery is indicated for your condition, would you be
agreeable to starting a supervised smoking cessation
program before surgery?
5. Would you be willing to undergo a smoking cessation
program if you knew that your surgery would be postponed
until you did?
Results 1. Prior to reading this information, were you aware that smoking
can slow bone and soft-tissue healing and can lead to poorer
results?
44% (104/237) were unaware of the effects of smoking on
bone and wound healing
2. Knowing this information, are you more likely to attempt to stop
smoking to aid in the healing of your foot or ankle condition?
82% (195/237) more likely to participate in a supervised
smoking cessation program after receiving this information
Results
3. If surgery is not required for your condition, would you be
agreeable to a supervised smoking cessation program?
64% (124/195) interested in smoking cessation even if surgery
not required
4. If surgery is indicated for your condition, would you be
agreeable to starting a supervised smoking cessation program
before surgery.
86% (168/195) interested in smoking cessation if surgery
required
5. Would you be willing to undergo a smoking cessation program if
you knew that your surgery would be postponed until you did?
96% (188/195) interested in smoking cessation if surgery would
be delayed until they stopped smoking
Results 237 patients completed the survey
Average cigarettes smoked per day -- 14 (1-50)
Average years smoked -- 22 (0.4 – 60)
18% (42/237) of the patients indicated that they were not interested in smoking cessation
Limitations No follow-up to determine if smoking education was effective in changing future behavior
No demographics collected so the surveyed population may not accurately represent the average patient population
Prior orthopedics visits and smoking cessation teaching unknown
Conclusions Nearly half of foot and ankle patients were unaware of
the effects of smoking on soft-tissue and bone healing
Most expressed interest in being involved in a
supervised smoking cessation program when they
learned of these effects
Short discussion, cessation hotline, and referral to
primary care provider takes little time and could have
significant positive effects
References 1. Wipfli H, Samet JM. Global economic and health benefits of tobacco control: part 1. Clin Pharmacol Ther.
2009 Sep;86(3):263-71.
2. Centers for Disease Control and Prevention. Current Cigarette Smoking Among Adults—united states, 2005-2012. Morbidity and Mortality Weekly Report 2014; 63(02):29-34.
3. U.S. Department of Health and Human Services. The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014
4. World Health Federation. Cardiovascular harms from tobacco use and secondhand smoke global gaps in awareness and implications for action. 2012. http://www.world-heart-federation.org/
5. Walker NM, Morris SA, Cannon LB. The Effect of preoperative counseling on smoking patterns in patients undergoing forefoot surgery. Foot Ankle Surg. 2009;15(2):86-9.
6. Nasell H, Ottosson C, Tornqvist H, Linde J, Ponzer S: The impact of smoking on complications after operatively treated ankle fractures: A follow-up study of 906 patients. J Orthop Trauma. 2011 Dec;25(12):748-55
7. Krannitz KW, Fong HW, Fallat LM, Kisk J. The effect of cigarette smoking on radiographic bone healing after elective foot surgery. J Foot Ankle Surg. 2009 Sep-Oct;48(5):525-7.
8. Ishikawa S, Murphy A, richardson G. The effect of cigarette smoking on hindfoot fusions. Foot Ankle Int. 2002 Nov;23(11):996-8
9. Guide to Quitting Smoking. American Cancer Society. www.cancer.org
10. Zhou X, Nonnemaker J. Attempts to quit smoking and relapse: Factors associated with success or failure from the ATTEMPT cohort study. Addict Behav. 2009 Apr;34(4):365-73.
11. Wolfenden L. Wiggers J, Knight J, Campbell E, Spigelman A, Kerridge R, Moore K. Increasing smoking cessation care in a preoperative clinic: a randomized controlled trial. Prev Med. 2005 Jul;41(1):284-90
12. Mills E, Eyawo O, Lockhart I, Kelly S, Wu P, Ebbert JO. Smoking cessation reduces postoperative complications: a systematic review and meta-analysis. Am J Med. 2011 Feb;124(2):144-154.
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