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So who are the cigarette smokers in the United States?
According to United States Center for Disease Control, smoking is the leading cause of preventable death in the United States. It is responsible for 1 in 5 preventable deaths every year.
It is estimated that 34.3 million adults in the United States currently smoke cigarettes, with at least 16 million US residents suffering from illnesses that result from tobacco use. Increase in health education and publicizing of negative effects of smoking has gradually decreased the number of people engaging in smoking tobacco by at least 5% over last 10 years.
Statistically, men of age 25-64 tend to engage in smoking more frequently than other age groups and definitely overall more than women tend to do. While almost every ethnic group has individuals that smoke, people of Asian ethnicity tend to smoke the least. People from Native American and Native Alaskan back ground tend engage in tobacco smoking behavior the most. Extent of formal education seems to have at least some correlation with smoking.
Only 4% of people with graduate degree tend to smoke tobacco.
37% of people who did not pursue education beyond obtaining GED use cigarettes.
Interestingly, those who are married tend to use cigarettes less than who are divorced, single, or separated.[1]
Should you really stop smoking before foot and ankle surgery?
However, when someone undergoes surgery, they sustain what is called “controlled trauma”. Traumatic state requires greater number of resources to undergo repair. If you are a smoker, you body will not be able to deliver enough oxygen and nutrients to achieve the repair, so your recovery may be significantly longer than expected. In fact, I like to describe what happens in terms of traffic.
Do people know what tobacco actually does to their bodies?
Because of significant education, people are generally aware of the link between tobacco use and cancer. Unfortunately, there is very little knowledge in regards to cigarette smoking impact on bone healing, wound healing, and cardiovascular system.
In addition to carcinogenic agents/cancer producing agents in tobacco smoke, cigarette use causes addiction to nicotine, which is one of the most difficult substances to quit. It also causes temporary narrowing of blood vessels and results in decrease in oxygen and nutrient delivery. This temporary decrease can be compensated by a healthy body.
Let’s pretend that there was an earthquake and a building partly collapsed. Now the landlord must call various contractors to bring in supplies to achieve repair. He must also bring in the workers to use the supplies. This, of course, will produce significant traffic around the construction site. Think of redness, swelling, and pain a person has after an injury. The body will experience increased demand for oxygen, nutrients, minerals, immune and repairs cells creating to significant traffic in the supplying blood vessels. Blood vessels are the freeways of the body! Now, if one decides to smoke a cigarette after surgery, this person will create significant traffic in the blood flow and will slow down the healing. This relates to all tissues including skin, tendon, muscle, bone etc.
In addition to narrowing blood vessels, nicotine makes platelets stickier than usual, which may result in blood clot formation. Platelets are repair molecules of the body and are usually the first cells to arrive at injury site to start the repair process.
Carbon monoxide in the cigarette smoke makes hemoglobin (oxygen transporter of the blood) carry oxygen more loosely. This results in less oxygen being delivered to the injury site. In addition, inflammation produced by smoking results in problems in the development and function of various aspects of the immune system that are responsible for combating infecting bacteria and viruses!
Smoking one cigarette will result in body tissue experiencing low oxygen state for almost one whole hour!
In addition, smoking predisposes you to Anesthesia related problems and post-operative respiratory system infections like pneumonia.
When broken bones do not heal…
There is evidence that bone health is severely affected by tobacco use including increased chance for fracture due to low mineral density, poor fracture healing due to low mineral density and poor blood supply to bone, bone disappearance around the orthopedic implants resulting in implant (screw/plate/prosthesis) loosening and failure. Smoking effects bone healing not only on anatomic level but also on the genetic level with decrease in manufacturing of proteins responsible for new bone formation.
In fact, orthopedic surgeries requiring fusion of joints have almost 3 times the rate of not fusing! This means that you will have longer recovery period requiring extended time off work, inability to use operated limb for prolonged period of time, and prolonged pain. You may need a more complex re-operation, may need to use a bone growth stimulator, may need to have hardware removed from the foot and ankle and more involved hardware placed which in turn will predispose you to the risk of infection.
Tendon health is compromised as well, as tobacco users tend to have thinner and weaker tendons which predisposes them to injury and potentially rupture.
How do doctors check if the patient quit smoking?
This is done by ordering a urine or blood cotinine test. Cotinine in a break down product of nicotine. Another test checks for anabasin. Anabasin is biomarker of tobacco. If the patient truly quits smoking, these tests should show normal results within 2 weeks.
If the doctor need to see a more recent(24-48 hours) exposure to nicotine smoke, exhaled carbon monoxide test can be ordered.
Cigarette users experience post-surgical pain differently
Of note, smokers who undergo surgery tend to experience pain differently. In fact, their experience of pain is greater and their satisfaction with surgical outcome tends to be worse as compared with non-smokers undergoing same procedures. Cigarette users tend to need more pain medication after surgery and also end up needing to use pain medication for a prolonged period of time into recovery.
Some studies indicate that reported post-surgical pain may last up to 3 months or more.
Researchers attribute this hypersensitivity to pain to greater number of inflammatory cells present in smokers.
When the cut just refuses to heal
Any surgical procedure involves cutting of the skin. Even a stab incision or minimally invasive procedure creates this skin defect that must be healed. Just as with bone healing, skin healing is significantly delayed by poor oxygen delivery, blood vessel narrowing and blood vessel clotting occurring around the surgical cut. Smokers are 4 times more likely to develop poor circulation to feet as compared with non-smokers. If circulation deficits become severe, surgical intervention will be required to open up the blood vessels from the inside or by undergoing vascular bypass. If corrective vascular surgery becomes impossible, severe pain due to oxygen and nutrient deficit will result and gangrene will ensue.
Smokers have 10-15% greater chance of developing a skin healing complication such as infection when undergoing foot and ankle surgery. This can involve superficial infections (can be treated with antibiotics alone and wound care) and deep infections that require surgery.
Is quitting tobacco worth it?
The answer is a resounding Yes!
In fact, studies showed that quitting prior to turning 40 years of age decreases the chance of dying from tobacco induced damage by as much as 90%.
One can start seeing earliest signs of reversal of tobacco damage within 8 hours of quitting.
Smokers can decrease the chance of an infection by at least 20% by quitting tobacco 4 weeks before surgery and continuing to stay away from tobacco for at least 4 weeks after surgery. However, the risk of developing a slow healing wound continues to be high even in people who quit smoking even as long as 3 months prior to surgery.
Tobacco use has a serious and potential lifelong effect on bone healing and health. In fact, one study found that it took 10 years to reduce the risk of bone fractures by 50%.
The risk of fracture continued to improve but did not fully resolve for a
total of 30 years!
How successful are smoking cessation techniques?
-people who try to quit on their own have 7% success rate
-smokers who use special technique achieve 30% success rate
-it takes an average of 6 years and almost 8 tries to those who succeed in quitting
There are several non-pharmacological and pharmacological modalities available for smoking cessation.
Scientific literature review showed that Chantix [4] is the most effective medication available to assist with smoking cessation at this time. Those who use it as 3 times more likely to spot smoking as compared with those exposed to placebo. It works by diminishing tobacco disuse withdrawal symptoms. Some of the common side effects of this medication is sleep abnormalities, insomnia, abnormal vivid dreams, and nausea.
E-cigarettes, vaporizers, or other nicotine delivery system substitutes have not been proved to help significantly with smoking cessation.
Benefits of using E-cigs is a decrease in nicotine consumption when compared to standard cigarette. They also have less carcinogens and toxic gases described previously in this blog. However, these still have nicotine and thus produce same negative side effects associated with its use.
In fact, e-cigarette users were compared to those on nicotine patch and outcomes were very similar. One study showed that only 20% of patch users successfully quit prior to surgery as compared to 15% of e-cigarette users. After surgery, these rates went up to 30% for patch and 25% for e-cigarette users.[2]
Resources
Center for Disease Control and Prevention offers a fairly comprehensive list of
resources[3] that can be helpful in finding a path to smoking cessation:
1. Tips from Former smokers
2. Coaching material, quit plans, resources local to where you live
3. Resources in Spanish language
4. Organizations that not only help you quit but also help you stay tobacco free
5. Assistance specific to women smokers
6. Teen specific tobacco cessation resources
7. Text and smartphone applications that can help
8. Resources for military families
9. Education resources on harms of smoking from National Cancer institute
Big points:
Nicotine in itself is extremely damaging and addicting. Further damage to bone, skin, immune and circulation system is done when nicotine is combined with toxic gases and cancer producing agents of cigarette smoking.
Patients undergoing surgery can almost expect complications! These complications can be reduced by quitting smoking and staying tobacco free into the recovery phase of post-surgical healing. The effects of tobacco linger for decades even in those who quit smoking.
Your best bet is to never start or to quit as soon as you can! Remember, it takes smokers an average of 7 tries before they successfully quit!
Seek help, strive to do better, TODAY is the day you can have a fresh start!
Until next time….happy moving!
[1]https://www.cdc.gov/tobacco/data_statistics/fact_sheets/adult_data/cig_smoking/index.htm
[2] Smoking Effects in Foot and Ankle Surgery: An Evidence-Based Review.
Beahrs TR, Reagan J, Bettin CC, Grear BJ, Murphy GA, Richardson DR. (Beahrs, et al.,2019) Foot Ankle Int. 2019 Oct;40(10):1226-1232.
[3] https://www.cdc.gov/tobacco/quit_smoking/how_to_quit/resources/index.htm
My name is Dr. Marat Kazak. I have been working as a professional Podiatrist serving Northern California community since 2014. My extensive medical and surgical knowledge combined with an ongoing curiosity to learn about the latest trends define my success in the field of foot, ankle and leg medical and surgical care.
The goal of this website is to give you the tools to better care for yourself, to dispel medical myths, and to empower you with information to save time and money! If you are looking for an answer on foot and ankle pain, this is the place to find it. If you do not see your topic of interest covered, please send me a message and I will do my best to discuss it thoroughly in my next upcoming post.
Visit this blog often to learn about latest developments, treatments, and approaches to healing and recovery!