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.