Over the past 50 years or so, cigarette smoking has transformed from a widespread practice into an isolated activity: Just 14% of American adults reported smoking cigarettes in 2019 compared to over 40% in 1965.

Yet certain segments of the population still smoke at higher rates, including one surprising group: those undergoing surgery, according to a recent study in JAMA Network Open.

A retrospective analysis of 328,578 Michigan residents who had a common surgical procedure done from 2012 to 2019 found that almost a quarter of them smoked in the previous 12 months, despite the presence of tobacco cessation programs across the state.

Among people who underwent general and vascular surgical procedures such as appendectomies and hysterectomies, certain demographic groups smoked more, including men, adults younger than 45, and those who identified as American Indian or Alaskan Native. Patients in the study's sample with chronic obstructive pulmonary disease also tended to smoke cigarettes, which are, in fact, the leading cause of COPD in the United States.

Across all characteristics studied, though, the proportion of smokers was highest among people enrolled in Medicaid and those who did not have health insurance.

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"We thought this was really important because these are patients with limited access to care who may not have the ability to go to regular health exams or to get smoking cessation help," says Ryan Howard, M.D., a general surgery resident at Michigan Medicine and first author of the study. "A major surgical episode may represent their most significant interaction with the health care system."

Why surgery is a good time to quit

Cigarette smoking is linked to myriad health problems, including lung and heart disease, strokes, cancer, vascular issues, and even hernias — all of which may require surgery to address. Smoking remains the most preventable cause of death in America. Yet kicking the habit isn't easy; a 2015 survey commissioned by the FDA showed that almost three-quarters of adult smokers nationwide wanted to quit, but only 7% had done so for at least six to 12 months.

However, evidence suggests that surgical consultations might be an opportune time for providers to help smokers kick their habit, partly because these interactions are considered "teachable moments."

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"Teachable moments are these times in a person's life where for one reason or another, they're more receptive to spontaneously improving their health," says Howard, who's also a health services research fellow at the University of Michigan's Center for Healthcare Outcomes and Policy. "Some examples include if someone is diagnosed with a new cancer or a chronic illness like diabetes — or if they need surgery."

"There's this natural motivation that patients have going through such a big event to heal well and recover well," he adds. "If, as providers, we can leverage that motivation, it could be really powerful."

How to quit

Plans are already in motion to do just that. Because this study relied on data from the Michigan Surgical Quality Collaborative, a group funded by Blue Cross Blue Shield of Michigan that works to improve patient care and lower costs at 70 Michigan hospitals, the collaborative is able to leverage its results to design interventions that surgeons across the state can use to help their patients stop smoking.

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One possible solution is smoking-specific "prehabilitation," which involves efforts to adopt healthy behaviors before undergoing surgery. Local health systems have already found that a more general version of this program consistently improves patients' recovery time and lowers their medical costs, according to additional studies.

Another option, Howard says, might be connecting smokers with low cost tobacco cessation services at the hospital where they're undergoing surgery or referring them to external resources. For instance, the Michigan Tobacco Quitline offers several free programs to help people quit smoking, including phone coaching and access to nicotine replacement therapy, for Michigan residents 18 and older.

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"The idea is, now that we've identified the prevalence of tobacco use, let's connect patients at the time of surgery to these preexisting resources that are already up and running," Howard says. "Because ultimately, if a patient smokes, and they go through a health care episode, and we as surgeons do not flag that and ask if they'd like some help quitting, then we've missed something."

Additional authors include Kushal Singh, M.P.H., of the Michigan Surgical Quality Collaborative, and Michael Englesbe, M.D., the Cyrenus G. Darling Sr., M.D. and Cyrenus G. Darling Jr., M.D. professor of surgery, of Michigan Medicine and the Michigan Surgical Quality Collaborative.

Paper cited/DOI: "Prevalence and Trends in Smoking Among Surgical Patients in Michigan, 2012-2019," JAMA Network Open. DOI: 10.1001/jamanetworkopen.2021.0553