- Email: [email protected]
Smoking cessation advice in limb reconstruction: An opportunity not to be missed
G Model JINJ 7008 No. of Pages 4
Injury, Int. J. Care Injured xxx (2016) xxx–xxx
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Smoking cessation advice in limb reconstruction: An opportunity not to be missed J. Ring* , A. Shoaib, R. Shariff Central Manchester University Hospital Trust, Manchester, UK
A R T I C L E I N F O
A B S T R A C T
Keywords: Smoking Smoking cessation Reconstructive surgical procedures Limb salvage
The adverse health effects of smoking are well known, including its effects on the musculoskeletal system. Limb reconstruction using external fixators is a high intensity process with high levels of patient contact time, complications and cost. The aim of this study was to examine smoking patterns in this group and in particular to assess trends in smoking cession. Data was collected from 41 patients all undergoing treatment using circular frame external fixation, for a variety of pathologies, most commonly acute tibial trauma. A patient reported questionnaire was used. Data was collected over a six-month period. In our population 56.1% of patients were smokers. During the study 47.8% patients stopped smoking and a further 39.1% decreased their smoking behaviour. 78.3% of patients could recall being given smoking cessation advice. In our group, 87% of patients were unaware of the effects of smoking on bone healing. Once made aware during discussion of proposed treatment, 73.9% stated that it was, in part, this knowledge that prompted them to positively change their smoking habits. The results of this study show that advice regarding smoking cessation during limb reconstruction treatment can potentially have a positive impact on patients smoking habits. The effect of smoking should be linked to the patient pathology and discussed during the consent process. Taking the time with the patient for this simple free intervention can have a positive impact on patient health, and potentially on the outcome of their current treatment, and is an opportunity not to be missed. © 2016 Elsevier Ltd. All rights reserved.
Introduction The adverse health effects of smoking are well known, with smoking being the biggest preventable killer and cause of major morbidity and healthcare associated expense in the UK [1]. Smoking affects many systems in the human body. It has been linked to cancers of most common areas particularly lung and oropharynx. It is responsible for chronic lung, cardiovascular and cerebrovascular disease and is still the leading cause of premature death in UK [1]. More specifically, related to this project, the effects on the musculoskeletal system and fracture healing are well documented [2–7]. In addition, the smoking related effects in the perioperative period are well established, as are the effects on anaesthesia, wound healing and post-operative complications. It
* Corresponding author at: Central Manchester University Hospital Trust, Department of Trauma & Orthopaedics, Manchester Royal Infirmary, Oxford Road, Manchester, M13 9WL, UK. E-mail address: [email protected] (J. Ring).
has been shown that, smoking cessation can result in 20–30% reduction in complications [8–11]. According to UK Statistical data around one in five adults over the age of 16 smoke in the UK (19%) [12]. The average number of cigarettes smoked per day is eleven, with women smoking slightly less than men and with unemployed people twice as likely to smoke as those in employment (35% compared to 19%) [12]. Data shows that a large percentage of smokers, about two thirds, express a desire to quit. However only 30–40% attempt this per year and less than this are successful [12]. Limb reconstruction using external fixators is a high intensity process with a high levels of patient contact time when compared to other methods of orthopaedic treatment. Patients undergoing this treatment often have complex pathology and prolonged treatment durations. By the nature of their injury or pathology they are prone to a range of complications including pin site infections and delayed- or non-union. This means that the orthopaedic team form a close relationship with the patient during this period, and the treatment and complications carry a significant healthcare cost [13].
http://dx.doi.org/10.1016/j.injury.2016.12.004 0020-1383/© 2016 Elsevier Ltd. All rights reserved.
Please cite this article in press as: J. Ring, et al., Smoking cessation advice in limb reconstruction: An opportunity not to be missed, Injury (2016), http://dx.doi.org/10.1016/j.injury.2016.12.004
G Model JINJ 7008 No. of Pages 4
2
J. Ring et al. / Injury, Int. J. Care Injured xxx (2016) xxx–xxx
Much of the evidence of smoking’s adverse effects had been taken from both animal and human studies using spinal fusion models [5]. However, from the results of recent systematic reviews there is good evidence that smoking has a significantly adverse effect on the healing of tibial fractures as well as many other orthopaedic conditions [5,6]. One of the striking conclusions of this work is that there is a 40% increase in the chance of a non-union and an equal increase in the time to union in smokers [5,6]. However, patients’ knowledge of these effects has been shown to be limited [14]. Although the evidence of the effects of smoking on bone health and fracture healing is good there is less evidence on the effects of smoking cessation, particularly the timing [5]. Regarding general perioperative complications, a cessation period of at least four weeks has been proposed but several months may be required according to some studies [4,3,15]. This is has been shown to help with general post-operative anaesthetic complications and also so have an effect on wound healing [3,4,8]. However, abstinence times may need to be as long as six months in order to achieve a positive effect on bone healing [3,4]. Smoking cessation advice forms part of the smoking cessation pathway. The UK National Institute of Clinical Excellence (NICE) recommends that clinicians should be aware of their patient's smoking status. In addition, they recommend that patients are asked if they are interested in quitting and if so they should be referred to a smoking cessation service. If they are struggling to abstain then they should be offered smoking cessation pharmacotherapy. NICE also suggest that this smoking cessation advice is linked directly to the patient health condition [16]. It is well known that up to two thirds of smokers are considering quitting and an event involving injury or surgery may represent a “teachable moment”. In some patients the event is enough to promote cessation and in others the impact of smoking cessation advice may be more effective in the promotion of smoking cessation at this key time [10,17,18]. There is evidence supporting a wide range of smoking cessation techniques and adjuvants ranging from brief interventions through counselling to pharmacotherapy. A Cochrane review of the evidence suggested that interventions delivered in the peri-operative period were more effective, in some cases up to ten times [10]. In a busy limb reconstruction clinic setting detailed smoking cessation advice is not always possible or practical. However, knowledge of a patients smoking status, awareness of their willingness to quit and referral to the appropriate services are all easily put into practice, especially as we can link the effects of smoking directly to the orthopaedic pathology we are treating [16]. Evidence suggests that brief cessation advice delivered by surgeons and other members of the multidisciplinary team is an effective tool in smoking cessation, but is often underutilised [19]. It is suggested that discussion of the adverse effect of cigarette smoking should be included in the consent process and certainly with the recent changes to the consent laws in England this should be clearly documented [2]. In elective reconstruction practice, allowing sufficient time for cessation would be backed by the literature [2]. This is more difficult in the trauma situation but continued smoking is likely to have a negative effect, potentially both on the anaesthetic and surgical aspects of the case and patients should be counselled accordingly. We wanted to assess the prevalence and impact of smoking cessation advice on our limb reconstruction group using a patient questionnaire, with a view to examining the incidence of smoking in this population and the prevalence of smoking cessation advice, and to assess the impact of any smoking cessation advice and support given.
Materials and method We collected data from consecutive patients undergoing circular frame external fixation during their treatment course using our patient questionnaire over a six-month period. We collected demographic data including initial pathology, comorbidities, type of treatment, employment status. Verbal consent to complete the questionnaire was obtained from all patients and we felt the information collected should form part of a normal history and its collection did not constitute a deviation from normal patient care and had no effect on the treatment which they were undergoing. The questionnaire was administered by a member of the team not responsible for the initial consultation to try to eliminate bias. If patients had never smoked or had stopped smoking prior to their treatment they were excluded from further questioning. This information gave us the prevalence of smoking in our population. From the smokers we collected data on their smoking history including type of product smoked, amount and duration, allowing us to calculate smoking pack years. We then asked patients if prior to their treatment they were aware of the impact of smoking on fracture healing. Patients were asked if they could recall being given any form of smoking cessation advice during their treatment. Patients were then asked to indicate how their pattern of smoking changed following their treatment and what factors impacted on this change. In our unit it was the limb reconstruction consultants who were responsible for delivering the smoking cessation advice and explaining in detail the negative impacts of smoking to the patients when they first met and prior to any planned surgery and also to reiterate this advice at every available opportunity for example immediately post op and in their regular OPD visits. Patients were also asked if they had been offered any additional smoking cessation support such as face–face contact, tablets, patches or gum. Finally, patients who had stopped or cut down smoking were asked if they had managed to maintain this level, this was taken at the time point of the data collection. We also reviewed the patient notes, via the electronic records, to see if there was documentation of a smoking history and any record of smoking cessation advice being given and any information on further treatment issued to the general practitioner. Data on fracture healing times and long term maintenance of smoking cessation was not collected in this study. Results We collected data from 41 patents during our six-month study period. The average age of patients in our group was 40 with a range of 19–72 years, with 68% male. The average American Society of Anaesthesia score (ASA) in our patient group was 1 with a range of 1–3. In this study group 46.3% of patients were unemployed. All of the patients in the group underwent treatment with a circular external fixator. Table 1 shows the types of pathology treated; acute tibial trauma was the commonest indication. In our trauma Table 1 Pathology treated. Pathology
N
%
Tibial Shaft Fractures Distal Tibia intra-articular/Pilon Fracture Proximal Tibia/Tibial Plateau Fractures Failed Ankle Fracture Fixation Deformity Correction Osteomyelitis Non-Union
20 8 4 3 2 2 2
48.8 19.5 9.8 7.3 4.9 4.9 4.9
Please cite this article in press as: J. Ring, et al., Smoking cessation advice in limb reconstruction: An opportunity not to be missed, Injury (2016), http://dx.doi.org/10.1016/j.injury.2016.12.004
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system the Orthoplastic team is located in another trust and we only managed closed injuries in our patient group. In the study population 56.1% of patients were smokers. The average number of cigarettes smoked per day in our group was 14.8 and the average number of pack years per patient was 17.4 years. We excluded the non-smokers from further analysis. During or following treatment 47.8% of patients stopped smoking and a further 39.1% decreased their smoking behaviour. The trends in smoking habits in our population is summarised in Table 2. In those who decreased the average percentage decrease was 73.7%, with a range of 60%–90% decrease in cigarette consumption. We do note that one patient continued to smoke at the same rate and 2 patients increased their smoking activity, citing pain and boredom as the main triggers for this. Of note the two patients who increased their smoking activity both stated they smoked more cannabis to help with pain. These patients were unable to recall being given smoking cessation advice or any information on the effect of smoking on fracture healing. The one patient who continued to smoke at the same rate was also noncompliant with other aspects of his care. In this group 78.3% of the patients could recall being given smoking cessation advice. Looking at documentation, specifically in the outpatient clinic letters, only 9.8% of patient had their smoking history commented on and any reference to smoking cessation advice being recommended. Regarding ongoing cessation support in the community, one patient had a documented request to the General Practitioner regarding further smoking cessation support. With regard to additional smoking cessation support no patients in our group received any additional support from ourselves or their General Practitioner as part of their treatment and only one patient had documentation requesting this from her General Practitioner. We asked patients if they were aware of the effects of smoking on fracture healing; 87% were unaware of the effects before being told, but 73.9% stated that once aware it was this knowledge which prompted them to decrease or stop smoking. Of the remaining patients one patient stated he had decreased smoking due to pressures on his finances since the injury, 1 patient stated due to his prolonged hospital stay he was unable to smoke and subsequently stopped, and one major poly-trauma patient stated it was the life changing events which prompted him to stop smoking. In our population all of the patients who had a positive change in smoking status stated this was due to health advice that they were given during treatment. All patients who decreased or stopped smoking maintained this to the time point when the study was conducted. Discussion In our patient group allowing for the mixed demographic there was a trend towards improved smoking cessation results in patients who had been given smoking cessation advice. We had a high initial smoking prevalence in our population, compared to national figures. At final review for this study 86.9% of our patients
had stopped or at least decreased their smoking, 73.9% of these patients indicated that this was due to the advice they had been given by the orthopaedic team during their treatment. In the light of these findings we believe that, at the time of initial treatment patient, education about the impact of smoking on fracture healing and encouragement to stop smoking are important and effective interventions at this key “teachable moment” [17]. If these are appropriately included in the early consultations cessation of smoking and maintenance of this can be achieved in a high number of cases. It is known that patient knowledge of all of the effects of smoking is often limited especially the effects on the muscul14eletal system [14]. None of the patients in our group received any additional support regarding smoking cessation and this is something that we are looking to include in our patient pathway. The addition of this may further improve the impact of the smoking cessation advice, especially in patients who are struggling to stop or maintain their cessation and this has the potential to increase the longer term effectiveness of this intervention. In any patient group one must consider the effects of patient non-compliance on the result of an intervention. Certain patients, despite the best advice, support and education, will continue to smoke. In our group these patients tended to show other signs of non-compliant behaviour. All of the patients who did not positively change their smoking habits had a history of substance misuse including intravenous drug use, and unemployment. Potentially these patients would have benefited from additional intervention to help address their smoking and other wider issues in order to achieve cessation and improved overall health. Information on the adverse effects of smoking and smoking cessation advice is an important health intervention. This work shows that it can have a good yield in achieving smoking cessation. We also suggest that regular reviews of patients smoking status occur as part of their ongoing follow up to track their progress and encourage their success. All of this should be documented in their notes, especially when included as part of the informed consent process. The results of our study suggest that, in the short term, advice and education appear to be an effective way to positively improve patients smoking behaviours, supporting previous work in the literature in other areas [20,10,14,21]. Additional support may not always be necessary to achieve cessation but it may be helpful for those who are struggling, as supported but NICE recommendation [16]. Our data supports that already published showing that brief smoking cessation advice by surgeons is an effective trigger to promote longer term smoking cessation [15,10] blt. Although there were some issues with documentation, a high percentage of our population could recall being given smoking cessation advice and hence acting on it. This study has a number of limitation. We have a small and diverse sample size but feel this reflects the nature of our limb reconstruction population. We used a non-validated patient questionnaire as a measure in this study, because there was no suitable validated alternative available. This study was designed to give a snapshot of smoking habits and the impact of cessation
Table 2 Smoking trends in our study population.
Total Smokers Stopped Smoking Reduced Smoking Continued Smoking Increased Smoking
3
N
%
Notes
41 23 11 9 1 2
56.1% 47.8% 39.1% 4.3% 8.7%
73.9% Stated the trigger was due to advice given during their treatment course Strong history of alcohol & substance misuse Both stated increased cannabis use for pain relief
Please cite this article in press as: J. Ring, et al., Smoking cessation advice in limb reconstruction: An opportunity not to be missed, Injury (2016), http://dx.doi.org/10.1016/j.injury.2016.12.004
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advice; it was not designed to look at the impact of smoking on outcome and we did not look at fracture healing or complications. This study did not include long term follow up to assess maintenance levels of smoking cessation but it does show that cessation advice has a positive impact in the short term. Longer term follow-up could be considered in future work. In addition, this study relied patient honesty; it was conducted in a nonjudgemental way. Anecdotally, most of the patients felt very positive and proud of their efforts to stop or at least reduce their smoking and were very frank and honest with the information they shared with us. This study concentrates on our limb reconstruction population, in our unit they form a captive audience and are closely cared for by a small team. This made it easy to study this particular group. However, the same principles could be applied when treating any group of fracture patients and potentially similar cessation results could be achieved with this simple but important health intervention. Conclusion The results of this study show that patient education and advice regarding the negative impact of smoking on fracture healing and smoking cessation advice during the treatment of complex injuries and pathology has a positive impact on patients smoking habits in a large majority of cases and may have the potential to improve overall outcome. We suggest that a clear smoking history is taken and documented alongside the advice given. We believe that this discussion forms an important part of the consent process for this complex treatment. This documentation should be copied to the general practitioner and consideration given to the provision of additional smoking cessation support, particularly in less compliant patients. Educating patients about the potential adverse effects of smoking on their outcome, linking smoking directly to their current condition, may be a key factor in encouraging positive changes in smoking behaviour. We believe that taking this important opportunity to undertake this simple free intervention can have a positive impact on patient health and potentially on the outcome of their current treatment. It is an important health intervention opportunity, especially for this complex patient group, but the principles can be equally applied when treating other trauma patients.
References [1] Department of Health: Smoking Kills: A White Paper on Tobacco. London: The Stationery Office; 1998 Accessed Online August 2016. [2] Lee JJ, Patel R, Biermann JS, Dougherty PJ. The muscul14eletal effects of cigarette smoking. J Bone Joint Surg Am 2013;95(9):850–9. [3] Glassman SD, Anagnost SC, Parker A, Burke D, Johnson JR, Dimar JR. The effect of cigarette smoking and smoking cessation on spinal fusion. Spine 2000;15 (20)2608–15 25. [4] Truntzer J, Vopat B, Feldstein M, Matityahu A. Smoking cessation and bone healing: optimal cessation timing. Eur J Orthop Surg Traumatol 2015;5(2):211– 5. [5] Patel RA, Wilson RF, Patel PA, Palmer RM. The effect of smoking on bone healing: a systematic review. Bone Joint Res 2013;2(6):102–11. [6] Al-Hadithy N, Sewell MD, Bhavikatti M, Gikas PD. The effect of smoking on fracture healing and on various orthopaedic procedures. Acta Orthop Belg 2012;78(3):285–90. [7] Porter SE, Hanley EN. The musculoskeletal effects of smoking. J Am Acad Orthop Surg 2001;9:9–17. [8] Rinker B. The evils of nicotine: an evidence-based guide to smoking and plastic surgery. Ann Plast Surg 2013;70(5):599–605. [9] Møller AM, Pedersen T, Villebro N, Munksgaard A. Effect of smoking on early complications after elective orthopaedic surgery. J Bone Joint Surg [Br] 2003;85-B:178–81. [10] Thomsen T, Villebro N, Møller A. Can people be helped to stop smoking before they have surgery? Cochrane Database Syst Rev 2014;27:3 CD002294. [11] Egan TD, Wong KC. Perioperative smoking cessation and anaesthesia. J Clin Anaesth 1992;4:63–72. [12] Health and Social Care Information Office Statistics on Smoking, England, http://digital.nhs.uk/catalogue/PUB20781/stat-smok-eng-2016-rep.pdf, 2016 (Accessed Online August 2016). [13] MacKenzie EJ, Jones AS, Bosse MJ, Castillo RC, Pollak AN, Webb LX, et al. Healthcare costs associated with amputation or reconstruction of a limb-threatening injury. J Bone Joint Surg Am 2007;89(8):1685–92. [14] Matuszewski PE, Boulton CL, O’Toole RV. Orthopaedic trauma patients and smoking: knowledge deficits and interest in quitting. Injury 2016;47(6):1206– 11. [15] Møller AM, Villebro N, Pedersen T, Tønnesen H. Effect of preoperative smoking intervention on postoperative complications: a randomised clinical trial. Lancet 2002;359(9301):114–7. [16] Smoking: Supporting People To Stop. NICE Quality Standard [QS43]. National Institute of Clinical Excellence; 2013 Accessed online august 2016, Published date: August. [17] McBride CM, Emmons K, Lipkus I. Understanding the potential of teachable moments: the case of smoking cessation. Health Educ Res 2003;18(2):156–70. [18] Warner D. Helping surgical patients quit smoking: why, when, and how. Anesth Analg 2005;101(2):481–7. [19] Lancaster T, Stead L, Silagy C, Sowden A. Effectiveness of interventions to help people stop smoking: findings from the Cochrane Library. BMJ 2000;321 (7257):355–8. [20] Tang MW, Oakley R, Dale CA, Purushotham A, Møller H, Gallagher JE. A surgeon led smoking cessation intervention in a head and neck cancer centre. BMC Health Serv Res 2014;14:636. [21] Susan L, Landry J, Jones P, Buhrmann O, Morley-Forster P. The effectiveness of a perioperative smoking cessation program: a randomized clinical trial. Anesth Analg 2013;117(3):605–13.
Conflict of Interest None.
Please cite this article in press as: J. Ring, et al., Smoking cessation advice in limb reconstruction: An opportunity not to be missed, Injury (2016), http://dx.doi.org/10.1016/j.injury.2016.12.004
Injury, Int. J. Care Injured xxx (2016) xxx–xxx
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Smoking cessation advice in limb reconstruction: An opportunity not to be missed J. Ring* , A. Shoaib, R. Shariff Central Manchester University Hospital Trust, Manchester, UK
A R T I C L E I N F O
A B S T R A C T
Keywords: Smoking Smoking cessation Reconstructive surgical procedures Limb salvage
The adverse health effects of smoking are well known, including its effects on the musculoskeletal system. Limb reconstruction using external fixators is a high intensity process with high levels of patient contact time, complications and cost. The aim of this study was to examine smoking patterns in this group and in particular to assess trends in smoking cession. Data was collected from 41 patients all undergoing treatment using circular frame external fixation, for a variety of pathologies, most commonly acute tibial trauma. A patient reported questionnaire was used. Data was collected over a six-month period. In our population 56.1% of patients were smokers. During the study 47.8% patients stopped smoking and a further 39.1% decreased their smoking behaviour. 78.3% of patients could recall being given smoking cessation advice. In our group, 87% of patients were unaware of the effects of smoking on bone healing. Once made aware during discussion of proposed treatment, 73.9% stated that it was, in part, this knowledge that prompted them to positively change their smoking habits. The results of this study show that advice regarding smoking cessation during limb reconstruction treatment can potentially have a positive impact on patients smoking habits. The effect of smoking should be linked to the patient pathology and discussed during the consent process. Taking the time with the patient for this simple free intervention can have a positive impact on patient health, and potentially on the outcome of their current treatment, and is an opportunity not to be missed. © 2016 Elsevier Ltd. All rights reserved.
Introduction The adverse health effects of smoking are well known, with smoking being the biggest preventable killer and cause of major morbidity and healthcare associated expense in the UK [1]. Smoking affects many systems in the human body. It has been linked to cancers of most common areas particularly lung and oropharynx. It is responsible for chronic lung, cardiovascular and cerebrovascular disease and is still the leading cause of premature death in UK [1]. More specifically, related to this project, the effects on the musculoskeletal system and fracture healing are well documented [2–7]. In addition, the smoking related effects in the perioperative period are well established, as are the effects on anaesthesia, wound healing and post-operative complications. It
* Corresponding author at: Central Manchester University Hospital Trust, Department of Trauma & Orthopaedics, Manchester Royal Infirmary, Oxford Road, Manchester, M13 9WL, UK. E-mail address: [email protected] (J. Ring).
has been shown that, smoking cessation can result in 20–30% reduction in complications [8–11]. According to UK Statistical data around one in five adults over the age of 16 smoke in the UK (19%) [12]. The average number of cigarettes smoked per day is eleven, with women smoking slightly less than men and with unemployed people twice as likely to smoke as those in employment (35% compared to 19%) [12]. Data shows that a large percentage of smokers, about two thirds, express a desire to quit. However only 30–40% attempt this per year and less than this are successful [12]. Limb reconstruction using external fixators is a high intensity process with a high levels of patient contact time when compared to other methods of orthopaedic treatment. Patients undergoing this treatment often have complex pathology and prolonged treatment durations. By the nature of their injury or pathology they are prone to a range of complications including pin site infections and delayed- or non-union. This means that the orthopaedic team form a close relationship with the patient during this period, and the treatment and complications carry a significant healthcare cost [13].
http://dx.doi.org/10.1016/j.injury.2016.12.004 0020-1383/© 2016 Elsevier Ltd. All rights reserved.
Please cite this article in press as: J. Ring, et al., Smoking cessation advice in limb reconstruction: An opportunity not to be missed, Injury (2016), http://dx.doi.org/10.1016/j.injury.2016.12.004
G Model JINJ 7008 No. of Pages 4
2
J. Ring et al. / Injury, Int. J. Care Injured xxx (2016) xxx–xxx
Much of the evidence of smoking’s adverse effects had been taken from both animal and human studies using spinal fusion models [5]. However, from the results of recent systematic reviews there is good evidence that smoking has a significantly adverse effect on the healing of tibial fractures as well as many other orthopaedic conditions [5,6]. One of the striking conclusions of this work is that there is a 40% increase in the chance of a non-union and an equal increase in the time to union in smokers [5,6]. However, patients’ knowledge of these effects has been shown to be limited [14]. Although the evidence of the effects of smoking on bone health and fracture healing is good there is less evidence on the effects of smoking cessation, particularly the timing [5]. Regarding general perioperative complications, a cessation period of at least four weeks has been proposed but several months may be required according to some studies [4,3,15]. This is has been shown to help with general post-operative anaesthetic complications and also so have an effect on wound healing [3,4,8]. However, abstinence times may need to be as long as six months in order to achieve a positive effect on bone healing [3,4]. Smoking cessation advice forms part of the smoking cessation pathway. The UK National Institute of Clinical Excellence (NICE) recommends that clinicians should be aware of their patient's smoking status. In addition, they recommend that patients are asked if they are interested in quitting and if so they should be referred to a smoking cessation service. If they are struggling to abstain then they should be offered smoking cessation pharmacotherapy. NICE also suggest that this smoking cessation advice is linked directly to the patient health condition [16]. It is well known that up to two thirds of smokers are considering quitting and an event involving injury or surgery may represent a “teachable moment”. In some patients the event is enough to promote cessation and in others the impact of smoking cessation advice may be more effective in the promotion of smoking cessation at this key time [10,17,18]. There is evidence supporting a wide range of smoking cessation techniques and adjuvants ranging from brief interventions through counselling to pharmacotherapy. A Cochrane review of the evidence suggested that interventions delivered in the peri-operative period were more effective, in some cases up to ten times [10]. In a busy limb reconstruction clinic setting detailed smoking cessation advice is not always possible or practical. However, knowledge of a patients smoking status, awareness of their willingness to quit and referral to the appropriate services are all easily put into practice, especially as we can link the effects of smoking directly to the orthopaedic pathology we are treating [16]. Evidence suggests that brief cessation advice delivered by surgeons and other members of the multidisciplinary team is an effective tool in smoking cessation, but is often underutilised [19]. It is suggested that discussion of the adverse effect of cigarette smoking should be included in the consent process and certainly with the recent changes to the consent laws in England this should be clearly documented [2]. In elective reconstruction practice, allowing sufficient time for cessation would be backed by the literature [2]. This is more difficult in the trauma situation but continued smoking is likely to have a negative effect, potentially both on the anaesthetic and surgical aspects of the case and patients should be counselled accordingly. We wanted to assess the prevalence and impact of smoking cessation advice on our limb reconstruction group using a patient questionnaire, with a view to examining the incidence of smoking in this population and the prevalence of smoking cessation advice, and to assess the impact of any smoking cessation advice and support given.
Materials and method We collected data from consecutive patients undergoing circular frame external fixation during their treatment course using our patient questionnaire over a six-month period. We collected demographic data including initial pathology, comorbidities, type of treatment, employment status. Verbal consent to complete the questionnaire was obtained from all patients and we felt the information collected should form part of a normal history and its collection did not constitute a deviation from normal patient care and had no effect on the treatment which they were undergoing. The questionnaire was administered by a member of the team not responsible for the initial consultation to try to eliminate bias. If patients had never smoked or had stopped smoking prior to their treatment they were excluded from further questioning. This information gave us the prevalence of smoking in our population. From the smokers we collected data on their smoking history including type of product smoked, amount and duration, allowing us to calculate smoking pack years. We then asked patients if prior to their treatment they were aware of the impact of smoking on fracture healing. Patients were asked if they could recall being given any form of smoking cessation advice during their treatment. Patients were then asked to indicate how their pattern of smoking changed following their treatment and what factors impacted on this change. In our unit it was the limb reconstruction consultants who were responsible for delivering the smoking cessation advice and explaining in detail the negative impacts of smoking to the patients when they first met and prior to any planned surgery and also to reiterate this advice at every available opportunity for example immediately post op and in their regular OPD visits. Patients were also asked if they had been offered any additional smoking cessation support such as face–face contact, tablets, patches or gum. Finally, patients who had stopped or cut down smoking were asked if they had managed to maintain this level, this was taken at the time point of the data collection. We also reviewed the patient notes, via the electronic records, to see if there was documentation of a smoking history and any record of smoking cessation advice being given and any information on further treatment issued to the general practitioner. Data on fracture healing times and long term maintenance of smoking cessation was not collected in this study. Results We collected data from 41 patents during our six-month study period. The average age of patients in our group was 40 with a range of 19–72 years, with 68% male. The average American Society of Anaesthesia score (ASA) in our patient group was 1 with a range of 1–3. In this study group 46.3% of patients were unemployed. All of the patients in the group underwent treatment with a circular external fixator. Table 1 shows the types of pathology treated; acute tibial trauma was the commonest indication. In our trauma Table 1 Pathology treated. Pathology
N
%
Tibial Shaft Fractures Distal Tibia intra-articular/Pilon Fracture Proximal Tibia/Tibial Plateau Fractures Failed Ankle Fracture Fixation Deformity Correction Osteomyelitis Non-Union
20 8 4 3 2 2 2
48.8 19.5 9.8 7.3 4.9 4.9 4.9
Please cite this article in press as: J. Ring, et al., Smoking cessation advice in limb reconstruction: An opportunity not to be missed, Injury (2016), http://dx.doi.org/10.1016/j.injury.2016.12.004
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system the Orthoplastic team is located in another trust and we only managed closed injuries in our patient group. In the study population 56.1% of patients were smokers. The average number of cigarettes smoked per day in our group was 14.8 and the average number of pack years per patient was 17.4 years. We excluded the non-smokers from further analysis. During or following treatment 47.8% of patients stopped smoking and a further 39.1% decreased their smoking behaviour. The trends in smoking habits in our population is summarised in Table 2. In those who decreased the average percentage decrease was 73.7%, with a range of 60%–90% decrease in cigarette consumption. We do note that one patient continued to smoke at the same rate and 2 patients increased their smoking activity, citing pain and boredom as the main triggers for this. Of note the two patients who increased their smoking activity both stated they smoked more cannabis to help with pain. These patients were unable to recall being given smoking cessation advice or any information on the effect of smoking on fracture healing. The one patient who continued to smoke at the same rate was also noncompliant with other aspects of his care. In this group 78.3% of the patients could recall being given smoking cessation advice. Looking at documentation, specifically in the outpatient clinic letters, only 9.8% of patient had their smoking history commented on and any reference to smoking cessation advice being recommended. Regarding ongoing cessation support in the community, one patient had a documented request to the General Practitioner regarding further smoking cessation support. With regard to additional smoking cessation support no patients in our group received any additional support from ourselves or their General Practitioner as part of their treatment and only one patient had documentation requesting this from her General Practitioner. We asked patients if they were aware of the effects of smoking on fracture healing; 87% were unaware of the effects before being told, but 73.9% stated that once aware it was this knowledge which prompted them to decrease or stop smoking. Of the remaining patients one patient stated he had decreased smoking due to pressures on his finances since the injury, 1 patient stated due to his prolonged hospital stay he was unable to smoke and subsequently stopped, and one major poly-trauma patient stated it was the life changing events which prompted him to stop smoking. In our population all of the patients who had a positive change in smoking status stated this was due to health advice that they were given during treatment. All patients who decreased or stopped smoking maintained this to the time point when the study was conducted. Discussion In our patient group allowing for the mixed demographic there was a trend towards improved smoking cessation results in patients who had been given smoking cessation advice. We had a high initial smoking prevalence in our population, compared to national figures. At final review for this study 86.9% of our patients
had stopped or at least decreased their smoking, 73.9% of these patients indicated that this was due to the advice they had been given by the orthopaedic team during their treatment. In the light of these findings we believe that, at the time of initial treatment patient, education about the impact of smoking on fracture healing and encouragement to stop smoking are important and effective interventions at this key “teachable moment” [17]. If these are appropriately included in the early consultations cessation of smoking and maintenance of this can be achieved in a high number of cases. It is known that patient knowledge of all of the effects of smoking is often limited especially the effects on the muscul14eletal system [14]. None of the patients in our group received any additional support regarding smoking cessation and this is something that we are looking to include in our patient pathway. The addition of this may further improve the impact of the smoking cessation advice, especially in patients who are struggling to stop or maintain their cessation and this has the potential to increase the longer term effectiveness of this intervention. In any patient group one must consider the effects of patient non-compliance on the result of an intervention. Certain patients, despite the best advice, support and education, will continue to smoke. In our group these patients tended to show other signs of non-compliant behaviour. All of the patients who did not positively change their smoking habits had a history of substance misuse including intravenous drug use, and unemployment. Potentially these patients would have benefited from additional intervention to help address their smoking and other wider issues in order to achieve cessation and improved overall health. Information on the adverse effects of smoking and smoking cessation advice is an important health intervention. This work shows that it can have a good yield in achieving smoking cessation. We also suggest that regular reviews of patients smoking status occur as part of their ongoing follow up to track their progress and encourage their success. All of this should be documented in their notes, especially when included as part of the informed consent process. The results of our study suggest that, in the short term, advice and education appear to be an effective way to positively improve patients smoking behaviours, supporting previous work in the literature in other areas [20,10,14,21]. Additional support may not always be necessary to achieve cessation but it may be helpful for those who are struggling, as supported but NICE recommendation [16]. Our data supports that already published showing that brief smoking cessation advice by surgeons is an effective trigger to promote longer term smoking cessation [15,10] blt. Although there were some issues with documentation, a high percentage of our population could recall being given smoking cessation advice and hence acting on it. This study has a number of limitation. We have a small and diverse sample size but feel this reflects the nature of our limb reconstruction population. We used a non-validated patient questionnaire as a measure in this study, because there was no suitable validated alternative available. This study was designed to give a snapshot of smoking habits and the impact of cessation
Table 2 Smoking trends in our study population.
Total Smokers Stopped Smoking Reduced Smoking Continued Smoking Increased Smoking
3
N
%
Notes
41 23 11 9 1 2
56.1% 47.8% 39.1% 4.3% 8.7%
73.9% Stated the trigger was due to advice given during their treatment course Strong history of alcohol & substance misuse Both stated increased cannabis use for pain relief
Please cite this article in press as: J. Ring, et al., Smoking cessation advice in limb reconstruction: An opportunity not to be missed, Injury (2016), http://dx.doi.org/10.1016/j.injury.2016.12.004
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advice; it was not designed to look at the impact of smoking on outcome and we did not look at fracture healing or complications. This study did not include long term follow up to assess maintenance levels of smoking cessation but it does show that cessation advice has a positive impact in the short term. Longer term follow-up could be considered in future work. In addition, this study relied patient honesty; it was conducted in a nonjudgemental way. Anecdotally, most of the patients felt very positive and proud of their efforts to stop or at least reduce their smoking and were very frank and honest with the information they shared with us. This study concentrates on our limb reconstruction population, in our unit they form a captive audience and are closely cared for by a small team. This made it easy to study this particular group. However, the same principles could be applied when treating any group of fracture patients and potentially similar cessation results could be achieved with this simple but important health intervention. Conclusion The results of this study show that patient education and advice regarding the negative impact of smoking on fracture healing and smoking cessation advice during the treatment of complex injuries and pathology has a positive impact on patients smoking habits in a large majority of cases and may have the potential to improve overall outcome. We suggest that a clear smoking history is taken and documented alongside the advice given. We believe that this discussion forms an important part of the consent process for this complex treatment. This documentation should be copied to the general practitioner and consideration given to the provision of additional smoking cessation support, particularly in less compliant patients. Educating patients about the potential adverse effects of smoking on their outcome, linking smoking directly to their current condition, may be a key factor in encouraging positive changes in smoking behaviour. We believe that taking this important opportunity to undertake this simple free intervention can have a positive impact on patient health and potentially on the outcome of their current treatment. It is an important health intervention opportunity, especially for this complex patient group, but the principles can be equally applied when treating other trauma patients.
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Conflict of Interest None.
Please cite this article in press as: J. Ring, et al., Smoking cessation advice in limb reconstruction: An opportunity not to be missed, Injury (2016), http://dx.doi.org/10.1016/j.injury.2016.12.004