Intended for healthcare professionals

Clinical Review State of the Art Review

Perioperative tobacco use treatments: putting them into practice

BMJ 2017; 358 doi: (Published 06 September 2017) Cite this as: BMJ 2017;358:j3340
  1. Margaret B Nolan, senior research fellow1,
  2. David O Warner, professor of anesthesiology2
  1. 1Department of Anesthesia and Nicotine Dependence Center, Mayo Clinic, Rochester, MN 55905, USA
  2. 2Mayo Clinic College of Medicine and Science, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN 55905, USA
  1. Correspondence to: D Warner Warner.David{at}


Treatment for tobacco use is efficacious and beneficial to health. Although guidelines recommend that all patients who use tobacco are offered treatment as a part of their clinical care, implementing treatment has proven challenging. In the case of surgical patients, this lack of treatment is particularly unfortunate, as the benefits of abstinence from tobacco are immediate in terms of reducing the risk of surgical complications, including cardiovascular, respiratory, and wound related complications. Surgery also presents an opportunity for patients to quit for good and reduce the long term health risk. This review examines the principles of tobacco use treatment, the rationale for tobacco use treatment in the perioperative period, and how treatment can be incorporated into the routine care of surgical patients. The discipline of implementation science helps to frame these efforts by seeking to better understand how changes in clinical practice occur, and it has the potential to guide an evidence based approach to embedding tobacco treatment into the routine clinical care of surgical patients. This review uses the consolidated framework for implementation research, which includes five major domains, as a representative conceptual framework. A basic understanding of factors potentially important to successful implementation can help to guide clinicians who accept the challenge of implementing tobacco use treatment in surgical care.


Clinicians observe the devastating consequences of tobacco use in their practices every day. Efforts by clinicians to help their patients quit could be an important element of the comprehensive approach that will be necessary to fight the tobacco epidemic. However, efforts to persuade clinicians to implement treatment for tobacco use in routine clinical practice have had mixed results.123456 The evidence that tobacco use treatment is efficacious is not in doubt, and neither is the evidence of health benefit.789 What is lacking is evidence of how best to incorporate tobacco use treatment into the routine care of patients who use tobacco. This lack is particularly unfortunate in the case of surgical patients, as the benefits of abstinence from tobacco are immediate in terms of reducing the risk of surgical complications.1011

This review will examine the evidence on treating tobacco use in the period surrounding surgery (that is, the perioperative period) and how treatment can be incorporated in the routine care of surgical patients, focusing on cigarette smoking as the most prevalent form of tobacco use in most settings. It will discuss the prevalence and consequences of perioperative smoking; the principles of tobacco use treatment; the benefits of treating tobacco use in the surgical patient; the current state of implementation of tobacco treatment in clinical practice, including guidelines; principles of a new discipline, implementation science, that can guide efforts to deploy treatments; challenges to implementing perioperative tobacco treatment; and practical ways that implementation science can guide efforts to make tobacco treatment a routine part of the clinical care of surgical patients, including emerging treatments.

Sources and selection criteria

We searched the available literature in Ovid Medline, including Epub ahead of print, in-process, and other non-indexed citations, Ovid Medline Daily, and Ovid Medline from 1946 to the present (table 1). We used terms alone and in combination, such as “smoking cessation”, “tobacco use”, “perioperative” and derivatives, “attitude of health personnel”, “postoperative complications”, and finally “implement” and “program”. We used only articles in English for review purposes. Evidence came from a variety of study types, including randomized trials, observational studies, meta-analyses, and systematic reviews. We selected studies mainly on the basis of relevance to the topic, as we found few directly related to perioperative smoking cessation interventions, but we prioritized studies published in the past two decades with robust methods based on an implementation framework or behavioral theory. Owing to the paucity of data specifically on perioperative implementation of smoking cessation interventions, we also considered studies examining tobacco use interventions delivered in other clinical settings, including patients admitted to hospital.

Table 1

Summary of search strategy

View this table:

Prevalence and consequences of perioperative smoking

Approximately 310 million major operations were performed globally in 2012,12 and approximately 970 million people smoked cigarettes daily in 2012.13 Thus, as a crude estimate, approximately 60 million smokers undergo surgery annually worldwide, highlighting the potential reach of efficacious perioperative tobacco use treatments.

Smoking is a risk factor for several perioperative complications, especially cardiovascular, respiratory, and wound related complications.14 Although smoking related diseases increase risk, status as a current smoker itself increases risk, even when the effects of such diseases are accounted for.15 A meta-analysis of 107 studies found relative risks of 2.15 (95% confidence interval 1.87 to 2.49) for wound related complications in smokers compared with non-smokers, 1.73 (1.35 to 2.23) for pulmonary complications, and 1.60 (1.14 to 2.25) for admission to intensive care units.16

These complications have economic consequences. In a propensity matched cohort study, with matching variables including surgical procedure, compared with never smokers, current smokers incurred $400 (95% confidence interval $131 to $669) monthly additional medical costs over the first year after surgery.17 When extrapolated to the US population, smoking results in approximately $10bn (£7.8bn; €8.8bn) annual excess postoperative costs. The risks of smoking extend beyond the smoker to people exposed to secondhand smoke; children and adults undergoing surgery who are exposed preoperatively to secondhand smoke have an increased risk of respiratory complications.18192021

Principles of tobacco use treatment

Although most smokers agree that quitting is difficult, approximately three quarters of US smokers want to quit—eventually.2223 Most eventually succeed in doing so, most of them without assistance,23 but tobacco treatment is efficacious in increasing the success rate of quit attempts.24 Treatment optimally incorporates two components—drug therapy and counseling (fig 1).25


Fig 1 Components of tobacco dependence treatment

Several drugs increase quit rates.26 Nicotine replacement therapy (NRT) aims to provide a sufficient blood concentration of nicotine to prevent nicotine withdrawal symptoms. Various delivery devices are available, including gum, inhalers, lozenges, nasal spray, and patches.24 The antidepressant bupropion also significantly increases quit rates.2627 The most recently approved drug, varenicline, is a partial agonist of the nicotinic acetylcholine receptor that may be the most efficacious of the available options.26 Drugs can also be combined—for example, a baseline nicotine patch can be combined with gum as needed for cravings. All of these drugs have potential side effects, such as nausea with NRT or a decreased seizure threshold with bupropion, but overall they have excellent safety profiles.2628293031

Even just brief advice from clinicians to quit smoking can produce small increments in quit rates, but the efficacy of counseling rises with increases in the length and frequency of counseling sessions.2432 Most counseling techniques are based on cognitive behavioral therapy (for patients ready to make a quit attempt) or motivational interviewing (exploring why a person smokes to motivate a quit attempt).33 Optimally, counseling will begin before a quit attempt and continue for several weeks afterward to provide support.32 Counseling is delivered in person or by means such as telephone counseling (“quitlines”).34 The latter services are available in many countries without cost. Treatment can be provided by a variety of practitioners. Tobacco treatment specialists (TTS) are healthcare professionals specifically trained in counseling and drug treatment.3536 Certification requires a week long didactic course and required hours of counseling time.

Treatment combining drugs and counseling will typically approximately double rates of successful quitting compared with unassisted attempts (table 2).33 This means that even with treatment, approximately four of five individual quit attempts will fail, but most smokers will eventually succeed in quitting.23 Thus, tobacco use is in this way analogous to chronic diseases that often cannot be “cured” with a single treatment, and both clinicians and patients should recognize that multiple treatments may be needed.

Table 2

Summary of effects from meta-analyses of behavioral and drug treatments for cigarette smoking

View this table:

Benefits of treating tobacco use in surgical patients

Smoking cessation reduces surgical risk

Tobacco use treatments are efficacious in surgical patients, and abstinence from smoking reduces surgical risk.14 Evidence for benefits comes from both observational studies and randomized trials.1037 Observational studies are valuable but are limited by the potential for confounding—smokers who can quit preoperatively are different from those who cannot. For example, smokers with more severe illness, undergoing more major procedures, and who are less dependent on nicotine are the most likely to quit, and these may represent confounding factors in interpreting the effects of quitting on complications.38

The most recent systematic review of randomized trials in 2014 concluded that both intensive (defined as multi-session in-person counseling started at least four weeks before surgery, usually with drug therapy in the form of NRT) and brief interventions produced cessation at the time of surgery (pooled risk ratios of 10.8 (95% confidence interval 4.5 to 25.5) and 1.3 (1.2 to 1.5) for intensive and brief interventions, respectively).10 For long term cessation, only intensive interventions were efficacious (risk ratio 3.0, 1.6 to 5.6). Intensive interventions reduced the incidence of any complication (risk ratio 0.42, 0.27 to 0.65) and the incidence of wound related complications (0.31, 0.16 to 0.62); brief interventions did not. However, analysis of complication rates is complicated by heterogeneity in the definition of a “complication” and method of ascertainment among studies.

Subsequent randomized controlled trials have shown similar benefit with a preoperative intervention started at least three weeks before surgery consisting of a brief (less than five minutes) counseling session by a trained preadmission nurse in the preoperative clinic, stop smoking brochures, referral to a telephone counseling service (“quitline”), and a free six week supply of nicotine patches.3940 This relatively simple intervention increased both short term (30 day) and long term (one year) abstinence rates (risk ratio 4.0 (1.2 to 13.7) and 3.0 (1.2 to 7.8), respectively). A similar approach using varenicline was also efficacious.41

The duration of preoperative abstinence needed to maximize benefit in terms of reducing perioperative complications is not known and likely depends on the type of complication.14 Observational studies are potentially confounded as described above, and no trial has randomized patients to intervening at different times preoperatively.37424344

The pharmacology of several smoke constituents such as nicotine and carbon monoxide suggests that even brief preoperative abstinence may be beneficial for some outcomes.14 An observational study found that smoking on the morning of surgery was associated with a significant increase in subsequent surgical site infections (odds ratio 1.8, 1.1 to 2.8), suggesting that even just promoting morning abstinence could be beneficial.11 Lower carbon monoxide concentrations caused by acute abstinence also reduce the risk of intraoperative myocardial ischemia.45 Even if preoperative abstinence is not achieved, tobacco treatments applied postoperatively may reduce risk.46 The pernicious myth that quitting smoking shortly before surgery increases risk is now debunked.4748

Surgery as a teachable moment

Reducing perioperative risk by treating tobacco dependence is a worthy goal, but it pales in comparison with a greater benefit of treatment—long term abstinence from smoking. Even without tobacco use treatment, surgery serves as a powerful “teachable moment” for behavior change—an event that motivates spontaneous behavior change. Undergoing a more minor surgical procedure increases the odds of quitting by 30%, and quit rates after major surgery necessitated by smoking related diseases can exceed 50%.38 Approximately one in 12 successful quit attempts in older Americans is associated with surgical procedures, representing a major contribution to public health. The robust quit rates noted in tobacco treatment trials in surgical patients in untreated control groups also provide evidence of this teachable moment10; tobacco treatments consistently applied could further magnify this health benefit.40 A meta-analysis in 2013 supports the concept that surgical patients may be uniquely receptive to interventions, finding that tobacco treatment for oncology patients significantly affected quit rates only when applied in the perioperative period.49

Guideline recommendations for clinician delivered tobacco treatment

Tobacco use treatments can be efficacious when evaluated in controlled clinical trials in healthcare settings, including both outpatient and inpatient practices.3350 Because smokers may have frequent contact with the healthcare system, many efforts have concentrated on equipping and encouraging all types of clinicians to deliver treatments. The US Public Health Service has formulated a clinical practice guideline recommending that every clinician should deliver tobacco treatment at every opportunity using a “5 As” approach, which includes asking all patients about smoking status, advising all smokers to quit, assessing readiness to quit, assisting those patients stating a willingness to make an immediate attempt by providing at least a brief counseling session, and arranging for follow-up (fig 2).33


Fig 2 Approaches to delivery of tobacco use treatment

The Canadian smoking cessation clinical practice guidelines recommend the same “5 As” approach.51 The guidelines of the National Institute for Health and Care Excellence (NICE) in the UK are also similar, with the exception of the “assess” component, which is not recommended for patients seeking acute health services 52 They also recommend that smoking cessation practitioners be available in every hospital.53 The New Zealand guideline also omits the “assess” portion of the 5 As and recommends the “ABC method,” to ask about smoking status, give brief advice to quit, and refer the patient to a cessation resource.54 No national clinical practice guidelines that are specific to the perioperative setting exist.

Implementation of guidelines in clinical practice

Despite the promulgation of guidelines, few patients who smoke receive the recommended elements of treatment when they visit healthcare providers. Assessments of practices in a variety of healthcare settings suggest that although most now have systems in place to identify patients who use tobacco, only a minority consistently deliver other elements of the guideline 5 As recommendations, such as advising patients to quit smoking or providing either assistance in quitting or referral to treatment resources.123456

Longitudinal surveys suggest that the implementation of recommendations is not improving over time.55 Low rates of tobacco treatment have also been found specifically in surgical patients.56 A US national survey of anesthesiologists and general surgeons found that although these physicians reported frequently or almost always asking their patients about tobacco use, 30% of anesthesiologists and 58% of surgeons reported advising their patients to quit, and 5% of anesthesiologists and 24% of surgeons reported providing any assistance to help them. Although most endorsed that it was their responsibility to advise their patients to quit, only 5% of anesthesiologists and 23% of surgeons thought that it was part of their responsibility to ensure that patients get assistance.57 Other surveys of other anesthesia and surgical clinicians have found similar results.58596061626364 Recent data from the UK are also discouraging, suggesting that only 8% of hospital patients who smoke are referred for any type of treatment, and only 50% of frontline healthcare staff in hospitals are offered any training in smoking cessation.53

Success of implementation using intensive approaches

Nonetheless, examples exist of successful efforts to increase the provision of tobacco treatment in healthcare settings, with the greatest success observed in hospital inpatients. For example, the “Ottawa model” includes embedded outreach facilitators who work with hospitals to provide consensus building and accountability, practice tools such as reminder systems, education outreach and training, and ongoing audits and feedback.65 In an observational study of nine hospitals in which trained outreach facilitators helped clinicians to implement the model, only a third of eligible nursing units successfully adopted the tobacco treatment program. Of patients cared for in these units, 69% were referred for counseling, and approximately a quarter received drug treatment or telephone follow-up.65 In a follow-up observational study of these patients, those who received the intervention were less likely to need hospital readmission and emergency department visits and less likely to die within two years after discharge (15.1% v 7.9% mortality).66

A similar interrupted time series study of an intensive practice support approach in 37 hospitals in New South Wales, Australia, assessed differences in practice between baseline, intervention, and follow-up periods. This showed that such support significantly increased the provision of six of the seven tobacco treatment elements evaluated (such as advice to quit and provision of drug therapy), although only about half of patients received any element of care.67 These studies show that increasing the implementation of tobacco treatment in hospital inpatients is possible with intensive effort but that, even so, many patients still do not receive treatment.

Success of implementation using “real world” approaches

In the absence of such intensive practice support efforts, results of efforts to increase clinicians’ delivery of tobacco treatments are less favorable. A meta-analysis of controlled trials found that increasing the provision of tobacco treatment for hospital inpatients by clinicians significantly improved provision of assistance and counseling (pooled risk difference 16.6, 95% confidence interval 4.9 to 28.3) but did not affect assessment of smoking status, advice to quit, or the provision or discussion of drug treatment.68 A series of nine studies enrolled approximately 9500 smokers admitted to 23 hospitals, testing a variety of strategies designed to be feasible in routine clinical care.69 Post-discharge abstinence rates were significantly increased in only two of the nine studies.

Reports of efforts to implement clinician delivered tobacco treatments in outpatient settings provide examples of successes and failures.70717273747576777879 Most studies do not actually evaluate patients’ quit rates, only the rates at which various treatment elements are delivered, and none provides data on long term (more than one year) maintenance of implementation.

To overcome these challenges, a different role for clinicians has been suggested. Rather than attempting to deliver all elements of the 5 As, clinicians would identify tobacco users, advise them to quit, and then refer them to other resources that could provide assessment, assistance, and follow-up—ask, advise, and refer (fig 2).5480 This approach has been shown to be feasible in a variety of clinical settings and can increase patients’ use of referral resources,7273748182 although evidence that this approach actually results in increased abstinence rates is limited.74

Implementation in surgical settings

The AAR approach has been studied specifically in the surgical setting. It was disseminated to 14 anesthesiology practices in the US (both academic and private) by using an education program consisting of in-person training, written materials, and web based resources.83 Rates of advice and referral three months after implementation were 79% and 58%, respectively, suggesting feasibility and acceptability. Pilot studies also showed feasibility of this approach in preoperative urology patients and those evaluated in a preoperative clinic.848586 The AAR approach can increase the use of telephone counseling services in the preoperative setting and in smokers admitted to hospital for surgery.8788 However, in neither study did referral actually increase quit rates. Thus, although the AAR approach can increase the use of referral resources, which of these resources is effective in promoting abstinence remains to be determined.

So, although tobacco treatment is efficacious in healthcare settings, and there have been some successes in implementing tobacco treatment in healthcare settings in general and surgical setting in particular, most patients who could benefit are not being treated. Efficacious treatments are useless if not applied.89 Thus, the most important question is not whether smoking cessation interventions are effective or beneficial in surgical patients, but how to ensure that they are consistently applied to all surgical patients who smoke—that is, how can we integrate tobacco treatment into the fabric of perioperative care in the “real world”?

Principles of implementation science

Implementation science aims to understand how changes in clinical practice occur and through such understanding guide the efforts to make such changes.9091 It has been defined as “the scientific study of methods to promote the systematic uptake of research findings and other evidence-based practices into routine practice, and, hence, to improve the quality and effectiveness of health services.”92 Although it has the same goal as quality improvement, implementation science also seeks to identify generalizable knowledge that can be widely applied beyond the specific topic of a quality improvement project.91

A basic understanding of the factors that are important in determining whether practice innovations are actually implemented can guide efforts to change clinical practice. It is useful to organize these factors in terms of a conceptual framework such as the consolidated framework for implementation research (CFIR).9394 Frameworks can be useful for both organizing theories of implementation and identifying factors that people attempting to implement practice changes must consider. Other frameworks have been proposed and are also useful.959697 This review is organized around the CFIR as a comprehensive taxonomy of concepts noted in other frameworks and theories.

This framework includes factors in five major domains (fig 3). The first four describe factors that can affect the process of implementing an intervention such as tobacco treatment, and the fifth describes the implementation process itself. Each domain includes several factors important to implementation (fig 4). The “intervention characteristics” domain focuses on the features of the intervention itself, such as the strength of evidence for its efficacy, its complexity, and its cost. Factors included in the “outer setting” domain include the patient’s perceived need for the intervention and external incentives for implementation, such as meeting the requirements of accrediting bodies or the potential for financial gain (or loss). The “inner setting” domain focuses on the implementation climate in the organization, including its culture, priorities, incentives, tension for change, readiness for implementation, leadership engagement, and access to resources necessary for implementation. The “characteristics of individuals” domain focuses on the people who work in an organization, including the attitudes of the staff who will be implementing the intervention, as well as their stage of change and self efficacy (that is, how ready are they to change and how confident are they that they can succeed). The final domain of “process” includes the actual steps followed during implementation, including tasks such as planning, engaging participants, executing the intervention as intended, reflecting on the process, and evaluating its success. The supplementary table provides a full description of the CFIR constructs and domains.


Fig 3 Domains of the consolidated framework for implementation research


Fig 4 Consolidated framework for implementation research—constructs and factors

Frameworks such as the CFIR are useful for classifying concepts important in implementation, but they are themselves not theories of implementation. As described by Damschroder and Hagedorn,94 these theories can be conceptualized as process theories that “prescribe how implementation should be planned, organized, and scheduled” or explanatory theories that “describe and explain how change occurs and the influences on the change process.” One example of a process theory is the Ottawa model of research use, which provides a recommended sequence of implementation activities.65 Perhaps the most commonly invoked example of an explanatory theory is Roger’s diffusion of innovation theory,98 which attempts to describe how ideas are spread within an organization or system. Major elements of this theory include the characteristics of the innovation itself, how communication occurs within a system, time, and the social systems comprising the system. Salient characteristics of the innovation and stages of change for people adopting the innovation are posited to be important determinants of the speed of innovation diffusion.

Regardless of the framework and theory used to ground implementation efforts, it is important to evaluate how implementation affects actual practice. The RE-AIM framework is an example of a tool that can be used to evaluate this impact.99 It includes five dimensions:

  1. Reach—the proportion of individuals that receive an intervention

  2. Efficacy—the impact of an intervention on a clinical outcome

  3. Adoption—the proportion of practitioners willing to try the intervention

  4. Implementation—how consistently the intervention is delivered

  5. Maintenance—the extent to which implementation is sustained.

The framework emphasizes that even if an intervention is highly efficacious, if it reaches only a small fraction of patients, is poorly adopted, incompletely implemented, or not maintained, its impact will be low.

Few attempts to implement tobacco use treatment use implementation frameworks and theories to plan, execute, and evaluate interventions. Using a conceptual framework such as the CFIR, the challenges to the implementation of tobacco use interventions in any practice setting can be more easily considered, organized, and overcome.

Challenges to implementation of perioperative tobacco use treatment

This section reviews challenges to the implementation of perioperative tobacco treatment; parenthetical references indicate how these challenges can be classified within the CFIR (fig 4).

Intervention characteristics

Heterogeneity in availability of treatment resources is a major challenge. Although some centers have excellent tobacco treatment programs staffed by dedicated personnel such as TTSs, this is the exception rather than the rule in many settings. Thus, considerable care needs to be taken to adapt treatment to the particular practice setting, taking advantage of existing (or if necessary creating) treatment services (ID). The complexity of the treatment and interference with the normal clinical workflow must be considered (IF). Doubts among clinicians that treatments work must also be overcome (IB).5783 Treatment can have significant costs, both direct costs and opportunity costs, and these need to be carefully defined (IH).100

Outer setting

The surgical patient seeks care to tackle the underlying condition necessitating surgery, not tobacco dependence. Thus, although most patients know that smoking harms their health and want to quit smoking eventually, they are often unaware of the immediate risks in the perioperative period and may not appreciate the acute need for tobacco treatment (IIA).101 In addition, external incentives to provide treatment may be inadequate, including absent or low reimbursement for such services and the inconsistent application of quality measures including tobacco use treatment (IID).102 For example, in the US, mandates exist for both government and private insurers to provide such reimbursement,103 but many clinicians are not aware of this fact, and reimbursement rates may not cover the costs of actually providing these services. As a positive example, New Zealand has government mandated goals, and hospital metrics are published annually to incentivize compliance with guidelines.54

Inner setting

There may be low “tension for change” (that is, little sense of urgency that treatments must be provided) in many institutions regarding tobacco use treatment (IIID1), which may result in a low relative institutional priority to provide treatment compared with the other pressing institutional needs (IIID3). Typically, few organizational incentives for providing treatment exist (IIID4). For practices with performance incentives such as the number of patients seen, time taken to provide treatment may represent a disincentive. For all of these reasons and more, inadequate institutional resources may be available to provide tobacco use treatment for any patient, let alone specifically for surgical patients (IIIE2).

Characteristics of individuals

Most clinicians have little knowledge about tobacco use treatment (IVA).575859104105 In addition, they may have misconceptions, such as concern that tobacco treatment is not efficacious, that drug therapy such as NRT may be dangerous to surgical patients,106 that quitting immediately before surgery has adverse effects,48 that perioperative abstinence may increase patients’ stress,107 or that patients may be offended if tobacco use is discussed.101 Because very few clinicians have received training in tobacco treatment, self efficacy for providing treatment may be low (IVB).575859105108


Although some practices have reported attempts to implement routine perioperative tobacco use treatment,83109110111112113 few report details of implementation, and none reports whether treatment was maintained over the long term. No systematic investigations of best practices in this setting exist to inform the process of implementation. In addition, there may be few champions (VB3) and few external change agents to assist in implementation efforts (VB4).

Applying implementation science to perioperative tobacco use treatment

Although the rationale for consistently providing tobacco use treatment to surgical patients is clear, these challenges are real and important. Frameworks such as the CFIR can provide an excellent means to identify and balance the multiple factors that may determine the optimal treatment for a given setting. For researchers who want to assist these implementation leaders by providing evidence based best practices, frameworks provide a guide to the research questions of greatest interest and the factors that are important to consider and measure. This section will provide examples of how the framework can be used to consider several practical questions, which all represent fruitful areas for future implementation research.

How should treatment be delivered?

Consideration of CFIR domains can help each practice to balance the factors that determine the optimal treatment for their setting. For example, the AAR approach does not expect clinicians themselves to deliver tobacco treatment, but rather for them to provide advice to quit and then refer their patients to personnel expert in providing treatment. This approach has several potential advantages within the framework compared with the full 5 As approach, including evidence that referral of surgical patients increases treatment use (IB),87 reduced complexity (IF), reduced cost to the clinician in terms of both opportunity costs and direct expenses (IH), reduced needs for clinician knowledge and training (IVA), and the potential for increased self efficacy if clinicians are asked only to refer rather than to provide treatment themselves (IVB).

On the other hand, the effectiveness of the AAR approach depends on the availability and efficacy of the referral resources for treatment (1B). Although more intensive treatment is more efficacious, the range of intensities that are efficacious in the perioperative period is not well defined. For example, telephone counseling services alone may not be sufficient.8788 Minimal requirements for efficacy seem to be an initial face-to-face counseling session, an offer of drug therapy (usually NRT in available trials), and the availability of long term follow-up.10 Decisions about how to provide these elements (ID) depend on practice specific considerations of complexity (IF), costs (IH), and available reimbursement for these costs (IID); patients’ knowledge and beliefs about the need for and acceptability of perioperative treatment (IIA); the potential for using provision of treatment to meet external quality and other benchmarks (IID); relative priority for treatment (IIID3); and readiness for implementation in terms of available resources and leadership engagement (IIIE). For example, if local resources such as TTSs are available, they should be used. If they are not, personnel will need training to deliver treatment. Whether this is best accomplished by adding tobacco treatment to the skills of existing personnel with other duties (for example, nurses or physicians staffing the preoperative clinic) or by training and hiring dedicated personnel whose primary responsibility will be to deliver treatment (for example, TTSs), will depend heavily on inner setting factors.

How can support of practice leadership be obtained?

Inner setting factors, including culture, implementation climate, and readiness for implementation, are key to successful implementation, with the overall goal of obtaining leadership engagement (IIIE1). Several lines of evidence supporting perioperative tobacco use treatment can be used to positively influence these factors. The culture of many institutions prioritizes the needs of patients (IIIA), and tobacco treatment is of undisputed benefit to patients. The low rates of treatment and postoperative abstinence in most settings can create tension for change when highlighted to leadership (IIID1). Increasing relative priority to provide treatment (IIID3) can be challenging in the face of the many other competing priorities. Discussion of evidence that smokers incur additional expenses compared with non-smokers can be used to bolster economic arguments,17 as can the fact that tobacco treatment is among the most cost effective medical interventions available.100114115 Outer setting factors that provide incentives to treat should also be identified and invoked. For example, provision of tobacco use treatment can be used as a quality measure for healthcare systems and as a performance measure for individual physicians.54102 Reimbursement for treatment, although often not covering the cost of care, continues to increase in most settings as policy makers increasingly mandate such reimbursement.103 Provision of treatment can provide a competitive advantage in relation to other practices as a demonstration of concern for patients’ wellbeing and health (IIC).

Misconceptions about tobacco interventions may also need to be tackled (IVA). Although surgeons may be concerned about the potential for adverse effects caused by NRT on outcomes such as wound healing, current evidence suggests that the benefits of such therapy to promote abstinence and reduce risk far outweigh any such effects.106 In addition, almost all of the studies showing that treatment reduces the risk of surgical complications included NRT in the active treatment arm.10 Concerns that perioperative abstinence will exacerbate psychological stress or that patients will be offended if clinicians address their tobacco use are baseless.101107116117

What implementation process should be followed?

Although descriptions of tobacco treatment implementation in clinical settings are available,83109110111112113 none has been evaluated within an implementation science framework. Thus, this area is ripe for future study.

In the meantime, there are several available implementation approaches that differ somewhat according to the underlying theory.118 Most have four common components (stated explicitly or implicitly) that the CFIR incorporates within its process domain.93 Although the need for planning before implementation of an intervention seems obvious, the planning should be based on an underlying theory or model of change and should consider relevant factors highlighted by conceptual frameworks such as the CFIR.119120 Engaging people relevant to implementation is vital.96121122 These people include those who will actually deliver the intervention (“first users”),121 opinion leaders who have formal or informal influence on the attitudes and beliefs of those implementing the intervention (both experts and peers),98 formally appointed internal implementation leaders,123 champions who are actively involved in implementing the intervention and dedicate themselves to driving the process through any resistance,124 and change agents external to the organization who bring content expertise in the field of intervention or implementation processes.125 Important elements of execution can include adherence to the implementation plan, engagement of the participants and leadership, and timeliness.124126 Finally, obtaining feedback about the implementation effort is crucial—for example, by defining appropriate milestones (such as what proportion of surgical patients receive treatment).99

Emerging treatments that could facilitate implementation

Consideration of the RE-AIM framework to evaluate the impact of interventions, and the domains of the CFIR, provides the opportunity to “design for dissemination”—that is, to design treatments with features that make them more likely to be implemented into clinical practice.127 This approach helps to guide people interested in developing tobacco use treatments that will have a greater impact on health. We here review three examples of novel approaches that could address CFIR factors important to implementation; many others are possible.

Decision aids

Clinicians may be uncomfortable with discussing patients’ smoking behavior, given the stigmatization of smoking in contemporary culture and that many clinicians are not well trained to address tobacco use.101 Reducing this discomfort could affect several factors that impede implementation and increase the reach of tobacco treatment (IIA, IVA, IVB). Decision aids are tools to facilitate clinician-patient interactions and patients’ participation in their healthcare. A decision aid designed specifically to help patients to manage their perioperative tobacco use behavior significantly enhanced both clinicians’ and patients’ measures of decisional quality and satisfaction.128 It consists of a series of laminated cards illustrating three options for tobacco management around the time of surgery: “Quit for good,” “quit for a bit,” or “continue smoking,” along with the advantages and disadvantages of each option. The patient is asked to read the cards and choose one that reflects his or her feelings about tobacco use, and the provider then has a guide for discussing the topic in a way that aligns with the patient’s preference. As clinicians’ self efficacy is an important factor in whether treatment is provided (IVB), this and similar approaches are potentially useful in implementation efforts.

New approaches to drug treatment

Although drug therapy is efficacious, it is not used by many smokers in the general population who could benefit.129 The recent explosion of interest in electronic nicotine delivery systems (ENDS, also known as electronic cigarettes) represents a potentially disruptive change in the tobacco control landscape.130131132 Although data are limited, some (but not all) studies suggest that at least some cigarette smokers are using ENDS to reduce or eliminate tobacco smoking.131133134 For a given person, any deleterious effects are probably less than those for conventional cigarettes. However, the potential population level impact (for good or harm) is a subject of considerable debate.131135 ENDS, as a form of NRT, could be useful in helping smokers to reduce their exposure to cigarette smoking in the perioperative period, given emerging data that these smokers may view ENDS more favorably than traditional drug therapy.136 Evidence now shows that a very high level of interest exists among patients scheduled for elective surgery in using ENDS to reduce or eliminate perioperative cigarette use137; that ENDS are feasible and acceptable to patients for use in the perioperative period137138; and that ENDS can replace a significant proportion of cigarette consumption in the postoperative period.138 Thus, if shown to be efficacious in future work, ENDS could extend the reach of drug therapy (IC, IIA) in the perioperative setting.

New technologies to deliver behavioral therapy

Follow-up after an initial intervention increases the efficacy of tobacco treatment but, from an implementation standpoint, may be difficult to achieve because of a lack of personnel, cost and availability of reimbursement for this service, and challenges in accessing patients (ID, IF, IH, IID, IID3). Short message service (SMS—text message) based interventions for smoking cessation are gaining increased popularity as the use of mobile phones becomes widespread. These programs have many advantages, including low cost and the potential for wide dissemination. A recent meta-analysis of randomized trials of existing text message interventions suggested that interventions generally increase abstinence rates by about 35% compared with controls.139 Studies have not explored the potential role of these interventions in surgical patients, but pilot studies are under way (unpublished observations). A text messaging smoking cessation program for patients undergoing surgery could provide continuous support and feedback to surgical patients at a reasonable cost and thus facilitate implementation.140 SMS services can also be combined with tailored web based cessation tools, which have also become popular methods of potentially increasing the reach of tobacco interventions at low cost.141


Treating tobacco use in patients undergoing surgery is of unquestioned benefit to both short term and long term outcomes, but implementation is challenging within the normal workflow of perioperative care. Implementation science has the potential to help us to take an evidence based approach to embedding tobacco use treatment into the routine clinical care of surgical patients. Although much work remains, a basic understanding of factors potentially important to successful implementation can help to guide those people who accept the challenge.

Research questions

  • What are the theory based factors of greatest importance for implementing tobacco treatment in routine perioperative care?

  • What implementation process is most effective for implementing tobacco treatment in the perioperative setting?

  • What emerging interventions could increase the reach and effectiveness of perioperative tobacco use treatments?

How patients were involved in the creation of this article

The BMJ did not request patient input on this article when it was commissioned


  • Series explanation: State of the Art Reviews are commissioned on the basis of their relevance to academics and specialists in the US and internationally. For this reason they are written predominantly by US authors

  • We thank Patricia Erwin, MLS, for her assistance with our literature search.

  • Contributors: Both authors contributed to the conceptualization, writing, editing, and design of this manuscript.

  • Competing interests: We have read and understood BMJ policy on declaration of interests and declare the following interests: none.

  • Provenance and peer review: Commissioned; externally peer reviewed.


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