Intended for healthcare professionals

Rapid response to:

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

Rapid Response:

Smoking and the role of Miswak in the control of tobacco consumption in Saudi Arabia

Yousuf Kharal,[1] Hamza Kharal,[1] Rajkumar Rajendram[2]

1. Department of Medicine, Al Faisal University, Riyadh, Saudi Arabia
Department of Medicine, Al Faisal University, Riyadh, Saudi Arabia
2. Department of Medicine, King Abdulaziz Medical City, National Guard Hospital Affairs, Riyadh, Saudi Arabia

Cigarette and shisha smoking are major public health concerns in Saudi Arabia. The prevalence ranges from 2 to 52% (Median 18%) across various strata of the population of Saudi Arabia.[1] To tackle this the Ministry of Health has established a Tobacco Control Program. This provides a comprehensive guide to help smokers to stop smoking.[2, 3] The Saudi Smoking Control Charitable Society has also established 33 clinics throughout Saudi Arabia over the last 14 years. However, these clinics have a success rate of only 13%.[2, 3]

So, any intervention which could facilitate smoking cessation in Saudi Arabia would be extremely beneficial. We therefore read the review of perioperative tobacco use treatments by Nolan and Warner [4] with great interest.

Smoking increases the peri-operative risks of respiratory, cardiovascular and wound-related complications, and mortality within 30 days of surgery [5, 6]. However, anaesthetists and peri-operative physicians are often reluctant to advise patients to stop smoking. This reflects the widely prevalent misconception that stopping smoking shortly before surgery may increase the risk of respiratory complications.

Long periods of abstinence (i.e. over eight weeks before elective surgery) are clearly most beneficial.[7] Yet, those who stop at least four weeks before surgery still have fewer respiratory and wound related complications than those who continue to smoke.[7] Most importantly, stopping smoking within four weeks of elective surgery does not increase the risk of respiratory or cardiovascular complications [7].

The peri-operative period therefore presents a unique opportunity to engage patients and promote a healthy lifestyle. Regardless, even motivated smokers require significant support to stop smoking. A wide range of formulations of nicotine replacement therapy are now available. The need to keep idle hands and mouths occupied has popularized electronic cigarettes (e-cigs) and ‘vaping’. However, the data on the role of e-cigs in smoking cessation are conflicting [8] and some constituents of e-cigs are linked to obstructive airway diseases such as asthma.[9]

So when advising on smoking cessation we therefore recommend the use of Miswak in combination with an alternative source of nicotine (e.g. patches or gum). The Miswak, a twig extracted from Salvadora Persica, is commonly used as a toothbrush in Middle Eastern culture.[10] Whilst there is little direct data on the role of Miswak in smoking cessation Salvadora Persica contains several bioactive compounds with broad range of pharmacological activity. These properties include antimicrobial, antioxidant, anticonvulsant, sedative, analgesic, anti-inflammatory, hypoglycaemic and lipid lowering effects. Within the Middle East this natural alternative to e-cigs is a well recognized as a tool to facilitate smoking cessation.[10]

1. Bassiony MM. Smoking in Saudi Arabia. Saudi Med J. 2009;30:876-81.
2. Jarallah JS. Tobacco Control in Saudi Arabia: Will it Work? J Family Community Med. 1996;3:9-12.
3. Moradi-Lakeh M, El Bcheraoui C, Tuffaha M, et al. Tobacco Consumption in the Kingdom of Saudi Arabia, 2013: findings from a national survey. BMC Public Health 2015;15:611.
4. Margaret B Nolan, David O Warner. Perioperative tobacco use treatments: putting them into practice. BMJ 2017; 358:j3340.
5. Gronkjaer M, Eliasen M, Skov-Ettrup LS, et al. Preoperative smoking status and postoperative complications: a systematic review and meta-analysis. Annals of Surgery 2014; 259: 52–71.
6. Turan A, Mascha EJ, Roberman D, et al. Smoking and perioperative outcomes. Anesthesiology 2011; 114: 837–46.
7. Wong J, Lam DP, Abrishami A, et al. Short-term preoperative smoking cessation and postoperative complications: a systematic review and meta-analysis. Canadian Journal of Anesthesia 2012; 9: 268–79.
8. Pasquereau A, Guignard R, Andler R, Nguyen-Thanh V. Electronic cigarettes, quit attempts and smoking cessation: a 6-month follow-up. Addiction. 2017;112:1620-1628.
9. Clapp PW, Jaspers I. Electronic Cigarettes: Their Constituents and Potential Links to Asthma. Curr Allergy Asthma Rep. 2017; 17: 79.
10. Aumeeruddy MZ, Zengin G, Mahomoodally MF. A review of the traditional and modern uses of Salvadora persica L. (Miswak): Toothbrush tree of Prophet Muhammad. J Ethnopharmacol. 2017;213:409-444.

Competing interests: No competing interests

20 December 2017
Yousuf Kharal
Medical Student
Hamza Kharal, Rajkumar Rajendram
Department of Medicine, Al Faisal University, Riyadh, Saudi Arabia
Department of Medicine, Al Faisal University, Riyadh, Saudi Arabia