The Effects of Cigarette Smoking on Anesthesia: PSYCHOLOGICAL ASPECTS OF SMOKING

In: Anesthesia

22 Feb 2010


Smoking is an addictive process. The sensation of drawing smoke into the mouth and the effect of nicotine provides smokers with satisfaction. Acute withdrawal may result in increased anxiety, sleep disturbances, and irritability.


In a study by Dennis et al, adverse effects such as coughing, breath holding, and laryngospasm during induction were significantly higher in smokers and passive smokers than in young smokers. There was no difference in the incidence between smokers and passive smokers. During adverse effects, the decrease in the oxygen saturation was greater in smokers and passive smokers. In this study, COHb was a better predictor of adverse effects than the status of smoking.

In children with a history of passive smoking, desat-uration was significantly higher in the postoperative period when compared with that of nonexposed children. The desaturation was related to the cumulative number of cigarettes smoked to which the child was exposed. It had no relationship to the COHb. Thus, the desaturation is probably more due to respiratory infection due to increased risk of exposure to microdroplets from respiratory disease of smokers who cough while smoking than due to exposure to the smoke itself.


Management of anesthesia in smokers includes the following:

Stopping Smoking

  • Ideally, stop smoking for at least 8 weeks prior to surgery.
  • Stop for 24 hours before surgery to negate effects of nicotine and COHb.
  • If an operation is scheduled for the next morning, stop smoking the previous evening.


  • Treat lung infections such as chronic bronchitis.
  • Prescribe bronchodilators, breathing exercises, and chest physiotherapy in symptomatic smokers.
  • Do blood gases to get baseline Pa02 and PaC02 if a long operation is planned.

Choice of Technique

  • Avoid general anesthesia. Local or regional anesthesia is better.


  • Use a parasymptholytic agent like glycopyrrolate to dry secretions.
  • Use an anxiolytic agent such as midazolam to negate the psychological effects of stopping smoking before the surgery.
  • Instill nebulized 4% lignocaine inward on call to the operating theater to prevent respiratory problems during anesthesia.

General Anesthesia Induction

  • Do preoxygenation to decrease carbon monoxide.
  • When using intravenous induction, any intravenous induction agent is satisfactory. Use intravenous lignocaine to prevent laryngospasm during intubation.
  • When using induction with volatile agents, sevoflura-ne or halothane is preferred.
  • Avoid manipulation under light anesthesia, which may result in coughing, breath holding, laryngospasm, or bronchospasm.


  • Prior to intubation, if nebulized lignocaine not given, spray with lignocaine to anesthetize the larynx and suppress laryngeal hyperreactivity.
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  • Avoid light anesthesia, which may result in bronchospasm.
  • Avoid desflurane, which is a respiratory irritant. It stimulates the respiratory irritant receptors in chronic smokers and thereby the sympathoadrenal system, resulting in higher blood pressure and tachycardia.
  • Increase minute volume over that used for nonsmokers to maintain the same PaC02.


  • When using current pulse oximeters, remember a gross overestimation of oxygenated hemoglobin saturation (Sa02) occurs.
  • Use a CO oximeter to measure oxygen saturation.
  • Monitor the electrocardiogram, especially in those having coronary heart disease since ventricular arrth-ythmias may occur during anesthesia.
  • Use a peripheral nerve stimulator to monitor the neuromuscular block since there are various reports on the requirement of muscle relaxants.
  • In long operations, carry out intermittent blood gas analysis to check the PaC02 since PaC02 – Et C02 is higher than in nonsmoking patients.


  • Do not extubate under light anesthesia because it may result in cough, breath holding, laryngospasm, or bronchospasm. buy cialis soft tabs

Postoperative Period

  • Give oxygen in the recovery room, while being transported, and for some time in the ward.
  • Postoperatively, administer more analgesics, which are needed due to (i) anxiety from stopping smoking, (ii) decreased pain threshold, and (iii) increased metabolism of the drug.
  • Give breathing exercises and chest physiotherapy to symptomatic smokers.


In recent years, medical officers have been more involved in advising smokers to give up smoking. Preop-eratively, Shah et al gave written advice to patients to stop smoking for 5 days before their operations. Though the majority did not comply with the 5-day advice, the majority had reduced or stopped smoking before the procedure. Verbal advice to stop smoking is regularly given to smokers by anesthesiologists prior to an operation. Many patients follow the anesthesiologists’ advice.

Intraoperatively  during  anesthesia,  tape-recorded messages advising patients to stop smoking have been tried by anesthesiologists, with some success. In one study, some patients reduced their cigarette intake and some stopped smoking. In another study, there was no difference. In the latter study, 8% had stopped smoking after 6 months. The majority of those that stopped were the ones who had had major surgery and those that smoked less than 10 cigarettes a day.

Egan and Wong have suggested that anesthesiologists should advise smokers to stop smoking during the postoperative ward rounds. This should be done especially in those patients who had smoking-related problems during anesthesia. Egan and Wong found patients to be especially compliant in those circumstances.
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In conclusion, patients must stop smoking prior to surgery. The best result occurs when the patient stops 8 weeks or more before surgery. Doing so will significantly reduce perioperative-specific respiratory events and postoperative morbidity, and it will eliminate carbon monoxide and nicotine, improve the clearance of tracheobronchial secretions, decrease small-airway narrowing, and improve immune functioning. If the patient does not stop smoking 8 weeks before surgery, the patient should at least stop smoking 12 hours before surgery or, if the surgery is the next morning, the previous evening. This will eliminate problems in tissue oxygen uptake due to carbon monoxide and reduce the cardiac and hemodynamic effects of nicotine. Last, it is time that anesthesiologists played a stronger role in advising patients to stop smoking.

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