Smoking cessation and elective surgery: the cleanest cut

To the Editor: I would like to congratulate Peters et al on their strong stance against elective surgery in patients who smoke.1 The plastic surgery community became aware in the last two decades of the problems of healing in smokers. When patients claimed that they gave up cigarette smoking before surgery, we often found that the serum cotinine levels on testing were elevated, indicating that they had not given up smoking.

Patients who are smokers and who develop a healing complication, in breast reduction, mastopexy, abdominoplasty or a facelift, often attribute the complication to the surgical technique rather than their own habit. Many of these patients have gone on to litigate successfully. Voracious plaintiff lawyers attribute only a small amount of blame to the patient whose smoking has, in fact, contributed significantly to their complication.

In our plastic surgery practice, we have a non-smoking policy, and my malpractice insurer will not cover me for patients on whom I operate and who develop a complication associated with smoking. Hence, all patients who are smokers who wish to have elective surgery are referred to a smoking-cessation program and have to have given up smoking for at least 2 to 4 weeks before surgery. I prefer not to operate on smokers at all, as serum cotinine tests often confirm that their cessation attempt has been incomplete.

In the United States, where patients pay for their own health insurance, their premiums are adjusted for lifestyle. In Virginia, in the 1990s, a “Healthy Virginian policy” existed where premiums were reduced for non-smokers. My suggestion would be that the Medicare levy also be either reduced for individuals who do not smoke or increased for those who do.