2024/03/05 by KHF Wong, Ronélle Mouton, Robert J. Hinchliffe · 1 voice
Medicine · #Cardiac, Anesthesia and Surgical Outcomes #Aortic aneurysm repair treatments #Peripheral Artery Disease Management
paper · pdf · doi:10.1111/anae.16266
openalex publication_date 2024/03/05 · openalex created_date 2024/03/07 · openalex updated_date 2026/07/16
Tobacco smoking has well-known deleterious effects on vascular disease progression and peri-operative outcomes [1]. Consequently, international guidelines and quality improvement programmes recommend smoking cessation as a central component of best medical therapy [2-4]. Smoking cessation interventions in the peri-operative period are effective, especially with a changing approach to targeted behavioural therapy and nicotine replacement rather than tobacco abstinence [5, 6]. However, the impact of these recommendations and the contemporary burden of smoking in patients in the UK undergoing vascular surgery are unknown. The aims of this study were to investigate the current prevalence of smoking in these patients, and to identify trends in smoking over time and associations with demographic and clinical characteristics, which is necessary to design targeted smoking cessation interventions to maximise sustained abstinence and identify quality care improvement targets. Permission was obtained from Health Quality Improvement Partnership for the National Vascular Registry (NVR) to release pseudo-anonymised patient data under a data sharing agreement with the University of Bristol. The NVR was interrogated for all adults undergoing elective carotid surgery, abdominal aortic aneurysm (AAA) repair and lower limb infrainguinal bypass for atherosclerotic disease between January 2014 and December 2021. Emergency surgery; revision surgery; hybrid procedures; arterial dissection; ruptured or symptomatic AAA were excluded. Case ascertainment was 86–97%, and data were validated annually via communication with vascular surgical units. The primary outcome was the prevalence of active smoking (smoked within the last 2 months); former smoking (not smoked within the last 2 months); and non-smoking (never smoked) at the time of surgery. The secondary outcomes were trends in smoking over time and to determine clinical and demographic characteristics associated with smoking. Trends in smoking prevalence were examined using mixed-effect logistic regression. Multivariable logistic regression was used to assess the likelihood of smoking compared with non-smoking while adjusting for age; sex; geographical region; Index of Multiple Deprivation decile; procedure type; and procedure year. The ASA physical status and comorbidities were not adjusted for in this model due to significant expected interactions with smoking status. All statistical analyses were performed with the R statistical programme (version 4.3.0, R Computing, Vienna, Austria) with a 2-sided significance level set at p < 0.05. In total, 59,811 patients were included in the analysis. At the time of surgery, 25.4% of patients were actively smoking, while 57.6% were former smokers and only 17.0% had never smoked. Smoking rates were highest in patients undergoing lower limb bypass (33.1%), followed by carotid surgery (25.4%) and AAA repair (21.9%). From 2014 to 2021, the prevalence of smoking in patients undergoing elective vascular surgery marginally increased from 24.9% to 26.2% (OR 1.01, 95%CI 1.00–1.02, p = 0.003). On subgroup analysis, the prevalence of smoking did not change significantly over time in patients undergoing carotid surgery (OR 0.99, 95%CI 0.98–1.01, p = 0.224) or AAA repair (OR 1.00, 95%CI 0.99–1.02, p = 0.664), but was modestly increased in patients undergoing lower limb bypass surgery (OR 1.03, 95%CI 1.01–1.05, p < 0.001). There was a 1.5-fold variation in the prevalence of smoking across the regions of the UK (range 20.9% to 31.0%). After excluding outliers and adjusting for patient and procedural characteristics, the variation in smoking prevalence across UK hospitals was 2.4-fold (16.0–37.8%) (Fig. 1). After adjusting for patient and clinical characteristics, older age and female sex were associated with lower odds of smoking (Table 1). Smoking was strongly associated with environmental deprivation, where each increase in Index of Multiple Deprivation decile (less deprivation) resulted in a 14% reduction in odds of smoking. Patients undergoing carotid surgery had lower odds of smoking compared with those undergoing AAA repair, while patients undergoing lower limb bypass had higher odds of smoking. Significant geographical variations remained after adjustment; the year the procedure was performed was not significantly associated with smoking. The main limitations of this study were potential errors with self-reported smoking status and lack of detailed smoking history. Several important socio-economic factors previously linked to smoking, such as ethnicity, education, income and employment were unavailable in the NVR. In this nationwide cohort study, over a quarter of patients were still current smokers at the time of elective vascular surgery, which modestly increased over the time period studied. This is in contrast to declining national trends in smoking prevalence and reflects an opportunity to further improve surgical outcomes in this high-risk patient cohort through smoking cessation programmes. Significant variation in smoking rates between UK hospitals and socio-economic characteristics suggest some centres may be more effective at smoking cessation than others, and represents a clear target for quality improvement and an area for further research. RM and RH are joint senior authors. The authors express their gratitude to all the vascular surgeons and patients who have contributed data to the NVR. Special thanks go to S. Waton from the Clinical Effectiveness Unit, Royal College of Surgeons of England, for conducting the data retrieval from the NVR. The work is part of the PROTECTOR Study on Perioperative Tobacco Cessation that is funded by a grant from the Association for Cardiothoracic Anaesthesia and Critical Care and the Vascular Anaesthesia Society of Great Britain and Ireland via the National Institute for Academic Anaesthesia. KW is funded by a National Institute for Health and Care Research Academic Clinical Fellowship. RM is supported by the North Bristol Vascular Surgery Charitable Trust. RH is supported by the Enid Linder Foundation and Royal College of Surgeons of England Chair in Clinical Trials in Surgery. The views expressed in this publication are those of the authors and not necessarily those of the NHS, the NIHR or the University of Bristol. No competing interests declared.