Smoking Cessation Program Benefits Patients Prior to Joint Replacement Surgery

    Smokers experienced better surgical outcomes and fewer adverse events, including hospital readmissions, surgical site infections, and blood clots, if they had enrolled in a smoking cessation program before hip or knee replacement surgery, according to the findings of a preliminary study presented at the 2017 Annual Meeting of the American Academy of Orthopaedic Surgeons.

    “We’ve known that smokers do worse than non-smokers after joint replacements, and now this research shows there’s good early evidence that quitting smoking before surgery may improve their outcomes,” said lead study author Amy Wasterlain, MD, a fourth-year resident in the Department of Orthopaedic Surgery at NYU Langone.

    “Not every risk factor can be reduced before a joint replacement, but smoking status is one that should be a top priority for orthopaedic surgeons and their patients.”

    Higher Risks, Higher Costs

    Smokers who undergo a total joint replacements have a 50% higher risk of experiencing complications during surgery than non-smokers, and on average, incur $5,000 more in hospital costs, according to previous research. A recent review of 7,000 joint replacement procedures found patients who used tobacco within 1 month of surgery were 2.1 times more likely to develop a deep surgical infection than those who had not used tobacco during that time period.

    To combat this risk, NYU Langone developed a voluntary smoking cessation program in October 2013 that was designed to get smokers tobacco-free within 1 to 2 weeks of surgery. The program consists of 4 preoperative telephone counseling sessions and nicotine replacement therapy as needed and 2 postoperative follow-up sessions.

    For this study, researchers reviewed medical records of 539 smokers who underwent total joint replacements at NYU Langone’s Hospital for Joint Diseases between October 2013 – after the smoking cessation program was implemented – through March, 2016.

    Surgeons referred 103 smokers to the program, with 73 voluntarily enrolling and 47 completing all 6 sessions. The researchers found that smokers who completed the program were 4.3 times more likely to quit smoking prior to surgery than those who were not enrolled in the program.

    The percentage of smokers who quit all tobacco use prior to surgery increased with each level of participation in the program: 52% of those enrolled and 68% of those who completed the program quit smoking prior to surgery, compared with 18% of smokers who were never referred.

    Smokers who completed the program reduced their daily cigarette consumption by more than 10.5 cigarettes per day, compared with a reduction of nearly 5 cigarette per day among those who participated but did not complete the program and a reduction of only 2 cigarettes per day in smokers who never enrolled in the program.

    Patients who completed the program had fewer surgical complications, with a decrease in reoperation rates from 4.9% among all other smokers to 4.3% in the group in the smoking cessation program. In knee replacements alone, researchers reported adverse events in 22% of patients who completed the program compared with 29% among all other smokers – a decrease of more than 24%. Adverse events included:

    • Hospital readmission
    • Superficial and deep surgical site infection
    • Deep vein thrombosis
    • Pulmonary embolism
    • Pneumonia
    • Stroke
    • Urinary tract infection

    Next Steps

    The researchers emphasized that these findings represent trends toward better outcomes, and a larger study of more than 900 smokers, which is currently underway, is needed to determine statistical significance. Another study limitation was the absence of chemical testing to confirm patients were tobacco-free, and future studies will include this testing.

    The researchers plan to build on their promising pilot study and expand the program’s capacity to include all smokers undergoing a total joint replacement or other elective orthopaedic operation, according to senior study author Richard Iorio, MD, the Dr. William and Susan Jaffe Professor of Orthopaedic Surgery and chief of the division of Adult Reconstructive Surgery at NYU Langone.

    He said that improved outcomes following smoking cessation could be worthwhile for reducing health care costs, especially as hospitals implement bundled payment and value-based care reimbursement models such as under Medicare’s mandatory Comprehensive Care for Joint Replacement (CJR) demonstration project. Under this model, hospitals assume financial responsibility for any complications over an entire care episode, including postsurgical infections and hospital readmissions.

    “By delaying surgery in high-risk patients until they enroll in a program to quit smoking, we are not only improving how the patient will do after surgery, but also eliminating some of the burden on the health care system caused by poor outcomes and increases in costly reoperations,” Dr. Iorio said.

    “Our study [shows] that telling patients to stop smoking likely is not enough, and an established smoking cessation program may be most beneficial.” 


    Wasterlain A, Stachel A, Sinha S, et al. Perioperative smoking cessation in total joint arthroplasty patients: a pilot study. Presented at the 2017 Annual Meeting of the American Academy of Orthopaedic Surgeons, March 14-18, 2017, in San Diego, California.