SUMMARY: Cigarette smoking demonstrably impairs healing in a variety of clinical circumstances. Refusal to quit smoking can constitute failure to mitigate or even a Novus Actus Interveniens. Smoking may predispose to musculoskeletal injury and poor outcome of orthopedic surgery. A number of plastic and cosmetic surgeries are demonstrably compromised.
Even though cigarette smoke contains thousands of noxious and carcinogenic substances, it is likely the nicotine1, perhaps aggravated by carbon monoxide, that most impairs healing.
Demonstration of the adverse effects of nicotine on healing in experimental animals began in 19782, and the first scientific observations in humans followed a couple of years later3.
A single cigarette reduces blood supply to the skin for up to an hour and a half4.
Refusal to quit smoking can constitute failure to mitigate or even a Novus Actus Interveniens. In 120 women who had undergone laparotomy, the midline scars of smokers were nearly three times as wide as those of nonsmokers5. Following breast cancer surgery, smokers were more likely to suffer postoperative wound infection, skin necrosis and blistering6.
Suture lines for rejoining large bowel are more likely to break down in smokers7.
Animal experiments suggest that the adverse effect of smoking on wound healing is greatest during the first 10 days8.
Practice PointThe first cigarette smoked during the immediate postoperative period can be considered a Novus Actus Interveniens for poor wound healing |
Smoking may predispose to musculoskeletal injury and poor outcome of orthopedic surgery.
It has been shown to adversely affect bone density, lumbar disc disease, the rate of hip fractures, and the processes of bone and wound healing9.Smoking has been implicated in compromised bone metabolism and fracture repair, and increasing the rate of postoperative infection and the incidence of nonunion10.
Compared to non-smokers, chronic smokers are more likely to suffer from Degenerative Disc Disease, and appear to be more susceptible to traumatic vertebral injury. Spinal fusion in chronic smokers is less often successful11
Practice PointSmoking may constitute a Thin Skull for Spinal Degeneration and the occurrence of some fractures, a Failure to Mitigate for the healing of others |
A number of plastic and cosmetic surgeries are demonstrably compromised.
Skin grafts, and plastic procedures on the face, abdomen12, breasts and fingers3 have all been shown to be adversely affected by smoking13,14. Practice PointQuantum of Damages could be reduced if advice to discontinue smoking before and after plastic surgery was ignored |