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Tobacco Treatment Specialists Across Healthcare: A Spotlight on Perioperative Care

This occasional series highlights some of the practice areas where tobacco treatment specialists (TTS) work. In this post, we share tips on working with surgical patients who need to quit tobacco.

The positive impacts of quitting smoking prior to surgery and remaining abstinent during recovery have been well documented in the literature. It decreases mortality risk and helps patients avoid respiratory complications, wound infections, and delayed wound and bone healing. Patients who smoke before surgery are more likely to need a ventilator or be admitted to the ICU, are at increased risk for anesthesia complications, have longer hospital stays and a higher chance of readmission, and are at increased risk for in-hospital mortality.


Despite the benefits of quitting tobacco, 25% of patients continue to smoke before and after surgery, which is why dedicated tobacco treatment services are so important for this population.


I sat down with Emily Walter, a nurse practitioner with the Duke Smoking Cessation Program and a tobacco treatment specialist, who works exclusively with patients who need surgery or have just had surgery. Below are her tips for working with this unique population.


TIP 1: Build a relationship, set clear goals, and have a backup plan


“It’s a dynamic type of relationship and very fast-paced,” explains Emily, who often sees patients for the first time a few weeks or days before their surgery. “I tell patients not to be intimidated by our time frame.”


She doesn’t see their short time together as a challenge. Instead it’s one of the things she enjoys most about the work. “These patients have a very clear and easily-definable motivator. They are preparing for surgery.

I like this population because I can help them identify a goal (quitting smoking). These patients have a lot that is outside of their control in regards to their surgery. This is something they can control to improve their surgical outcomes.” – Emily Walter, NP, Duke Smoking Cessation Program

She starts her first visit by asking a lot of questions. “I like for patients to feel like we are building a relationship. I am completely open to hearing what their goals are and what their challenges are, and those can change. Their goal might be to quit after surgery.”

“I think not thinking about the long-term is important with this population. I work with them a week at a time and set small goals that are tangible and within their control.”

She always has a backup plan in place and typically sees patients for follow up 3 to 7 days after their initial visit. “That first week is very pivotal for patients. I don’t want to lose them if they have medication side effects or are not making progress.”


TIP 2: Quitting after surgery is still important


Even if patients aren’t able to quit before surgery, helping them quit afterward is important for recovery, especially in the first 30 days.


Emily views the post-op period as a continuation of recovery. “I say to patients, ‘Your body is healing, and what is the best way for your body to heal?’ Often patients are participating in other forms of rehab. I piggyback onto that, exploring how we can best utilize this time of recovery. Patients often see time in the hospital as a jump start to being smoke free. I’ll ask patients, ‘What would it look like if you came home to a smoke-free environment?’


TIP 3: Face challenges with good communication

There are some challenges unique to perioperative smoking cessation treatment, such as handling patients who are frustrated about having to quit smoking prior to surgery, especially when they are in a lot of pain.


With these patients, Emily tries to explore their feelings and goals. “I’ll say, ‘Tell me more about what you like about smoking?’ Then I ask about the things they don’t like about smoking. I remind them that we aren’t looking at long-term cessation. Let’s cut down first and see how you feel, taking a more step-by-step approach. I tend to always try to be positive. I try to normalize setbacks or lack of progress.”


Another big challenge can be limitations in regards to medications. “Some surgeons want patients to be nicotine free (including nicotine replacement),” Emily explains. Largely, it is plastic surgeons and occasionally neurosurgeons worried about wound healing. “They are usually very clear in their referrals about nicotine restrictions. I also ask the patient and make sure they are aware, especially if they need to be nicotine tested. I try to discuss other options, especially varenicline.”


In a perioperative setting, communication is key, whether it’s with the surgeon, the surgical team, or the patient. “At the end of our first visit, I always send a message to their surgeon. That gives the opportunity to have the surgeon on the care team.”

“This relationship is not forever so we have to be tight for this short period of time. Creating that expectation with the patient is important,” Emily says. “Many of my patients are surprised by how quickly I get back to them. I think that is key with this population. It’s creating an urgency and priority.”

“I like helping patients out in this vulnerable moment. I just make myself available. I try to be a liaison between the patient and their surgeon.” - Emily Walter, NP, on helping patients quit smoking during the perioperative period

She explains that many people refer to the perioperative period, as a teachable moment, a time when patients have a lot of awareness on the impact of quitting smoking. This often translates to motivation for quitting, which is why it is so important to offer tobacco cessation services during this time.


For more great evidence-based content on how to help patients quit tobacco, check out our upcoming Comprehensive Tobacco Treatment Specialist Training (July 17-25).


About The Author

Rachael Joyner is a family nurse practitioner with the Duke Smoking Cessation Program. She holds a National Certificate in Tobacco Treatment Practice and received her Doctorate in Nursing Practice from the University of Florida. She loves working collaboratively with patients to help them become tobacco free.

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