Another policy zombie
Ban on elective surgery till you have stopped smoking. Pitched as a policy device to save money.
My own view, based on this is that there is NOT a case for this
I’d advise (strongly) against heading down this path
- The policy should be considered through the standard lens of the 4 pillars of medical ethics.
- As set out v clearly by the GMC, a doctors primary ethical duty is to their patients
- whilst there is also a concurrent duty to use scarce resources wisely it seems hard to justify a policy of no tx for smokers (if that is what is being suggested) on ethical grounds. I have yet to see any economic evidence on this. I doubt it has been done and doubt there is any scope for resource save here. In absence of any economic evidence….makes the ethical issues all the more important
- Smoking more common in some population groups. So implementing such a policy exacerbates inequity of access.
- Makes it harder to ensure equal access for equal need – which is a primary duty for CCG
Also think through practicality, implementability, reputational risk, unintended consequences
It’s worth reading through this excellent BMJ article from 9 years ago
Should smokers be refused surgery?
BMJ | 6 January 2007 | Volume334
- Failure to quit = clinical risk in surgery
- When all other clinical features are identical, costs are increased and outcomes are worse in a smoker than in a current non-smoker.
- Utilitarian approach – in system with limited £ – > outcomes if non smokers are prioritised for surgery.
- Sensible clinical judgement. Complications, healing, infections. Compromises outcome and increased cost of care
- Limit to areas where risk is >. orthopaedic, plastic and reconstructive are obvious examples.
- Opportunity cost of Rx smokers (with their > complication rate and LOS and poorer / costlier outcomes) = less opportunity to Rx other patients.
- On the basis of these data, five non-smokers could be operated on for the cost and bed use of four smokers and the non-smokers’ surgical outcomes would be better
- Some unanswered questions – how long cessation / how to measure / limited RCT data on the above arguments re LOS / complications etc
- Short term cessation – rather than LT quit is ethically justifiable.
- Practical implementation is a problem. How enforced. By whom
- Doctors routinely treat patients who are despised by the society in which they live—enemy troops, terrorists, murderers – what is so bad about smokers.
- undermine the doctor-patient relationship – may significantly harm future relationship and patient may not disclose other info,
- Simple victimisation of smokers. Who may not be able to quit.
- How to classify smokers – all in one group. 60 a day smokers vs 2 a week smokers.
- Most smokers have no complications. This is a relative risk v absolute risk thing. The absolute risk of complications is low. Relative risk (compared in non smokers) is high.
- Simple discrimination
- Thin end of wedge. Obesity next, then drinking, then where. May put serious limitations on the notion of liberty. Should we treat a person with a sports injury – after all it is self inflicted
All up, an absolute threshold is something I wouldn’t recommend on money saving (and other) grounds.
My standard advice to a CCG is seriously considering implementing a policy of “if you dont stop you wont get your op” ie – an absolute threshold policy is that it is bonkers and may end court.
Encouraging stronger push to stopping pre op is entirely different, and a good thing. We should set up systems to encourage this. That should be done with a view to improving operative and maybe long term (on the premise that some of those who stop pre op may stop for good and many will move along in the behaviour change cycle).
I wrote a CCG paper on this a year or so ago with @healthyann and others. To save others the trauma it’s at the bottom
This recent JAMA surgery paper is interesting on smoking status and status and post op complications
Sadly paywalled, so can only glean a little from the abstract
· All types of elective surgery
2% patients develop surgical site infection
· OR for smoking and SSI is 1.5
· Higher odds for smoking on day of surgery (1.9)
· So not insignificant.
· But remember context = 2% absolute risk, albeit in high volume care process.
· Still no reason for absolute block till stopped, but adds to reasons for strong, structured and pathway based support to stop, swap – either permanently or as min pre op. might also consider role of e cigs in this
Smoking is the primary cause of preventable illness and premature death. NHS stop smoking services provide clinically and cost effective ways for people to stop smoking. There is a well established pathway to access support to stop smoking in Bradford; it starts with brief interventions and advice, through to the smoking cessation service which is operated by the City of Bradford Metropolitan District Council (CBMDC).
Smoking rates have fallen over the years, 1 in 5 people in City and Districts still smokes and inequalities remain. Accordingly, further efforts are needed to support people to stop smoking.
Smoking not only contributes to premature mortality and morbidity but increases health inequalities. The Five Year Forward View reports that that “more than half of the inequality in life expectancy between social classes is now linked to higher smoking rates amongst poorer people.” Reducing health inequality should remain a priority for the CCG and the local authority. Demonstrable actions to reduce health inequality are required to be included in forward planning documents for the CCG.
Smoking cessation and secondary care
Hospital focused smoking cessation services are both clinically and cost effective, and in some cases may even be cost saving. Although the CBMDC smoking cessation service has made inroads into working with secondary care through training, in-reach and pathway development, there is still underuse of smoking cessation as an active treatment modality – something which will increase the value of currently committed spend.
In recent years a number of CCGs have begun to explore the benefits of introducing pre-operative stop smoking as a pre-requisite to having a planned procedure – so called ‘stop before your op’ policies. The evidence underpinning this type of proposal is well established. It is a recommendation within NICE PH10 – ‘patients should be encouraged to stop prior to elective surgery’. Further, its importance is recognised in NICE PH6, ‘at…and…a hospital admission may boost a person’s receptivity to smoking cessation interventions as…and increase their motivation to stop smoking.’
Evidence also shows that pre-operative smoking cessation reduces post operative morbidity: it reduces length of stay, reduces post operative complications, reduces cardiovascular and pulmonary complications, and promotes faster recovery.
There are an estimated 48,000 elective admissions at BTHFT each year (including inpatient and day case procedures). Based on the current smoking prevalence of 22.8%, just under 11,000 smokers will undergo elective surgery each year. However, as smokers tend to be younger than the population undergoing elective surgery, it is unlikely that the prevalence estimate can be applied in this way.
CCGs would need to carefully consider the practical implications of a pre elective cessation policy. As it is proposed that the referral takes place prior to the referral to secondary care, this policy will not impact on the RTT. The onus, however, will be on GPs to give a brief intervention and then refer to a smoking cessation service. There is, however, a risk that individuals will relapse between the initial quit and the elective procedure, however, there is arguably more evidence supporting earlier quit attempts. Furthermore, if the referral to smoking cessation services is made after the pre-operative work up, this policy would affect the RTT.
Considerations in implementing smoking based threshold
Voluntary vs mandatory approach. A mandatory approach such as that adopted by York would mean that all smokers would be referred first to smoking cessation services prior to referral for an elective procedure in secondary care, unless clinical reasons meant that the patient should be referred direct to secondary care. A voluntary approach would give the patient choice. The risk with the latter is that patients may not want to delay their referral, particularly if they are unwell, in pain etc.
Absolute V relative threshold. At what point do GPs initiate referral to secondary care – once the patient has quit smoking and this is verified, or after a defined quit attempt?
Should this be implemented across all elective care pathways or piloted in a small number of specialties in the first instance (guided by the evidence base and clinical risk).
Smoking is associated with significant health inequalities and is more common in some population groups. Whilst implementing such a policy has the potential to address inequalities it raises issues around equity, making it harder to ensure equal access for equal need, which is a primary duty for CCGs.
Requirement of patients to sign a disclaimer indicating that referral may be delayed until after the quit attempt, and that even after the referral an anaesthetist may delay surgery when the risks of smoking exceed the clinical risk of waiting for surgery whilst a quit attempt is made.
- Clinical engagement and ownership is critical – whilst commissioners develop such a policy and embed into contracts, there must be strong and overt clinical support across the system. This includes support from GPs.
- Project management and a clear pathway, indicators of success and a clear expectation of what is expected from clinicians.
- Direct route through hospital stop smoking advisor to the service.
- Support from surgical teams
- Staff training
Wider considerations for CCG smoking cessation and tobacco control interventions
Any stop before your op type policy needs to be viewed in the broader context of smoking cessation in hospital settings and tobacco control. Accordingly, the CCG may wish to consider further steps that they can take beyond a stop before your op type policy. Examples include:
The consideration of smoking cessation in ALL care pathways. A recent British Thoracic Society audit found that 38% of respiratory units did not have a smoking programme as part of their system. There should be an expectation that all pathways consider smoking cessation.
Focusing on high risk groups such as mental health service users and people with disabilities. Funding has already been made available to address smoking in pregnant women.
Investment in high impact media campaigns to reduce the number of young people starting smoking and to encourage smokers to quit.
Lobbying both local and national government with regard to population level policy changes that further denormalises smoking – recent examples include standard packaging and smoking in cars with children.
The Clinical Board is asked to:
Consider the extent to which it is prepared to collaborate to reconsider a stronger push to embed stop smoking as part of the clinical pathways that they commission, particularly elective care.
Consider the implementation of an elective care threshold – stop before your op type policy and if so, what format would this look like given the issues raised in this paper.
Consider the resource requirements to implement a stop before your op type policy.
We also estimated the short terms gains in bed day and complication terms of ramping up pre operative stop,smoking as a a voluntary policy.
You can have that paper if you want. Email me