By Gary Evans, AHC Media Senior Staff Writer

A study in press for publication by the National Institute of Occupational Safety and Health (NIOSH) will report that, despite longstanding hazard warnings, healthcare workers are still frequently exposed to toxic smoke and plumes created by burning tissue during laser surgery and electrosurgery, Hospital Employee Health has learned.

In a particularly disturbing finding, almost half of those surveyed said they never received any training about the potent mix of chemicals and biologicals found in the smoke created from burning tissue. The NIOSH study had not been published as this issue went to press, but one of the authors previewed some of the findings in Chicago at the November 3, 2015 meeting of the American Public Health Association (APHA).1

“One of the main recommendations for working around surgical smoke is that the [plume] be evacuated using local exhaust ventilation [LEV],” said Andrea Steege, PhD, NIOSH epidemiologist and study author. “LEV is not widely used. This is especially true for electrosurgery procedures, where workers report more days, more hours, and more procedures exposed to surgical smoke. Our results indicate that workplaces do not prioritize control of surgical smoke. There is a lack of training that could facilitate procedures for preventing surgical smoke. Some of the reasons for not using local exhaust ventilation were that it wasn’t part of their protocol, the exposure was not great enough to use it, and about a fourth said it was not provided by employers.”

A situation that has been going on for some 20 years is marked by a seeming disconnect between NIOSH and OSHA.

OSHA told HEH that surgical smoke is indeed “hazardous,” but it has no specific standard to enforce the issue. It can enforce worker protections from plumes with its General Duty clause, but its e-tool webpage on the issue refers to the issue as more of a potential problem and instills little sense of urgency. (See related story in this issue.)

The lack of a specific OSHA standard and insufficient enforcement is frequently cited by proponents of plume safety. Indeed, a telling moment came when Steege was asked at the end of her presentation at the APHA meeting by a member of audience: Who is going to enforce these recommendations to protect healthcare workers?

“I don’t think — it’s not going to be OSHA,” Steege said.

A branch of the CDC, NIOSH warned of “toxic gases and vapors” and various biologic and mutagenic threats in surgical smoke — in 1998.2 Still, skeptics3 question whether there is sufficient evidence of surgical plume harms to warrant mandated smoke evacuation. Others say follow the money, whether it is held by tight-fisted hospitals unwilling to part with it for LEVs, or sought by manufacturers who are trying to make a profit by selling the devices.

A Question

All this aside for a moment, consider this metaphorical question: If someone offered you a cigarette containing benzene, hydrogen cyanide, formaldehyde, and viral and bacterial particles, would you smoke it? You might at least read the NIOSH warning label: “Surgical smoke has been shown to be mutagenic, cytotoxic and genotoxic.”1

That means essentially that exposure could mutate cellular DNA and kill both cells and genetic material. “No, thanks,” would be your rational answer.

But what if the caveat was that you had to partake of these “Surgical Smokes” as a part of your job in an operating room — even in a hospital that is an otherwise smoke-free campus?

This is the situation many surgical healthcare workers face daily because their facility does not use smoke evacuation devices to protect them from plumes formed in laser surgery and electrosurgery. Voluntary guidelines to protect workers have been on the books for years, but surgical plume safety advocates say that regulatory enforcement is insufficient and hospitals — as underscored by the NIOSH study — continue to ignore the recommendations.

“[Employee health professionals] need to raise awareness and provide education — they need to discuss this [hazard] at their safety committee meetings because this is not going to go away,” says Kay Ball, PhD, RN, CNOR, FAAN, an associate professor of nursing at Otterbein University in Westerville, OH. “We are going to continue to produce smoke in surgery. All the research is out there and it shows that it is a hazard. There are toxic chemicals [produced] when we burn tissue, when we coagulate and cut through tissue with electrosurgery devices, lasers, or ultrasonic scalpels.”

A member of the Association of periOperative Registered Nurses, Ball says AORN has started a “Go Clear” campaign that will recognize facilities that ensure their workers are protected from inhalation of surgical plumes. Having given her first lecture on the hazards of surgical smoke in 1985, Ball is neither surprised nor daunted by the NIOSH survey findings.

“We need to get rid of this [smoke] so we are not breathing it in,” she says. “We are in a confined area and we have ventilation and air currents in the room that are taking these small particles and delivering it to everybody in the room. I could be scrubbed in at the surgery table and you would could be two yards away, but because of the ventilation in the room you are going to be exposed as much to the plume as I am.”

Thus the need for one of the handheld LED devices, as workers donning masks and even respirators are not considered adequately protected.

“A mask is never — I want to stress never — to be used as the first line of defense to protect you against surgical smoke,” Ball says. “It has to be local exhaust ventilation and that means the smoke evacuators being used. The regular room ventilation that moves the air [is not sufficient]. The toxic gases from the smoke and the small size of the particles — most of them in surgical smoke are less than 1.1 microns — go right through a regular surgical mask. If you wear an N95 respirator or a high filtration mask, are you wearing it right? Have the particles gone around the side if the mask is not adhered to the face?”

NIOSH Findings

The surgical smoke data were drawn from the NIOSH Health and Safety Practices Survey of Healthcare Workers, an anonymous, multi-module, Web-based survey conducted in 2011. Respondents on the surgical smoke question were members of organizations representing anesthesiologists, nurse anesthetists, operating room nurses, and surgical technologists. Of 4,750 respondents reporting they worked within five feet of surgical plume within the week prior, 47% reported that LEV was always used when smoke was generated during laser surgery. Only 14% reported it was always used during electrosurgery.

In the survey results, LEV was used “sometimes” by 22% for lasers and 26% for electrosurgery. LEV was reported as “never” used by 31% for lasers and 59% for electrosurgery. Though LEV is the NIOSH-recommended method for removal plumes, the use of a “different system to remove smoke” was reported by 21% for lasers and 36% electrosurgery. In addition, 49% of those exposed to lasers and 44% of those exposed to electrosurgery had never received any training on the hazards of surgical smoke.

Though not considered adequate protection, one might assume masks and respirators were widely used in the absence of LEV for plume removal. However, that was not the case, as Steege reported that 90% of those working with lasers did not wear a respirator and 96% answered similarly for electrosurgery.

In addition to AORN, the use of LEV to prevent plume exposures is recommended by American National Standards Institute. NIOSH recommends a combination of general room ventilation and LEV.

Cases of HPV Transmission

There are two commonly-cited cases suggestive of human papillomavirus (HPV) transmission via surgical smoke. The first involved a 44-year-old laser surgeon with laryngeal papillomatosis.4 DNA hybridization of tissue from the tumors revealed HPV DNA. History revealed that the surgeon had given laser therapy to patients with anogenital condylomas, which are known to harbor the same viral types. “These findings suggest that the papillomas in [the surgeon] may have been caused by inhaled virus particles present in the laser plume,” the authors concluded.

The other case5 involved a 28-year-old gynecological operating room nurse, who assisted repeatedly in electrosurgical and laser surgical excisions of anogenital condylomas, and then developed recurrent laryngeal papillomatosis. “The expert opinion of a virological institute confirmed a high probability of correlation between the occupational [exposure] and the laryngeal papillomatosis,” the researchers noted.

In addition, Ball’s doctoral dissertation found that perioperative nurses have twice the incidence of some respiratory problems compared with the general population.6 Nurses’ respiratory problems may be linked to the cumulative inhalation of surgical smoke contaminants, she notes. Results indicated that nurses who reported respiratory conditions were usually more alert to the need to evacuate surgical smoke and comply with smoke evacuation recommendations, she says. Of course, the accumulating anecdotal evidence does not carry the weight of clinical trials, though one could hardly be conducted with human subjects.

“It is not ethical to divide a group of practitioners and say you are going to use smoke evacuators and the other group will not,” Ball says. “We can’t do that to see if any disease forms in their airways. But we have a lot of anecdotal evidence where surgeons have acquired papilloma venereal warts in their throat by not evacuating smoke. They have gotten it in the conjunctiva of their eyes. Research has shown even cancer cells during laparoscopic procedure are floating around in the smoke from the belly of a laparoscopic patient. Benzene has been shown to be a trigger for leukemia.”

While the long-term effects of surgical plume exposure may be more difficult to show in terms causality, the acute immediate effects of some exposed sufferers have been observed and documented.

“Surgical smoke can cause acute health effects — eye, ear, nose, and throat irritation, headaches, nasal congestion, nausea, dizziness, asthma, asthma-like symptoms,” Steege said. “There are also animal studies that link it to inflammatory changes including emphysema, asthma, and chronic bronchitis. There have been health and safety guidelines dealing with surgical smoke for around 20 years, so this is not a new concern. These guidelines were developed by professional practice organizations as well as government agencies. There is no OSHA standard, but they do have an ‘e-tool’ site that talks about surgical smoke.”

OSHA: 500,000 exposed

OSHA estimates that 500,000 healthcare workers are exposed to surgical smoke each year. Yet in the absence of routine inspections, the onus falls to healthcare workers to report facilities that have not adopted protection measures.

“Nurses have reported their institutions because they have not provided enough smoke evacuators for each surgical room,” Ball says. “Nurses have been forced to report their own facility to OSHA, which has come in, inspected, and issued fines and said you need to have smoke evacuators in every room. You have to provide a safe workplace environment for your workers.”

Though OSHA has whistleblower protections, there is certainly the perception that reporting the lack of surgical plume protections could put healthcare workers in some job jeopardy.

“Nurses are afraid that their anonymity will be breached and [administration] will find out who reported to OSHA that their own hospital does not have a safe work environment,” Ball says. “You may have a couple of nurses verbalizing this [concern], and all of sudden OSHA shows up. So many nurses are afraid to report their facility even though this is definitely a workplace safety issue for staff members and nurses that are in surgery all of the time.”

Industry sources that sell the plume evacuator equipment to hospitals say they are typically told it is too expensive and/or surgeons don’t want them in the OR. This may be lingering perception from early models that were very loud, though new models are now much quieter, they say.

“The surgeon may say, ‘You don’t have to evacuate surgical smoke during my procedure,’” Ball says. “Well, that’s all well and good for one or two procedures those surgeons are exposed to this particulate smoke. But the surgical team members like the surgical nurses or the techs, anesthesia providers, are in there much more often and are exposed to a greater amount of surgical smoke than individual surgeons are. Surgeons should not have any say in making decisions that will affect the health of the staff who are working with them. It should come from the occupational health and safety committee at the hospital.”

In addition to the aforementioned issues that have contributed to slow uptake of smoke removers, Ball says a certain complacency has crept into the exposed workforce. “They say, ‘I’ve been breathing it for so many years I am not going to bother with it now,’” she says. “Or, ‘We have smoke evacuators, but I just don’t want to pull them out to use them.’ We are trying to address this complacency in staff [by emphasizing] what could happen if you continue to breathe in surgical smoke. The research is there; we have already shown conclusively that this is a hazard. We have to get them educated.”

Ball is chairing the clinical advisory committee of the newly formed International Council on Surgical Plume, Inc. (, which is becoming a sort of clearing house for all data and publications on the longstanding issue. Surgical plume safety advocates are also pushing for state laws requiring worker protections.

“It may happen state by state, but when it goes — when it is finally approved by the state legislatures — that is going to be big,” Ball says. “One state is kind of leading the way, but we don’t want to publicize it yet until everything is through the legislature and then hospitals will be forced to use smoke evacuation.”


  1. NIOSH. Steege AL, Boiano J, Sweeney MH, et al. Surgical smoke and healthcare worker health and safety. American Public Health Association. Chicago: Oct.31-Nov. 4, 2016.
  2. NIOSH. Control of Smoke From Laser/Electric Surgical Procedures. Hazard Controls HC11. Publication No. 96-128. March 2, 1998.
  3. Skeptical Scalpel. Surgical smoke: Is it dangerous to your health? March 28, 2013:
  4. Hallmo P, Naess O. Laryngeal papillomatosis with human papillomavirus DNA contracted by a laser surgeon. Eur Arch Otorhinolaryngol 1991;248(7):425-427.
  5. Calero L, Brusis T. Laryngeal papillomatosis — first recognition in Germany as an occupational disease in an operating room nurse. Laryngorhinootologie. 2003;82(11):790-793.
  6. Ball, K. Compliance With Surgical Smoke Evacuation Guidelines: Implications for Practice. AORN J 2010;92:142-149.