In the face of accumulating evidence and political momentum, there are still skeptics and critics who claim the hue and cry over surgical smoke is much ado about nothing.

The consensus from these observers seems to be that the risk to healthcare workers is being exaggerated by manufacturers trying to sell plume removal devices.1 But consider that this is the equivocal conclusion of a 2013 peer-reviewed article from the United Kingdom that is commonly cited among the evidence that the threat is overblown:

“The potentially carcinogenic components of surgical smoke are sufficiently small to be respirable,” the authors note.2 “Infective and malignant cells are found in the smoke plume, but the full risk of this to the theater staff is unproven. Future work could focus on the long-term consequences of smoke exposure.”

That is not particularly reassuring, especially to an OR nurse who may be inhaling surgical smoke for many hours a day throughout a full work week.

“I would challenge them to work in a smoky environment in the OR day after day like a perioperative nurse, tech, or anesthesia provider,” says Kay Ball, PhD, RN, CNOR, FAAN, professor of nursing at Otterbein University in Westerville, OH. “Our exposure is much greater than surgeons in many cases. My PhD research3 shows that perioperative nurses report twice the incidence of many respiratory problems compared to the general population.”

The duration and frequency of exposure is an important variable, says Christian DiPaola, MD, a surgeon at the University of Massachusetts Medical School in Worcester.

“Most surgeons have a clinic schedule and an OR schedule,” he says. “I tend to operate two or three days a week. An OR nurse or a scrub tech is going to be in that setting typically 40 hours a week. That’s an important factor.”

Still, it can be difficult to link long-term occupational exposure with development of disease, as another paper cited by skeptics concluded that “long-term exposure to surgical smoke, as measured by the duration of operating room employment, does not appear to increase the risk of lung cancer.”4

Intuitive Repulsion

Some compare the situation to cigarette smoking, which went through various research and challenges before being irrefutably linked to cancer. DiPaola, who uses smoke removal devices, cites more immediate reactions and intuitive repulsion.

“Have you smelled the air? Take a whiff and you’ll know it. Your brain is telling you,” he says. “You walk outside an OR where they are not using smoke evacuation — it smells like a barbecue.”

The presence of the smoke bothered him from the onset in surgery, but the only clinical sign DiPaola links to the smoke is headaches.

“There were times I would get headaches, and that is probably one thing I would tie to it,” he says. “I have allergies, anyway. I take seasonal allergy medication, and I certainly don’t want to be adding to that. I noticed the headaches got way better. But the long-term things, you are not going to necessarily link. Are you going to get lung cancer?”

To those outside the OR, it may be difficult to understand why anyone would willingly breathe surgical plume given these findings by the National Institute for Occupational Safety and Health (NIOSH).5

“Surgical smoke has been shown to contain a variety of toxic gases, vapors, and particulates including carbon monoxide, polyaromatic hydrocarbons, benzene, hydrogen cyanide, formaldehyde, viable and nonviable cellular material, viruses, and bacteria,” according to NIOSH. Transmission of human papillomavirus (HPV) “through surgical smoke has been documented,” NIOSH warns. “Surgical smoke has been shown to be mutagenic, cytotoxic, and genotoxic.”

Surgical smoke exposure can cause eye, nose, and throat irritation. It also has been linked to headaches, coughs, and nasal congestion, the agency notes.

“Surgical smoke has been shown to induce acute and chronic inflammatory changes (e.g., emphysema, asthma, chronic bronchitis) in the respiratory tract of animal models, but data on long-term effects of exposure to surgical smoke are not available,” NIOSH states.

Given such findings by the nation’s leading occupational health research agency, proponents of smoke removal have lost patience with what they see as a debate marked by false equivalency. After all, patients and healthcare workers alike see the no-smoking signs when they walk through the doors of any hospital.

“The sign on every front door reads ‘This is a Smoke-Free Facility,’” Ball says. “Maybe we should add, ‘Except in the OR.’ The evidence is there and the smoke evacuation equipment and devices are available, so why are some healthcare professionals still dragging their feet?”

Ball began researching and speaking on the surgical smoke issue more than three decades ago. She finds the prevailing complacence astounding, noting that there has been a near doubling of the Institute of Medicine’s estimate that it takes about 17 years to change clinical practice after research evidence shows it is warranted.

“It’s a challenge to enlighten the naysayers on all of the evidence showing surgical smoke is hazardous,” Ball says, noting that AORN has compiled a list of roughly 200 studies on the hazards of inhaling plume.

Both Ball and DiPaola say the solution is not as easy as healthcare workers wearing masks, which do not filter out the particles in surgical smoke.

“It doesn’t work — the mask doesn’t block smoke,” DiPaola says. “We are not wearing sealed respirator devices. We all have to get certified for TB masks so they have a certain level of air filtration, but the standard surgical masks don’t function that way.”

The issue may eventually have to be resolved in the courts, as people who develop cancer or another disease with no other risk factors than surgical smoke will hire attorneys and sue hospitals and surgery centers.

“One lawsuit and the whole system is going to be scrambling,” DiPaola says. “When the attorneys get involved and hospitals find they are on the hook, that is going to be the straw that breaks the camel’s back.”

Another aspect of the questioning and criticism is that plume-removal advocates are sometimes tarred with charges of conflict of interest. Some get involved in education or supporting the companies that manufacture the equipment. DiPaola discloses he has investments with one of the companies he contacted to find plume removal equipment. However, he emphasizes that he undertook to protect himself on his own initiative years earlier, trying to invent a plume removal device he could use during surgery.

Asked about this issue, Ball said, “I give noncommercial presentations on the hazards of surgical smoke and how to properly evacuate it. Sometimes my lectures are at conferences, and sometimes they are sponsored by industry. I never promote one product over another, and my lecture content is always based on evidence.”


  1. McFarlin UL. Blowing smoke: Profit motive — and scant evidence — propel dire warnings about surgical fumes. Stat May 11, 2017. Available at:
  2. Mowbray N, Ansell J, Warren N, et al. Is surgical smoke harmful to theater staff? a systematic review. Surg Endosc 2013;(9):3100-3107.
  3. Ball, K. Compliance with Surgical Smoke Evacuation Guidelines: Implications for Practice. AORN J 2010;92:142-149.
  4. Gates MA, Feskanich D, Speizer FE, et al. Operating room nursing and lung cancer risk in a cohort of female registered nurses. Scand J Work Environ Health 2007;33(2):140-147.
  5. Steege AL, Boiano JM, Sweeny MH. Secondhand Smoke in the Operating Room? Precautionary Practices Lacking for Surgical Smoke. Am J Ind Med 2016;59(11):1020–1031.