For more than three decades, safety advocates have warned of the serious health dangers caused by surgical smoke. There is a simple solution that involves installing smoke evacuation devices in operating rooms (ORs). Still, the problem persists because of a lack of urgency among regulators and OR leadership.

“A lot of operating rooms don’t see the need to buy these to make a safe environment; hospitals are not justifying the cost, and it’s terrible because research about the dangers of OR smoke has been validated time and again,” says Kay Ball, PhD, RN, FAAN, professor of nursing at Otterbein University in Westerville, OH. Ball also is a perioperative consultant who speaks about OR smoke at educational sessions nationwide. She based her doctorate research on surgical smoke.

Ball’s research revealed that perioperative nurses report twice as many respiratory problems as the general population.1 Health problems for nurses and other staff working in ORs that produce surgical smoke have been known for decades.

“My first time talking [publicly] about surgical smoke was in 1985,” Ball says. “It long has been a problem, and laser technology brought it to everyone’s attention. It’s a workplace safety issue.”

“In a laser course in the 1990s, I remember a surgeon teaching us that there’s no such thing as safe smoke,” says Vangie Dennis, MSN, RN, CNOR, executive director, perioperative services, WellStar Atlanta Medical Center. “It doesn’t matter what we burn it with.”

Anyone who is exposed frequently to such smoke will experience respiratory symptoms. “When people start to experience symptoms of eyes watering, headaches, double vision, respiratory problems, emphysema, asthma, or when their symptoms worsen or are exacerbated, it’s time to get rid of surgical smoke,” Ball says. “Operating rooms need to evacuate the plume.”

The Association of periOperative Registered Nurses (AORN) has been following the surgical smoke issue since the early 1990s. “There were studies in the late 1980s that talked about the content of surgical smoke, comparing it to cigarette smoke,” says Mary Ogg, MSN, RN, CNOR, senior perioperative practice specialist at AORN. “If cigarette smoke is bad for us, then surgical smoke is, as well.”

After more than two decades of AORN advocating for government agencies to address this issue, OSHA was close to creating a regulation regarding surgical smoke, but it never happened, Ogg laments.

“Administrations change, and when that happens, priorities change, and it has not been on their radar,” Ogg says. “There is some language on OSHA’s website about evacuating smoke. Now, it falls under OSHA’s general duty clause of how operating rooms should provide a safe environment for employees.”2

Without a specific mandate from OSHA, many ORs do not include smoke evacuators, although many already contain equipment that could be adapted for this purpose. “It’s a simple solution to use an evacuator, and many surgery centers already have things in place,” Ogg explains.

For example, fluid waste systems can be adapted for smoke evacuation. Also, there are smoke evacuators in some surgery centers already — tucked into the back of closets. “They don’t know it’s there. That’s one we hear a lot,” Ogg reports. “I heard one story from a manufacturer about a hospital that said they wanted to do smoke evacuation. They did an inventory, finding out they had equipment already, but they didn’t use it.”

Dennis has helped operating rooms go smoke-free over the past 25 years. She developed a replicable formula for a smoke-free OR. (Editor’s Note: See the story on implementing a smoke-free program later in this issue.)

The hazards of surgical smoke make it worth the extra expense and effort, Ball notes. “There are over 150 chemical compounds in surgical smoke, and many are also in cigarette smoke,” she observes. “The size of the particles is a problem: 77% of them are less than 1.5 microns, so they can go right through the surgery mask.”

Those tiny particles settle into the lungs, exacerbating allergies, asthma, emphysema, and other lung conditions. “One nurse said, ‘I have to rinse out my sinuses every morning before coming to work, and then I rinse them out again. And I have to have inhalers in my purse because I’m exposed to surgical smoke so much,’” Ball recalls. “When you laser 1 gram of tissue, which is not a whole lot, it’s like smoking [six] unfiltered cigarettes. When using electrosurgery or laser surgery, it’s like smoking 27 to 30 cigarettes every day in a surgery suite.”3

Nurses have reported their facilities to OSHA, and OSHA has fined them, telling ORs to put smoke evacuators in every room, Ball says. “My research says that freestanding surgery centers are more compliant with smoke evacuation guidelines and recommendations,” she adds.

But not enough ORs follow best practices when it comes to smoke evacuation. “It’s easy to evacuate plume, but so many people don’t,” Ball says. “The cost of the evacuator can be $2,500. It’s well worth the cost because it protects staff, doctors, and nurses.”

There have been case studies of people who developed severe lung problems because of long-term exposure to surgical smoke, Ball adds. Some of those people even required lung transplants. The chief barriers to smoke-free ORs include apathy and inconvenience. “Physicians might say, ‘Don’t worry about it, it’s just a little bit of plume,’” Ball says. “But there is no safe amount of plume.”

Another barrier is that the evacuation devices are loud. “I heard a doctor say that the devices are too noisy, but the industry is making these less noisy,” Ball says.

Cost is another issue for some centers. “Smoke evacuators cost from $1,000 to $4,000, depending on features you want with them,” Dennis reports. “But some companies will place them if a surgery center buys the tubing and filters from them.”

The cost of a smoke-free OR is well worth it because it protects staff, doctors, and nurses, Ball says.


  1. Ball K. Compliance with surgical smoke evacuation guidelines: Implications for practice. ORNAC J 2012;30:14-16.
  2. Occupational Safety and Health Administration. Laser/Electrosurgery Plume. Available at: Accessed Sept. 26, 2019.
  3. Hill DS, O’Neill JK, Powell RJ, Oliver DW. Surgical smoke - A health hazard in the operating theatre: A study to quantify exposure and a survey of the use of smoke extractor systems in UK plastic surgery units. J Plast Reconstr Aesthet Surg 2012;65:911-916.