The Joint Commission recently issued a safety advisory about the dangers of surgical smoke.

  • Surgical smoke can contain toxic gases, vapors, viruses, and bacteria, all of which can be harmful to operating room staff and patients.
  • Problems with surgical smoke were known for decades, but only in recent years have some states sought to address this problem with legislation mandating evacuation systems.
  • Researchers defined surgical smoke for use in future research and to help policymakers and leaders with adopting evacuation practices.

A new study and an advisory from The Joint Commission have put more attention on the decades-old problem of dangerous surgical smoke.1,2

The Joint Commission says a surgical smoke plume can contain toxic gases and vapors, including benzene, hydrogen cyanide, and formaldehyde.2 This smoke also may contain bacteria and viruses that could affect the health of OR staff.1

“Surgical smoke is a workplace safety hazard for the perioperative team, and it may have negative affects for patients, too,” says Rebecca Vortman, DNP, RN, CNOR, clinical assistant professor at the University of Illinois at Chicago.

Surgical smoke has been a problem in ORs for more than 30 years. Research has shown perioperative nurses report respiratory problems twice as often as found in the general public.3,4

There is less risk for patients who are exposed to the smoke short-term. But surgeons, perioperative nurses, and other OR staff are exposed to the smoke daily, which can cause ocular and upper respiratory tract irritation, as well as visual problems.2 The Occupational Safety and Health Administration and the National Institute of Occupational Safety and Health recommend ORs use local smoke evacuation systems and ventilation techniques.2

The Association of periOperative Registered Nurses (AORN), ECRI, and the American National Standards Institute provide standards and guidance on how to handle safety concerns of surgical smoke. The Joint Commission advisory says healthcare organizations that conduct surgery should implement standard procedures for removing smoke through evacuators and high-filtration masks.

Perhaps the best solution is for state governments to pass laws mandating healthcare facilities to evacuate surgical smoke. There have been discussions over the years of a federal bill, but nothing has happened. Some states have passed their own bills. Rhode Island and Colorado require smoke evacuation systems and written policies regarding such. Rhode Island’s mandate took effect Jan. 1, 2019, and the Colorado mandate will go into effect in May 2021.5,6

Executive nurse leaders can collaborate with states and professional organizations to advocate for smoke evacuation legislation, and they can create policies at their facilities to mitigate surgical smoke.7

“We have decades of research saying surgical smoke is harmful,” Vortman says. “Evacuating surgical smoke is effective and the right practice, based on evidence, to keep surgical team members and patients safe.”

Surgical smoke evacuation devices are affordable, especially when compared with the costs of employee sick days and negative health consequences. The estimated cost of using a smoke evacuation device is $19 per surgical procedure. A case of ultra-low particulate air filters, placed in the evacuators, is $25 each. Electrosurgery pencils used with smoke evacuation tubing cost about $20, in comparison to $5 for the standard electrosurgical pencil.7

The estimated loss of productivity related to illness in the United States is $530 billion a year. However, specific estimates of what surgical smoke costs in employee health and sick days needs further study.7

Vortman’s latest research is a concept analysis of surgical smoke to provide a better definition for future investigations and also for leaders and policymakers to use when adopting evacuation practices.

The paper defines surgical smoke as “a visible plume of aerosolized combustion byproducts produced during electrosurgery.”1 The definition also includes a description of what comprises surgical smoke, how it is distributed in the OR, how it is produced, how it can cause physical symptoms, how it can obscure the surgical field, and the odor.

“When you smell surgical smoke, you always remember what it smells like,” Vortman says. “There is no other smell like that.”

Despite the known dangers and available solutions, other barriers remain, including noise perceptions and concerns about “bulky” tubing. Also, some professionals still simply do not understand the problem. Without understanding, managerial support may evaporate. Perioperative nurses will not be able to convince surgery centers to invest in smoke evacuation equipment and supplies without managerial support.

Start conversations of reform by providing continuing education about the dangers of surgical smoke and available solutions. Use attention-grabbing data, like how surgical smoke exposure is similar to inhaling as many as 30 unfiltered cigarettes, or how perioperative teams report twice as many respiratory health issues as the general public.7

Vortman worked in an OR where orthopedic surgeries were performed in the early 2010s. She recalls experiencing regular problems with upper respiratory infections. “The smoke was thick in those procedures,” she explains. “When I compare my health now vs. back then, I don’t have nearly the number of sore throats and respiratory illness.”

Other symptoms reported by perioperative teams in surgical smoke environments include headaches, watery eyes, cough, sneezing, drowsiness, dizziness, and rhinitis.2,7

“I would love to see every state in the U.S. have smoke-free operating rooms,” Vortman offers. “I think our perioperative team members deserve to breathe clean air in the OR. They work hard for their patients and each other. They need to work in a safe environment that is smoke-free.”


  1. Vortman R, McPherson S, Wendler C. State of the science: A concept analysis of surgical smoke. AORN J 2021;113:41-51.
  2. The Joint Commission. Quick Safety Issue 56: Alleviating the dangers of surgical smoke. Dec. 16, 2020.
  3. Ball K. Compliance with surgical smoke evacuation guidelines: Implications for practice. ORNAC J 2012;30:14-16.
  4. Young M. Surgery’s not-so-secret problem: Operating room smoke is hurting nurses’ health. Same-Day Surgery. November 2019.
  5. AORN. Colorado second state to enact surgical smoke evacuation law. March 28, 2019.
  6. Doyle C. Surgical smoke: A risk too real to ignore. OR Management News. Sept. 14, 2020.
  7. Vortman R, Thorlton J. Empowering nurse executives to advocate for surgical smoke-free operating rooms. Nurse Leader. Nov. 20, 2020.