Research, reimbursement support: Motivate patients to stop smoking

Physicians, anesthesiologists reimbursed for cessation counseling

A just-released study showing that smokers have significantly more complications post-surgery than non-smokers, including a higher death rate, coupled with new Medicare reimbursement for physicians who provide counseling to prevent tobacco use for outpatients and hospitalized patients have outpatient surgery managers taking a new look at smoking cessation programs.

The results from the study conducted by The Cleveland (OH) Clinic, released at the recent Anesthesiology 2010 meeting of the American Society of Anesthesiologists, show increased incidents of adverse outcomes among smokers, including surgical site infections, respiratory complications, pneumonia risk, unplanned intubation, artificial mechanical ventilation, cardiac arrest, heart attack, stroke, and death. The more patients smoke, the more complications they were likely to experience, the study found. (See details of study's findings, below.)

"Hopefully, surgeons can utilize the upcoming operation as a "teachable moment" to educate their patients about their risks of postoperative wound infection, failure of the intended procedure — i.e. recurrence of an incisional hernia — hospital readmission, prolonged intubation, and postoperative pneumonia, which are clearly documented in the medical literature," says John Maa, MD, FACS, assistant professor in the Department of Surgery and assistant chair, Surgery Quality Improvement Program, at the University of California — San Francisco.

And now physicians have another incentive. Since Aug. 25, 2010, the Centers for Medicare & Medicaid Services (CMS) has covered counseling services to prevent tobacco use for outpatients and hospitalized patients. CMS will cover tobacco cessation counseling for outpatient and hospitalized Medicare beneficiaries:

  • who use tobacco, regardless of whether they have signs or symptoms of tobacco-related disease;
  • who are competent and alert at the time that counseling is provided; and
  • whose counseling is furnished by a qualified physician or other Medicare-recognized practitioner. Some private payers have followed Medicare and also are reimbursing physicians for tobacco cessation counseling. There is no reimbursement from Medicare that covers the facility fee.

Some studies have indicated that people are more likely to quit smoking when they have a surgical procedure scheduled. [For more information, see "Surgery Is Good 'Teachable Moment' to Help Smokers Quit," Same-Day Surgery Weekly Alert, July 16, 2010. To subscribe to our free ezine, contact customer service at or (800) 688-2421.] During informed consent, surgeons can discuss active smoking and its risks "and many patients, once they are made aware of the potential adverse outcomes resulting from their active smoking, will choose to delay surgery and try to stop smoking in their own interest of safety," Maa says.

Smoking cessation is not without its challenges, he acknowledges. "Smoking cessation is indeed a lengthy and challenging process, which often requires multiple efforts to achieve success," Maa says. "It is indeed difficult for surgeons to counsel patients in this time-intensive process, and recruiting the assistance of additional staff and resources is essential, as attempting to achieve this task alone is unlikely to be fruitful."

Consider involving the patient's referring provider, as well as family and children, anesthesiologists, administrators, and respiratory therapy staff, Maa advises.

Anesthetists play a role

The American Society of Anesthesiologists (ASA) encourages anesthesiologists to use a three-step method of "ask, advice, and refer," says David O. Warner, MD, professor of anesthesiologist, Mayo Clinic, Rochester, MN, and leader of the smoking cessation initiative of the ASA. According to Warner, anesthesiologists should:

  • Ask all patients about their tobacco use.
  • Advise those who do use to stop.
  • Refer patients to other resources that can get them the assistance they need to quit successfully. The primary resources are free telephone quitlines, which provide extended counseling services, Warner says. Those services can be accessed through the toll-free number (800) QUIT NOW, which directs callers to quitline services in their area. The quitline counselors tailor a quit plan and advice for each individual caller, Maa says.

Maa says, "Having adequate brochures and cards to refer patients to quitlines and outpatient counseling services ... can help save time."

Physicians can prescribe low dose nicotine replacement, Maa says, "and it may be worthwhile to familiarize oneself with the types of medications and services that Medicare, Medicaid, and standard insurance companies will reimburse for patient out-of pocket expenses."

Also, it might be appropriate to cancel the operation, even on the morning of surgery, if there is evidence that a patient has not been compliant with required preop smoking cessation, or if the anesthetic and cardiopulmonary risks to the patient are significant, he says. "For some patients at risk of noncompliance, it is useful to encourage compliance by alerting the patient that a serum cotinine concentration or a urinary test strip for nicotine content can be performed the morning of surgery to monitor their tobacco use," Maa adds.

Physicians have a "special and unique opportunity" when it comes to smoking cessation, he says. Discussing smoking cessation not only will provide benefits for the surgical procedures, "but also for their patient's overall health looking beyond the procedure," Maa says. He advises physicians to "not allow this excellent opportunity to improve the overall health of Americans to be lost." (The Agency for Healthcare Research and Policy has a smoking cessation guideline.)


  • The American Cancer Society has resources to stop smoking. Web:
  • The American Society of Anesthesiologists has information for patients and anesthesiologists about its stop smoking program. The site includes information about anesthesiologist billing for smoking cessation counseling. Web:
  • The Medicare Learning Networks offers information on physician reimbursement for tobacco cessation counseling. Web:
  • The U.S. government offers information on methods to help smokers quit. Web:

Details on complications smokers have after surgery

Smokers have higher rate of adverse outcomes

A recent study from The Cleveland (OH) Clinic found increased incidence of adverse outcomes among smokers. The study was presented at the Anesthesia 2010 meeting of the American Society of Anesthesiologists.

The researchers evaluated 635,265 patients from the American College of Surgeons National Surgical Quality Improvement Program database. There were more than 200 participating centers prospectively collecting data with standardized methods. The study compared 82,304 smokers with 82,304 non-smoking patients who had similar surgical procedures and similar preoperative risk factors using sophisticated statistical techniques.

Some of the increased incidence of adverse outcomes among smokers included:

• Smokers were 40% more likely to develop major complications and die within 30 days of surgery.

• Smokers had an increased risk for respiratory complications.

• Pneumonia risk was doubled among smokers.

• Smokers were 87% more likely to experience unplanned intubation.

• Smokers were 53% more likely to require artificial mechanical ventilation that lasted more than 48 hours after surgery.

• Smokers saw a significant increase in cardiovascular complications and were:

— 57% more likely to experience cardiac arrest;

— 80% more likely to have a heart attack;

— 73% more likely to have a stroke.

• Surgical site complications also were higher among smokers. Smokers were:

— 30-42% more likely to have a surgical site infection;

— have a 30% increase in the risk for serious systemic infections such as sepsis.

How one facility helps patients stop smoking

Interventions offered before elective surgery

The University of California — San Francisco (UCSF) Medical Center uses a variety of interventions to help patients stop or reduce smoking before elective surgery.

In the outpatient setting, patients are referred to an in-hospital smoking cessation leadership program, tobacco education center, and a habit abatement center. "The goal is to facilitate the referral of active smokers to these resources, which offer inexpensive smoking cessation counseling, social support, and guide the use of cessation medication," says John Maa, MD, FACS, assistant professor in the Department of Surgery and assistant chair, Surgery Quality Improvement Program, UCSF.

As a first step, surgery patients are directed to smoking cessation quitlines through a national toll-free number (800-QUIT-NOW), Maa says. "They are also evaluated for immediate intervention with nicotine replacement therapy prescribed by the surgeon, which can be further coordinated with their referring primary care provider," he says.

Before most surgeries, patients are seen in the Prepare (pre-anesthesia) clinic. "The anesthesiologists or nurse practitioners will remind the patient of the benefits of preoperative smoking cessation, and again offer the resources of quitlines, the habit abatement clinic, or other measures to assist in smoking reduction," Maa says.