Smokers who do not try or do not succeed in quitting should not be offered a wide range of elective surgical procedures, according to an editorial published in the current issue of The Medical Journal of Australia.

The authors acknowledge this would be a controversial, overtly discriminatory approach, but they say it is also evidence-based.

Dr Matthew Peters and colleagues from Concord Repatriation General Hospital say smokers who undergo surgery have substantially higher risks, poorer surgical outcomes and therefore consume more healthcare resources than non-smokers.

These new concerns are not based on cardiac and respiratory risks, but increased wound infection. The authors cite numerous instances where infection rates are significantly higher in smokers.

Almost 8 per cent of breast reconstruction patients who smoke experience abdominal wall site necrosis, compared with 1 per cent of non-smokers.

"A randomised study examining smoking cessation intervention before joint replacement surgery, saw wound infection rates reduced from 27 per cent in continuing smokers to zero in those who quit smoking," Dr Peters said.

Dr Peters said patients should stop smoking at least six weeks prior to surgery, adding that smoking cessation three weeks prior to colorectal surgery was not associated with a benefit.

The reasons for higher infection rates in smokers are unclear, but the authors surmise that carbon monoxide (a by-product of cigarette smoke) decreases the supply of oxygen to body tissue, impairing the wound's capacity to heal. There are many other chemicals in cigarette smoke that could contribute to the adverse effects.

"Wound infection after joint replacement surgery is associated with increased risk of infection in the prosthesis, delays in hospital discharge, increased time to effective rehabilitation and massively increased cost of hospital care," Dr Peters said.

"Continuing smokers must accept that some risks are simply unacceptable given the intent of the surgery. The risk of adverse outcomes from wound infections alone is clear enough evidence to suggest that aesthetic plastic surgery should not be offered to current smokers.

"Public heath systems are faced with overwhelming demand and must generate the greatest benefit from limited resources.

"Continued smoking in the face of elective surgery increases the risk to the individual and stretches already stretched healthcare resources and expenditure unnecessarily.

"The community has to decide whether this is justified.

"If discriminatory policies are implemented, they must be matched by a commitment to fully and effectively support smokers in quitting, which is an altogether different challenge," Dr Peters said.

The Medical Journal of Australia is a publication of the Australian Medical Association.

CONTACT      Dr Matthew Peters             02 9767 6712 / 0407 499440

                   Judith Tokley, AMA             02 6260 5471 / 0408 824 306