Smoking Cessation Before Surgery

Smoking impairs healing in several ways that matter directly to spinal surgery. It reduces the blood supply and oxygen delivery to tissues and to bone, interferes with the biology of bone formation, and slows and weakens the process by which a fusion knits together. The most important practical consequence is a higher rate of non-union — where a fusion fails to become solid, a condition called pseudarthrosis — which can leave a person with ongoing pain and sometimes the need for further surgery. Smoking is also linked to more wound and general complications and, in some studies, to a higher chance of needing revision surgery. These are not small effects, which is why I take the issue seriously.

The encouraging side of this is that stopping smoking, particularly in the weeks before an operation, measurably reduces these risks. Preoperative smoking cessation improves quit rates and is associated with fewer complications, and giving the body time without tobacco before and during the healing period improves the chances of a fusion uniting. Even where someone finds it very hard to stop permanently, a period of abstinence around the operation is worthwhile. I frame this not as a hurdle but as one of the most effective things a person can do to improve their own surgical result.

Stopping smoking is genuinely difficult, and willpower alone is often not enough, so the right support makes a large difference. Structured stop-smoking services, GPs, nicotine replacement and other aids all improve success rates, particularly when started well before the operation. My role is to explain clearly and honestly why it matters for their surgery, and to help people access that support in good time; the cessation programme itself is delivered by those services. For planned fusion surgery in particular, I regard giving people the time and the referral to stop as an important part of preparation.

The evidence here is strong and consistent. A Cochrane review found that intensive preoperative smoking-cessation interventions increase quit rates and may reduce complications. Systematic reviews of smoking and spine surgery show higher rates of pseudarthrosis and complications in smokers and benefit from cessation, and a meta-analysis confirmed a substantially higher risk of spinal non-union in smokers. Studies in cervical and deformity surgery link smoking to more complications and reoperation, and smoking is an independent risk factor for reoperation after disc surgery. This body of evidence is why I counsel every smoker facing surgery to stop and to accept the support to do so.

Where surgery is planned, I encourage stopping smoking as early as possible beforehand and help arrange referral to stop-smoking support; the ideal is to stop several weeks before and to remain off tobacco through the healing period. The cessation support is provided by dedicated services and the GP. Stopping is one of the clearest ways a person can improve their own chances of a solid fusion and a smooth recovery.

• —Thomsen T, et al. Interventions for preoperative smoking cessation. Cochrane Database Syst Rev 2014. (PMID 24671929)
• —Berman D, et al. The effects of smoking and smoking cessation on spine surgery: a systematic review. Global Spine J 2017. (PMID 27781190)
• —The risk of nonunion in smokers revisited: a systematic review and meta-analysis. 2021. (PMID 34583570)
• —Relationship between smoking and postoperative complications of cervical spine surgery: systematic review and meta-analysis. Sci Rep 2022. (PMID 35654928)
• —Impact of smoking on 30-day morbidity and mortality in adult spinal deformity surgery. Spine 2016. (PMID 27434180)
• —Smoking is an independent risk factor of reoperation due to recurrent lumbar disc herniation. 2018. (PMID 29977723)