To the Editor,

There is a growing interest in multimodal prehabilitation programs prior to surgery. Several recent guidelines have recommended multimodal prehabilitation programs that include smoking cessation. While preoperative smoking cessation programs reduce perioperative complications and increase long-term abstinence,1 the impact of smoking cessation interventions as part of multimodal prehabilitation programs has not been described. As such, we performed a systematic review to summarize the literature on prehabilitation programs that have included smoking cessation.

A literature search was performed in April 2018 of Medline, Medline In-Process, Embase, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, PubMed-NOT-Medline, CINAHL, Web of Science, and Scopus. Studies that evaluated the effect of preoperative smoking cessation as part of surgical prehabilitation were included.

The literature search identified seven studies for inclusion (Table). Five studies were observational studies and two were randomized-controlled trials. The study populations included patients undergoing elective thoracic, abdominal, and orthopedic surgeries. Interventions generally consisted of a combination of aerobic exercise, strength training, pulmonary rehabilitation, and lifestyle modification including smoking cessation.

Table Study characteristics
Full size table

Five studies assessed the effect of their interventions on postoperative outcomes. Three studies found an improvement in outcomes, primarily a reduction in postoperative pulmonary complications and hospital length of stay; however, two other studies failed to show a reduction in postoperative pulmonary complications.

Three studies examined the effect of the intervention on exercise capacity and health-related quality of life. The results show that the interventions can effectively improve exercise capacity; however, the results for quality of life were inconsistent.

Three studies reported the number of current smokers undergoing the intervention that quit smoking preoperatively, with abstinence rates from 46-100%. The results show that the interventions resulted in a high smoking abstinence rate prior to surgery; however, long-term abstinence was not measured in any of the studies.

Even though the evidence suggests some beneficial effects, the evidence for smoking cessation interventions in the context of multimodal prehabilitation programs is limited. Most of the studies were observational, and only two were randomized studies with small sample sizes. The studies were heterogeneous with regards to the surgical population, types of interventions, and outcomes. Most of the studies did not start the smoking cessation intervention early enough (at least four weeks before surgery—the minimum period shown to reduce postoperative complications).1 Most importantly, as no study compared prehabilitation programs with and without smoking cessation, we are not able to identify the specific benefits of preoperative smoking cessation in the context of a multimodal prehabilitation program and to examine potential synergistic effects.

Only three studies described in detail the smoking cessation interventions (a combination of counselling with or without nicotine replacement therapy). For preoperative smoking cessation, effective interventions should include both counselling and pharmacological components. In addition to direct counselling, telephone quit-lines and patient e-learning programs providing both preoperative and postoperative support improve quit rates.2,3 For pharmacotherapy other than nicotine replacement, varenicline and bupropion have been shown to help patients quit smoking perioperatively.4,5 None of these additional interventions were utilized in the included studies and should be considered in future multimodal prehabilitation trials. Additionally, the smoking cessation intervention should be started at least four weeks before surgery to reduce postoperative complications.1

Whether smokers are more likely to quit and have better postoperative outcomes if they are participating in multimodal prehabilitation programs versus smoking cessation interventions alone should be explored in future studies. It is important to investigate the efficacy and appropriateness of different aspects of such programs.