Current issues of ACP Journal Club are published in Annals of Internal Medicine


A preoperative smoking intervention decreased postoperative complications in elective knee or hip replacement


ACP J Club. 2002 Jul-Aug;137:7. doi:10.7326/ACPJC-2002-137-1-007

Source Citation

Møller AM, Villebro N, Pedersen T, Tønnesen H. Effect of preoperative smoking intervention on postoperative complications: a randomised clinical trial. Lancet. 2002 Jan 12;359:114-7. [PubMed ID: 11809253] (All 2002 articles were reviewed for relevancy, and abstracts were last revised in 2008.)



In patients having elective knee or hip replacement, is a preoperative smoking intervention more effective than usual care for reducing postoperative morbidity and mortality?


Randomized {allocation concealed*}†, blinded (outcome assessor),* controlled trial with follow-up time to discharge.


3 university-affiliated hospitals in Copenhagen, Denmark.


120 patients who were scheduled for primary elective hip or knee alloplasty and were daily smokers. Patients with a weekly alcohol intake > 35 units were excluded. 108 patients (90%) were included in the analysis (median age 65 y, 57% women).


At 6 to 8 weeks before surgery, 60 patients were allocated to the smoking intervention and were offered a weekly meeting with the project nurse. At the first meeting, a Fagerstöm test was done to estimate the patient’s nicotine dependence. Test results and patient preference were used to devise a personalized nicotine substitution schedule. Patients were strongly encouraged to stop smoking, but they also had the option to reduce tobacco consumption by ≥ 50%. Smoking status was monitored, and nicotine substitution products were provided free of charge. At subsequent meetings, tobacco use was recorded, and patients were given advice about smoking cessation or reduction, benefits and side effects, and management of withdrawal symptoms and weight gain. 60 patients were allocated to usual care (little or no information or counseling on smoking).

Main outcome measures

Postoperative complications (death or postoperative morbidity requiring treatment within 4 wk after surgery).

Main results

Analysis was by intention to treat. No patients died before discharge. Rates of any postoperative complication and wound-related postoperative complications were lower in the smoking-intervention group than in the usual-care group (Table).


A preoperative smoking intervention was more effective than usual care for reducing any postoperative and wound-related postoperative complications in patients having elective knee or hip replacement.

*See Glossary.

†Information provided by author.

Sources of funding: Danish Research Councils; Danish Ministry of Health; Director Danielsen’s Foundation. Pharmacia Upjohn sponsored the nicotine substitution products.

For correspondence: Dr. A.M. Møller, Bispebjerg University Hospital, Copenhagen, Denmark. E-mail

Table. Smoking intervention vs usual care in elective knee or hip replacement‡

Outcomes to time of discharge Intervention Usual care RRR (95% CI)§ NNT (CI)
Any postoperative complication 18% 52% 65% (42 to 83) 3 (2 to 6)
Wound-related postoperative complication 5% 31% 83% (48 to 95) 4 (2 to 8)

‡Abbreviations defined in Glossary.
§CI calculated from data in article.


Preoperative assessment seeks to reduce postoperative morbidity or mortality. These assessments are typically for patients with increased risk for cardiac and pulmonary complications. Smoking within 8 weeks of surgery increases postoperative pulmonary, cardiovascular, infectious, and wound complications (1). Although patients are encouraged to stop smoking before elective surgery, no prospective data exist to validate this advice. The study by Møller and colleagues showed that a formal smoking-cessation program reduced postoperative complications and wound-related complications in motivated patients having elective hip or knee replacements.

In this small study population, no deaths occurred before discharge so that no conclusions for effects on mortality could be drawn. The 120 patients who entered the study were those who agreed to participate among the 166 who were eligible, and the study was done in Denmark, so generalizability of the results may be somewhat limited. For example, the median hospital stay in this study was 12 days compared with 5 days in the United States (2). The patients were given an American Society of Anesthesiology Physical Status Score classification, which is a subjective risk assessment; an objective cardiac or pulmonary risk assessment (3, 4) would have reassured me that the intervention and control groups were similar in overall medical health.

Any intervention that reduces postoperative morbidity warrants attention. The study should be replicated in other settings, and a cost–benefit analysis should be done. Meanwhile, patients who are scheduled for elective surgery and who currently smoke should be encouraged to quit smoking by using whatever formal smoking-cessation interventions are locally available.

Elizabeth Kozak, MD
Spectrum Health Primary Care Partners
Grand Rapids, Michigan, USA


1. UpToDate. Wellesley, MA: UpToDate Inc; 2002.

2. HCUPnet, Healthcare Cost and Utilization Project, Rockville, MD, Agency for Healthcare Research and

3. Goldman L, Caldera DL, Nussbaum SR, et al. Multifactorial index of cardiac risk in noncardiac surgical procedures. N Engl J Med. 1977;297:845-50. [PubMed ID: 904659]

4. Arozullah AM, Daley J, Henderson WG, Khuri SF. Multifactorial risk index for predicting postoperative respiratory failure in men after major noncardiac surgery. The National Veterans Administration Surgical Quality Improvement Program. Ann Surg. 2000;232:242-53. [PubMed ID: 10903604]