RSS 1.0Smoking and Tobacco
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Smoking habits, awareness and support needs for cessation among people with multiple sclerosis in Australia: findings from an online surveyOBJECTIVES: To assess smoking habits, nicotine use, exposure to passive smoking, awareness of associated harms, and experiences with and preferences for smoking cessation support among people with multiple sclerosis (MS). DESIGN: Online survey, convenience sampling. SETTING: Community setting, Australia. PARTICIPANTS: Adults living in Australia with probable or diagnosed MS were recruited via social media and newsletters to participate in 2020. RESULTS: Of the 284 participants in our convenience sample, 25.7% were current smokers (n=73) and 38.0% were former smokers (n=108). Awareness of the harms of smoking on MS onset (n=68, 24.3%) and progression (n=116, 41.6%) was low. Almost a quarter (n=67, 23.8%) of participants were regularly exposed to passive smoke, and awareness of associated harm was also low (n=47, 16.8%). Among current smokers, 76.1% (n=54) had tried quitting and 73.2% considered quitting within 6 months (n=52). Many participants reported perceived short-term benefits of smoking, and long-term benefits of quitting, on MS symptoms and general well-being (short-term n=28, 40.0%; long-term n=28, 82.4%). While most participants reported that their neurologist (n=126, 75.4%) or other healthcare providers (n=125, 74.9%) had assessed smoking status, very few neurologists (n=3, 1.8%) or other healthcare providers (n=14, 8.4%) had provided help with quitting. Most current smokers preferred speaking about smoking to a neurologist (n=36, 52.2%) or general practitioner (n=41, 59.4%). Almost 60% of the current smokers wanted additional cessation information specific to MS (n=41, 59.4%), and 45.5% said this information would motivate them to quit smoking (n=30). CONCLUSIONS: Our convenience sample, which may not be representative, indicated an urgent need for regular evidence-based smoking cessation supports for people with MS. Most participants felt they would benefit from smoking cessation advice. MS clinicians, in collaboration with patient organisations, smoking cessation services and general practitioners, should make smoking cessation promotion with people with MS a priority.
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Improving smoking cessation support for people with multiple sclerosis: A qualitative analysis of clinicians' views and current practiceIntroduction Smoking is a key modifiable risk factor in multiple sclerosis (MS). MS healthcare providers have a central role informing people of the deleterious effects of smoking on MS progression and promote smoking cessation, yet there is limited information about smoking cessation and support provided by these providers. This study aimed to gain an understanding of MS healthcare providers current practices, barriers and facilitators related to providing smoking cessation support for people with MS. Methods A total of 13 MS nurses and 6 neurologists working in public and private MS clinics across Australia were recruited through professional networks and MS organisations. Telephone interviews were conducted, transcribed and evaluated using framework analysis. Results MS nurses and neurologists reported that they routinely assess smoking status of people with MS at initial appointments and less regularly also at follow-up appointments. Clinicians considered it important to provide information about smoking impact on MS health outcomes and advise to cease smoking, but the content and delivery varies. Beyond this, some clinicians offer referral for smoking cessation support, while others stated this was not their responsibility, especially in light of competing priorities. Many were unsure about referral pathways and options, requiring more information, training and resources. Conclusion Results of this research indicate that there is potential to improve support for MS clinicians to promote smoking cessation among people with MS. Smoking cessation support may include tailored patient resources, clinician training and stronger collaboration with smoking cessation service providers.
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Barriers and motivators for tobacco smoking cessation in people with multiple sclerosisINTRODUCTIONSmoking is a key modifiable risk factor for health outcomes of people with multiple sclerosis (MS). Little evidence exists on whether the information and support needs of people with MS who smoke are met. This study aimed to explore knowledge, attitudes and beliefs about smoking and quitting, and quitting support needs in Australian people with MS.METHODSCurrent and recent smokers were recruited for phone interviews through social media and newsletters. Interview data were analysed in NVivo using framework analysis.RESULTSWe interviewed 25 people with MS (20 current and five recent smokers). Many participants had little knowledge about the risks of smoking on MS progression. Some reported perceived benefits from smoking on MS symptoms, while others perceived smoking worsening their symptoms. Similarly, quitting was believed to have health benefits, but concerns about withdrawal symptoms and the impact on MS symptoms and relapses were common. Participants reported ambivalence discussing smoking with clinicians; some wanting more information and support, while also feeling shame or guilt. Many participants were asked about their smoking status by MS clinicians, however, the provision of evidence-based information, and referrals to quitting support services was very infrequent. General practitioners were often found helpful and supportive, but participants gave more weight to quit advice from MS clinicians.CONCLUSIONOur results are the first to indicate that smoking cessation needs of Australian people with MS are not met. These findings should be confirmed in a larger sample, but there is potential to investigate whether implementing routine provision of brief advice in MS care, as a coordinated effort between MS researchers, practitioners, consumer advocates and behavioural intervention services, may meet these needs. Further, developing targeted resources and training quit counsellors to provide appropriate information and support specific to people with MS may improve smoking cessation success in people with MS.
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Modifiable risk factors for poor health outcomes in multiple sclerosis: The urgent need for research to maximise smoking cessation successTobacco smoking is a well-established risk factor for multiple sclerosis (MS) onset, progression and poor health outcomes in people with MS. Despite smoking being a modifiable risk factor, no research has been undertaken to understand how, or who is best placed, to assess or understand smoking behaviour in people with MS, or how healthcare professionals can best assist people with MS to quit. People with MS may have unique motivators to continue smoking, or unique barriers to smoking cessation, that are not addressed by existing cessation tools. Research is urgently needed in this area if the aim is to maximise health outcomes for all people with MS.
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Lung cancer screening: does pulmonary nodule detection affect a range of smoking behaviours?Background: Lung cancer screening can reduce lung cancer mortality by 20%. Screen-detected abnormalities may provide teachable moments for smoking cessation. This study assesses impact of pulmonary nodule detection on smoking behaviours within the first UK trial of a novel auto-antibody test, followed by chest x-ray and serial CT scanning for early detection of lung cancer (Early Cancer Detection Test-Lung Cancer Scotland Study). Methods: Test-positive participants completed questionnaires on smoking behaviours at baseline, 1, 3 and 6 months. Logistic regression compared outcomes between nodule (n = 95) and normal CT groups (n = 174) at 3 and 6 months follow-up. Results: No significant differences were found between the nodule and normal CT groups for any smoking behaviours and odds ratios comparing the nodule and normal CT groups did not vary significantly between 3 and 6 months. There was some evidence the nodule group were more likely to report significant others wanted them to stop smoking than the normal CT group (OR across 3- and 6-month time points: 3.04, 95% CI: 0.95, 9.73; P = 0.06). Conclusion: Pulmonary nodule detection during lung cancer screening has little impact on smoking behaviours. Further work should explore whether lung cancer screening can impact on perceived social pressure and promote smoking cessation.
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A survey of smoking behaviour and attitudes to quitting in psychiatric outpatientsBackground: Patients with psychiatric illnesses, especially schizophrenia smoke in excess compared to general population. Smoking is associated with excess morbidity and mortality in general population as well as psychiatric patients. Smoking cessation is associated with improved physical and mental health outcomes. Aim: To ascertain the smoking behaviour and attitude to quitting in a sample of Pakistani psychiatric outpatients with a view to increasing awareness and suggest appropriate interventions. Method: One hundred willing patients from psychiatry outpatient department, who identified themselves as smokers were invited to take part in a semi-structured survey. The questionnaire included inbuilt CAGE screening questionnaire modified for smoking Results: Out of 100 smokers who participated in the survey, 45% screened positive for nicotine dependence and 62% of them smoked at least 20 or more cigarettes a day. 91% of all smokers attributed their smoking to habit. Amongst a range of emotional states, boredom and anxiety or worry were identified as the most common reason for smoking by all smokers, whether nicotine dependent or non-dependent. Conclusion: A high proportion of psychiatric patients who smoke are dependent on nicotine. Habit and anxiety or worry and boredom have been identified as the most common reasons for smoking. Majority of smokers are able to identify potential health and economic benefits of quitting, however find the idea of quitting difficult.
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The experience of a smoke-free policy in a medium secure hospitalAims and method: A Trust-wide smoke-free policy was introduced in March 2007. This service evaluation retrospectively reviewed the outcome by focusing on recorded changes in behaviour, incidents and prescribing. Results: The majority of patients (89%) smoked before the smoke-free policy. There was no significant change in the rate of clinical incidents or the use of tranquillising medication at 3 months and 12 months post-implementation. Clozapine serum levels were raised significantly, necessitating dose reduction in 17% of patients. Fifty-four per cent of patients used nicotine replacement therapy and a small minority continued this treatment for 12 months. Clinical implications: Despite initial concerns there were no significant problems in implementation of the smoke-free policy. This was assisted by extensive preparation, education, patient advocacy and access to treatment beforehand. Declaration of interest: None.
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Impact of a total smoking ban in a high secure hospitalAims and method: To assess the impact of a total smoking ban in a high secure psychiatric hospital. Staff and patients were surveyed before and after implementation. Data were collected on untoward incidents, seclusions, nicotine replacement therapy and changes in psychotropic medication. Results: Of the 298 patients in the hospital for the evaluation period, 72.8% were smokers before the ban. There were no significant differences in rates of seclusion before and after the ban and only one significant comparison (P = 0.01) showed an increase in untoward incidents for smokers. There were no significant increases in the use of psychotropic medication after the ban. Clinical implications: With adequate preparation, it is possible to implement a total smoking ban in a high secure psychiatric setting without serious negative consequences. Declaration of interest: None.
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Smoking prevalence and knowledge of associated risks in adult attenders at day centres for people with learning disabilitiesBACKGROUND: Increased longevity among people with learning disabilities is accompanied by an increase in morbidity. A possible explanation is that living in the community and a move to greater independence may bring higher health risks through obesity and smoking. The study aimed to see if rates of smoking have increased from earlier published rates and to ascertain the awareness of the risks of smoking among people with learning disabilities.
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Efficacy and safety of bupropion for smoking cessation and reduction in schizophrenia: Systematic review and meta-analysisBackground The benefits and harms of bupropion as an aid for smoking cessation in schizophrenia remain uncertain. Aims To summarise the current evidence for efficacy and safety of bupropion as treatment for nicotine dependence in schizophrenia. Method Systematic review and random-effects meta-analysis of randomised controlled trials (RCTs) comparing bupropion with placebo or alternative therapeutic control in adult smokers with schizophrenia. Results Twenty-one reports from seven RCTs were included. Biochemically verified self-reported smoking cessation rates after bupropion were significantly higher than placebo at the end of treatment (risk ratio (RR)=2.57, P=0.004) and at 6 months (RR = 2.78, P=0.05). Expired carbon monoxide level was significantly lower with bupropion at the end of therapy (P=0.002) but not at 6 months (P=0.37). There was no significant difference in positive (P=0.28) or negative symptoms (P=0.49) between the bupropion and the placebo group. Conclusions Bupropion increases the rates of smoking abstinence in smokers with schizophrenia, without jeopardising their mental state.
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Interventions for smoking cessation and reduction in individuals with schizophreniaBackground Individuals with schizophrenia smoke more heavily than the general population and this contributes to their higher morbidity and mortality from smoking-related illnesses. It remains unclear what interventions can help them to quit or to reduce smoking. Objectives To evaluate the benefits and harms of different treatments for nicotine dependence in schizophrenia. Search methods We searched electronic databases including MEDLINE, EMBASE and PsycINFO from inception to October 2012, and the Cochrane Tobacco Addiction Group Specialized Register in November 2012. Selection criteria We included randomised trials for smoking cessation or reduction, comparing any pharmacological or non-pharmacological intervention with placebo or with another therapeutic control in adult smokers with schizophrenia or schizoaffective disorder. Data collection and analysis Two reviewers independently assessed the eligibility and quality of trials, as well as extracted data. Outcome measures included smoking abstinence, reduction in the amount smoked and any change in mental state. We extracted abstinence and reduction data at the end of treatment and at least six months after the intervention. We used the most rigorous definition of abstinence or reduction and biochemically validated data where available. We noted any reported adverse events. Where appropriate, we pooled data using a random-effects model. Main results We included 34 trials (16 trials of cessation; nine trials of reduction; one trial of relapse prevention; eight trials that reported smoking outcomes for interventions aimed at other purposes). Seven trials compared bupropion with placebo; meta-analysis showed that cessation rates after bupropion were significantly higher than placebo at the end of treatment (seven trials, N = 340; risk ratio [RR] 3.03; 95% confidence interval [CI] 1.69 to 5.42) and after six months (five trials, N = 214, RR 2.78; 95% CI 1.02 to 7.58). There were no significant differences in positive, negative and depressive symptoms between bupropion and placebo groups. There were no reports of major adverse events such as seizures with bupropion. Smoking cessation rates after varenicline were significantly higher than placebo, at the end of treatment (2 trials, N = 137; RR 4.74, 95% CI 1.34 to 16.71). Only one trial reported follow-up at six months and the CIs were too wide to provide evidence of a sustained effect (one trial, N = 128, RR 5.06, 95% CI 0.67 to 38.24). There were no significant differences in psychiatric symptoms between the varenicline and placebo groups. Nevertheless, there were reports of suicidal ideation and behaviours from two people on varenicline. Two studies reported that contingent reinforcement (CR) with money may increase smoking abstinence rates and reduce the level of smoking in patients with schizophrenia. However, it is uncertain whether these benefits can be maintained in the longer term. There was no evidence of benefit for the few trials of other pharmacological therapies (including nicotine replacement therapy (NRT)) and psychosocial interventions in helping smokers with schizophrenia to quit or reduce smoking. Authors' conclusions Bupropion increases smoking abstinence rates in smokers with schizophrenia, without jeopardizing their mental state. Varenicline may also improve smoking cessation rates in schizophrenia, but its possible psychiatric adverse effects cannot be ruled out. CR may help this group of patients to quit and reduce smoking in the short term. We failed to find convincing evidence that other interventions have a beneficial effect on smoking in schizophrenia.
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Interventions for smoking cessation and reduction in individuals with schizophreniaBackground Patients with schizophrenia smoke more heavily than the general population and this contributes to their higher morbidity and mortality from smoking-related illnesses. It remains unclear what interventions can help them to quit or reduce smoking. Objectives To evaluate the benefits and harms of different treatments for nicotine dependence in schizophrenia. Search strategy We searched the Cochrane Tobacco Addiction Group Specialized Register and electronic databases including MEDLINE, EMBASE and PsycINFO from inception to April 2010. Selection criteria We included randomized trials for smoking cessation or reduction, comparing any pharmacological or non-pharmacological intervention with placebo or with another therapeutic control in adult smokers with schizophrenia or schizoaffective disorder. Data collection and analysis Two reviewers independently assessed the eligibility and quality of trials and extracted data. Outcome measures included smoking abstinence, reduction in the amount smoked and any change in mental state. We extracted abstinence and reduction data at the end of treatment and at least six months after the intervention. We used the most rigorous definition of abstinence or reduction and biochemically validated data where available. Any reported adverse events were noted. Where appropriate, we pooled data using a random effects model. Main results We included 21 trials (11 trials of smoking cessation; four trials of smoking reduction; one trial for relapse prevention; five trials reported smoking outcomes for interventions aimed at other purposes). Seven trials compared bupropion with placebo; meta-analysis showed that smoking cessation rates after bupropion were significantly higher than placebo at the end of treatment (seven trials, N= 340; risk ratio [RR] 2.84; 95% confidence interval [CI] 1.61 to 4.99) and after six months (five trials, N=214, RR 2.78; 95% CI 1.02 to 7.58). Expired carbon monoxide (CO) level and the number of cigarettes smoked daily were significantly lower with bupropion at the end of therapy but not after six months. There were no significant differences in positive, negative and depressive symptoms between bupropion and placebo group. There was no report of major adverse event such as seizures with bupropion. Contingent reinforcement (CR) with money may increase smoking abstinence rates and reduce the level of smoking in patients with schizophrenia. However, it is uncertain whether these benefits are maintained in the longer term. There was no evidence of benefit for the few trials of other pharmacological therapies (including nicotine replacement therapy (NRT)) and psychosocial interventions in helping smokers with schizophrenia to quit or reduce smoking. Authors' conclusions Bupropion increases smoking abstinence rates in smokers with schizophrenia, without jeopardising their mental state. Bupropion may also reduce the amount these patients smoke. CR may help this group of patients to quit and reduce smoking. We failed to find convincing evidence that other interventions have a beneficial effect on smoking behaviour in schizophrenia.
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Smoking in pregnancy: The role of the transtheoretical model and the mother's attachment to the fetusThis study investigated whether pregnant smokers demonstrated cognitive and behavioural patterns hypothesised to underpin the different stages of change (SOC) and whether fetal attachment varied according to this process. A cross-sectional design with women categorised by SOC was used and the sample was recruited from hospital maternity services in the U.K. at their booking clinics with a mean gestation of 14 weeks. Experiential and behavioural processes together with self-efficacy and attachment to the fetus were measured in 637 women. As predicted by the transthoretical model experiential processes were used mostly by women in contemplation and preparation; behavioural processes mostly by women in preparation and action. However, self-efficacy remained constant between precontemplation, contemplation and preparation, but women in action showed significantly higher levels. Women in preparation were significantly more attached to the fetus than women in precontemplation and never smokers. The relevance of the transtheoretical model with pregnant smokers is supported. Foetal attachment may be differentially associated with different SOC in smoking cessation and yield potential for the development of new interventions. (PsycINFO Database Record (c) 2016 APA, all rights reserved)(journal abstract)
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Total smoking cessation and clozapine treatment - a diabetogenic combination?Presents the case report of a series of five patients, all from one consultant psychiatrist's caseload of twenty inpatients detained on the same ward in a high-secure psychiatric hospital in England. All five stopped smoking following a hospital-wide smoking ban implemented on 1st April 2007. Prior to the ban, improvements had been made in screening procedures and monitoring for patients receiving clozapine. Each patient was prescribed a therapeutic dose of clozapine both before and after the smoking ban. All five developed type 2 diabetes mellitus during the 3 months after the ban. Each patient gave informed written consent for inclusion in anonymized research relating to the smoking ban and their treatment. The five cases appeared in quick succession. We conclude that the diabetic status of patients about to undergo total smoking cessation must be very closely monitored throughout and for many months postcessation. The clozapine serum level in patients about to quit smoking must also be closely monitored and, given that a rapid rise in serum level may be a trigger, consideration should be given to a pre-emptive dose reduction. However, because large serum level rises are not ubiquitous, this carries with it a risk of patients experiencing a suboptimal serum level for a period and possibly suffering a consequent relapse. (PsycINFO Database Record (c) 2016 APA, all rights reserved)
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A retrospective evaluation of the impact of total smoking cessation on psychiatric inpatients taking clozapineObjective: To investigate the effect of a complete smoking ban on a group of psychiatric inpatients maintained on the antipsychotic medication clozapine.; Method: Retrospective data on clozapine dose and plasma levels were collected from a three month period before and a six month period after the introduction of the smoking ban.; Results: Before the ban only 4.2% of patients who smoked had a plasma clozapine level > or =1000 microg/l but after the ban this increased to 41.7% of the sample within the six month period following the ban despite dose reductions.; Conclusion: Abrupt cessation of smoking is associated with a potentially serious risk of toxicity in patients taking clozapine. Plasma clozapine levels must be monitored closely and adjustments made in dosage, if necessary, for at least six months after cessation.;
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Tobacco smoking, associated risk behaviours, and experience with quitting: A qualitative study with homeless smokers addicted to drugs and alcoholBackground: The prevalence of tobacco smoking among homeless people can reach more than 90%, with related morbidity and mortality being high. However, research in this area is scarce. This study aims to explore smoking and quitting related behaviours, experiences and knowledge in homeless smokers in the context of other substance abuse. Methods: Face-to-face interviews were conducted with homeless smokers accessing a harm reduction service in Nottingham, UK. Data on smoking history, nicotine dependence, motivation and confidence to quit were collected using structured instruments; a semi-structured interview guide was used to elicit responses to predefined subject areas, and to encourage the emergence of unprecedented themes. Data were analysed using framework analysis and descriptive statistics. Results: Participants were generally highly dependent smokers who did not display good knowledge/awareness of smoking related harms and reported to engage in high risk smoking behaviours. The majority reported notable motivation and confidence to quit in the future, despite or indeed for the benefit of addressing other dependencies. Of the many who had tried to quit in the past, all had done so on their own initiative, and several described a lack of support or active discouragement by practitioners to address smoking. Conclusion: High levels of tobacco dependence and engagement in unique smoking related risk behaviours and social interplays appear to add to the vulnerability of homeless smokers. Given reported motivation, confidence, previous attempts and lack of support to quit, opportunities to address smoking in one of the most disadvantaged groups are currently missed.
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Treating tobacco dependence in older adults: A survey of primary care clinicians' knowledge, attitudes, and practiceBACKGROUND: The benefits of smoking cessation among older people are well documented. Despite this, evidence suggests that older smokers are rarely engaged in smoking cessation efforts, and that existing tobacco dependence treatments require further tailoring to the specific needs of older smokers. This study assesses the knowledge, attitudes, and clinical practice of primary care clinicians in relation to addressing tobacco dependence among older people.
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A cross-sectional survey of mental health clinicians' knowledge, attitudes, and practice relating to tobacco dependence among young people with mental disordersBackground: Mental health services in England are smoke-free by law and expected to provide comprehensive support to patients who smoke. Although clinicians' knowledge in this area is reported to be limited, research exploring the issue in Child and Adolescent Mental Health Services (CAMHS) is lacking. This study aimed to investigate the knowledge, attitudes, and practice of clinicians working within specialist and highly specialist Child and Adolescent Mental Health Services (CAMHS) relating to tobacco dependence, its treatment and its relation to mental disorder. Methods: A cross-sectional survey of clinicians working across all CAMHS teams of a large UK National Health Service mental health Trust. Results: Sixty clinicians (50% response rate) completed the survey. Less than half (48.3%) believed that addressing smoking was part of their responsibility, and half (50%) asserted confidence in supporting patients in a cessation attempt. Misconceptions relating to smoking were present across all staff groups: e.g. only 40% of respondents were aware of potential interactions between smoking and antipsychotic medications, although psychiatrists were more knowledgeable than non-medical clinicians (91.6% vs 27.1%; OR 3.4, p < .001). Self-reported attendance at smoking-related training was significantly associated with more proactive clinical practice. Conclusions: There is a need to improve clinicians' knowledge, capacity and confidence in effectively identifying, motivating, supporting and treating young smokers in the context of treatment for mental disorders.
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How to implement a smoke-free policyIt takes courage, leadership and planning to successfully implement a smoke-free policy in mental health settings. The content of the policy is crucial in setting parameters for implementation. Management and clinicians should work closely together to develop and coordinate the implementation strategy, ensuring that resources are effectively used and deadlines are met. Key success factors are effective management at both central and local levels, as well as consultation with service users, carers and staff to gain support for the policy and obtain suggestions for improvement. Other important factors are advance planning, recruitment of experienced staff, effective communication and extensive training of staff in smoking cessation support. Local teams should develop appropriate procedures based on the policy. They should work closely with the central management team. The resources developed and obtained by local teams should be shared throughout the organisation and should be tailored to meet the needs of particular services.
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Screening for nicotine dependence and smoking behaviour in general surgical patientsBackground: Tobacco use is the single most important preventable health risk in the world and smoking-related mortality is set to rise in particular in developing countries including Pakistan. Smoking in surgical patients has been associated with local wound complications, pulmonary and cardiac complications, an increased need for postop intensive care and longer periods of hospitalisation. Aim: To ascertain the prevalence of smoking in Pakistani surgical outpatients and to assess their smoking behaviour with a view to increase awareness and suggest appropriate interventions. Study design: Cross-sectional survey Method: 300 consecutive general surgical outpatients were asked to identify if they smoked and were invited to take part in a semi-structured survey. The questionnaire had inbuilt questions from CAGE screening questionnaire modified for smoking and in addition asked questions about smoking behaviour and motivation to quit. Results: Prevalence of smoking in the study population was 45.6%. Out of these 45.2% screened positive for nicotine dependence. Majority of smokers acknowledged their habit. Boredom, anxiety or worry and feeling angry, depressed or lonely were identified as common themes of emotional state linked to smoking behaviour. Almost all the smokers identified health improvement and money saving as potential benefits of quitting. About two third (67.3%) of the nicotine dependent group and a half (50.7%) of the non-dependent group thought it was difficult to give up smoking. Nonetheless a significant majority in the both groups, 67.3% of the nicotine dependent and 80.9% of the non-dependent group considered that it was a good thing to quit smoking. Conclusion: Prevalence of smoking is high in Pakistani urban general surgical outpatients and is comparable to general population trends. A significant proportion of the smoking population may be dependent on nicotine. Smoking behaviour may be associated with a number of emotional states. Majority of the smokers are able to identify health and economic benefits of smoking cessation and have a positive attitude towards quitting despite thinking it may be difficult. Routine screening for smoking and nicotine dependence and appropriate support for smoking cessation and harm reduction should help promote a healthier lifestyle and improve outcomes in the pre and postoperative period.
