5 Ways to Stop Smoking Before Spine Surgery: New Study

What might Stanford scientists learn when they compare five different smoking cessation strategies in an effort to optimize lumbar fusion patients? That even a little bit of cessation can go a long way.

This work, conducted at the VOICES (Value in Orthopaedics, Innovation and Choices) Health Policy Research Center, Stanford University, was published in the December 2, 2020 edition of The Journal of Bone and Joint Surgery. It is titled, “A Cost-Effectiveness Analysis of Smoking-Cessation Interventions Prior to Posterolateral Lumbar Fusion.”

Co-author Serena Hu, M.D. explained to OTW why she and her colleagues tackled this well-known and still very challenging issue, “As the senior spine surgeon involved in this paper, I have long required patients to quit smoking before elective spine surgery because of the well-known compromise of fusion rates and increased complication rates that were associated with smoking and spinal fusion. It was a logical step to join this practice and Dr. Kamal's team's expertise in cost-effectiveness analysis to design this study.”

Why, we asked Dr. Hu, did she and the team choose posterolateral lumbar fusion for the study? “We thought the greatest effects of smoking cessation would be where the successful achievement of fusion—which is goal of surgery—would be affected, in addition to decreasing the complication rates associated with having surgery. It is also one of the most common spine surgeries performed and therefore the study results are directly applicable to those surgeries.”

The five strategies assessed in the study were:

• behavioral counseling
• nicotine replacement therapy
• bupropion monotherapy
• varenicline monotherapy
• a combined intervention

All strategies were employed prior to treating patients with a single-level, instrumented lumbar posterolateral fusion.

“Every smoking-cessation intervention was more effective and less costly than usual care at the lifetime horizon,” wrote the authors. “In the short term, behavioral counseling, nicotine replacement therapy, varenicline monotherapy, and the combined intervention were also cost saving, while bupropion monotherapy was more effective but more costly than usual care.”

“The mean lifetime cost savings for behavioral counseling, nicotine replacement therapy, bupropion monotherapy, varenicline monotherapy, and the combined intervention were $3,291, $2,571, $2,851, $6,767, and $34,923, respectively…A PSA [probabilistic sensitivity analysis] revealed that the combined smoking-cessation intervention was always more effective and less costly than usual care.”

And, say the authors, this work may improve access to smoking cessation programs.

“We hope that this work will further support the expectation that patients quit smoking and nicotine use before elective spine fusion, or indeed any surgery that needs bone to heal. We also hope that it helps patients get the interventions needed to quit smoking; even though smoking is known to be so detrimental to health, we still see patients for whom access to those programs is difficult.”