Smokers who needed a hip or knee replacement experienced better surgical outcomes and fewer adverse events including hospital readmissions, surgical site infections, and blood clots if they were enrolled in a smoking cessation program prior to surgery, according to preliminary new research from NYU Langone that needs to be confirmed by larger studies.

The researchers recommend that orthopaedic surgeons consider implementing smoking cessation programs, which may lead to better outcomes for this higher–risk patient population and reductions in healthcare costs.

Their findings were presented March 16, 2017, at the American Academy of Orthopaedic Surgeons (AAOS) 2017 Annual Meeting.

“We’ve known that smokers do worse than nonsmokers after joint replacements, and now this research shows there’s good early evidence that quitting smoking before surgery may improve their outcomes,” says lead study author Amy Wasterlain, MD, a fourth–year resident in the Department of Orthopaedic Surgery at NYU Langone. “Not every risk factor can be reduced before a joint replacement, but smoking status is one that should be a top priority for orthopaedic surgeons and their patients.”

Smokers who undergo a total joint replacements have a 50 percent increased risk of experiencing complications during surgery and, on average, result in $5,000 more in hospital costs compared to nonsmokers, according to previous research. A recent review of 7,000 joint replacements found patients who used tobacco within one month of surgery were 2.1 times more likely to develop a deep surgical infection than those who hadn’t.

To combat this risk, NYU Langone developed a voluntary smoking cessation program in October 2013 that was designed to get smokers tobacco–free within one to two weeks of surgery. The program consists of four preoperative telephone counseling sessions and nicotine replacement therapy as needed, and two postoperative follow–up sessions.

For the new study, researchers reviewed medical records of 539 smokers who underwent total joint replacements at NYU Langone’s Hospital for Joint Diseases between October 2013 – after the smoking cessation program was implemented – through March 2016.

Of those patients who used tobacco, 103 smokers were referred to the program by their surgeons, 73 of whom voluntarily enrolled and 47 of whom completed all 6 sessions. The researchers found that smokers who completed the program were 4.3 times more likely to quit smoking prior to surgery than those who were not enrolled in the program. The percentage of smokers who quit all tobacco use prior to surgery increased with each level of participation in the program: 52 percent of those enrolled and 68 percent of those who completed the program quit smoking prior to surgery, compared to 18 percent of smokers who were never referred. Smokers who completed the program reduced their daily cigarette consumption by more than 10.5 cigarettes per day, compared with a nearly 5 cigarettes per day reduction in those who participated but didn’t complete the program, and only 2 cigarettes per day in smokers who never enrolled.

Patients who completed the program had fewer surgical complications, with a decrease in reoperation rates from 4.9 percent among all other smokers to 4.3 percent in the group in the smoking cessation program. In knee replacements alone, researchers reported adverse events in 22 percent of patients who completed the program compared to 29 percent among all other smokers – a decrease of over 24 percent. Adverse events included hospital readmission, superficial and deep surgical site infection, deep vein thrombosis, pulmonary embolism, pneumonia, stroke, and urinary tract infection.