title: Variation in smoking cessation after vascular operations.
abstract: OBJECTIVE
  Smoking is the most important modifiable risk factor for patients with vascular disease. The purpose of this study was to examine smoking cessation rates after vascular procedures and delineate factors predictive of postoperative smoking cessation.
  
  
  METHODS
  The Vascular Study Group of New England registry was used to analyze smoking status preoperatively and at 1 year after carotid endarterectomy, carotid artery stenting, lower extremity bypass, and open and endovascular abdominal aortic aneurysm repair between 2003 and 2009. Of 10,734 surviving patients after one of these procedures, 1755 (16%) were lost to follow-up and 1172 (11%) lacked documentation of their smoking status at follow-up. The remaining 7807 patients (73%) were available for analysis. Patient factors independently associated with smoking cessation were determined using multivariate analysis. The relative contribution of patient and procedure factors including treatment center were measured by χ-pie analysis. Variation between treatment centers was further evaluated by calculating expected rates of cessation and by analysis of means. Vascular Study Group of New England surgeons were surveyed regarding their smoking cessation techniques (85% response rate).
  
  
  RESULTS
  At the time of their procedure, 2606 of 7807 patients (33%) were self-reported current smokers. Of these, 1177 (45%) quit within the first year of surgery, with significant variation by procedure type (open abdominal aortic aneurysm repair, 50%; endovascular repair, 49%; lower extremity bypass, 46%; carotid endarterectomy, 43%; carotid artery stenting, 27%). In addition to higher smoking cessation rates with more invasive procedures, age >70 years (odds ratio [OR], 1.90; 95% confidence interval [CI], 1.30-2.76; P < .001) and dialysis dependence (OR, 2.38; 95% CI, 1.04-5.43; P = .04) were independently associated with smoking cessation, whereas hypertension (OR, 1.23; 95% CI, 1.00-1.51; P = .051) demonstrated a trend toward significance. Treatment center was the greatest contributor to smoking cessation, and there was broad variation in smoking cessation rates, from 28% to 62%, between treatment centers. Cessation rates were higher than expected in three centers and significantly lower than expected in two centers. Among survey respondents, 78% offered pharmacologic therapy or referral to a smoking cessation specialist, or both. The smoking cessation rate for patients of these surgeons was 48% compared with 33% in those who did not offer medications or referral (P < .001).
  
  
  CONCLUSIONS
  Patients frequently quit smoking after vascular surgery, and multiple patient-related and procedure-related factors contribute to cessation. However, we note significant influence of treatment center on cessation as well as broad variation in cessation rates between treatment centers. This variation indicates an opportunity for vascular surgeons to impact smoking cessation at the time of surgery.
authors: Division of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH 60611, USA. awhoel@nmh.org
authors: Andrew W
authors: AW
authors: Hoel
authors: Brian W
authors: BW
authors: Nolan
authors: Philip P
authors: PP
authors: Goodney
authors: Yuanyuan
authors: Y
authors: Zhao
authors: Andres
authors: A
authors: Schanzer
authors: Andrew C
authors: AC
authors: Stanley
authors: Jens
authors: J
authors: Eldrup-Jorgensen
authors: Jack L
authors: JL
authors: Cronenwett
mesh_terms: D000368:Aged; D017130:Angioplasty / Q000295:instrumentation; D017544:Aortic Aneurysm, Abdominal / Q000601:surgery; D019917:Blood Vessel Prosthesis Implantation; D002340:Carotid Artery Diseases / Q000601:surgery; D016009:Chi-Square Distribution; D016894:Endarterectomy, Carotid; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D009511:New England / Q000453:epidemiology; D016017:Odds Ratio; D016491:Peripheral Vascular Diseases / Q000601:surgery; D011182:Postoperative Care; D010818:Practice Patterns, Physicians'; D015995:Prevalence; D012042:Registries; D012307:Risk Factors; D040242:Risk Reduction Behavior; D012907:Smoking / Q000009:adverse effects / Q000453:epidemiology; D016540:Smoking Cessation; D000074606:Smoking Prevention; D015607:Stents; D013997:Time Factors; D016896:Treatment Outcome; D014652:Vascular Diseases / Q000453:epidemiology / Q000601:surgery*; D014656:Vascular Surgical Procedures / Q000009:adverse effects / Q000295:instrumentation
references: Arch Intern Med. 2000 Oct 23;160(19):2934-8
references: 11041900
references: Ann Intern Med. 1993 May 15;118(10):753-61
references: 8470850
references: J Am Coll Cardiol. 2000 Sep;36(3):878-83
references: 10987614
references: Am J Epidemiol. 1991 Oct 1;134(7):699-703
references: 1951275
references: Br J Surg. 1991 Apr;78(4):401-4
references: 2032097
references: J Vasc Surg. 2007 Dec;46(6):1093-1101; discussion 1101-2
references: 17950568
references: JAMA. 1986 Sep 12;256(10):1315-8
references: 3091857
references: JAMA. 1989 Jan 6;261(1):75-9
references: 2491762
references: Am J Public Health. 1994 Jul;84(7):1086-93
references: 8017530
references: Ann Vasc Surg. 1989 Jan;3(1):20-5
references: 2713228
references: JAMA. 1997 Dec 3;278(21):1759-66
references: 9388153
references: Anesthesiology. 2010 Jan;112(1):102-7
references: 19996946
references: MMWR Morb Mortal Wkly Rep. 2011 Nov 11;60(44):1513-9
references: 22071589
references: Scand Cardiovasc J. 2010 Oct;44(5):295-300
references: 21080847
references: Circulation. 2004 Jul 6;110(1):16-21
references: 15210603
references: Eur Heart J. 1997 Apr;18(4):671-6
references: 9129900
references: BMJ. 1989 Sep 9;299(6700):643-6
references: 2508847
references: Am Heart J. 2002 Jun;143(6):961-5
references: 12075249
references: N Engl J Med. 2012 Mar 29;366(13):1172-4
references: 22417200
references: Am J Epidemiol. 2001 Apr 15;153(8):807-14
references: 11296155
references: JAMA. 1987 Apr 10;257(14):1916-9
references: 3820511
references: Ann Surg. 2008 Nov;248(5):739-45
references: 18948800
references: Am J Med. 2011 Feb;124(2):144-154.e8
references: 21295194
references: MMWR Morb Mortal Wkly Rep. 2004 May 28;53(20):427-31
references: 15163928
references: J Am Coll Cardiol. 2010 Dec 14;56(25):2105-12
references: 21144971
references: BMJ. 1989 Mar 25;298(6676):789-94
references: 2496858
references: Br J Surg. 2009 May;96(5):451-61
references: 19358172