The Unseen Risks: Nicotine's Deep Impact on Surgical Procedures
Any form of nicotine consumption, whether from traditional cigarettes, vaping, or nicotine pouches, introduces significant challenges and risks during procedures requiring anaesthesia [1.2.1, 1.2.2]. Its systemic effects on the cardiovascular, respiratory, and metabolic systems can complicate anaesthetic management and compromise patient recovery. Nicotine acts as a vasoconstrictor, narrowing blood vessels, increasing heart rate, and causing blood pressure fluctuations, all of which create an unstable environment for an anaesthesiologist [1.2.1]. Furthermore, the carbon monoxide in cigarette smoke reduces the oxygen-carrying capacity of blood, leading to decreased oxygen delivery to vital tissues at a time when they need it most [1.2.3, 1.4.8]. This combination of factors not only makes the administration of anaesthesia more complex but also sets the stage for a host of potential complications during and after surgery [1.2.6].
Pharmacological Interactions: The Need for Higher Doses
One of the most direct ways nicotine affects anaesthesia is by altering the body's response to anaesthetic drugs. Studies have consistently shown that smokers and even passive smokers require higher amounts of anaesthetic agents like propofol and remifentanil to achieve the desired level of sedation and analgesia compared to non-smokers [1.4.1]. This is partly because polycyclic aromatic hydrocarbons from smoke induce liver enzymes (cytochrome P450), which increases the metabolism of opioids, benzodiazepines, propofol, and most neuromuscular blockers [1.4.8]. This increased requirement can make it challenging for anaesthesiologists to gauge the correct dosage, potentially leading to moments of awareness during surgery or other adverse events [1.2.3]. While some studies on specific muscle relaxants like rocuronium have yielded conflicting results, the general consensus points towards increased anaesthetic needs in nicotine users [1.4.1, 1.4.3]. The same effect has been noted with local anaesthetics, where smokers, particularly those with symptomatic issues like pain, often require a greater amount of lidocaine to achieve effective numbing [1.4.5, 1.4.7].
Cardiovascular and Respiratory Complications
The most life-threatening effects of nicotine during anaesthesia are on the heart and lungs. Nicotine stimulates the release of catecholamines (like adrenaline), leading to increased heart rate, blood pressure, and myocardial oxygen demand [1.4.8]. When combined with the reduced oxygen supply from carbon monoxide, this creates a dangerous imbalance that puts patients at a higher risk of heart attack during or immediately after surgery [1.2.4]. Smokers are reported to have a 77% greater risk of heart attack after surgery than non-smokers [1.2.6].
From a respiratory standpoint, smoking irritates the airways, decreases cilia function, and can lead to increased mucus production [1.2.4, 1.4.8]. This makes individuals who smoke more prone to breathing problems like bronchospasm and laryngospasm during anaesthesia [1.4.1]. Postoperatively, these patients face a significantly higher risk of complications such as pneumonia, lung collapse, and the potential need for mechanical ventilation [1.2.5]. Even vaping, often perceived as a safer alternative, causes airway inflammation and hyperreactivity, presenting similar risks to the anaesthesia team [1.7.4].
Comparison of Nicotine's Effects: Smokers vs. Non-Smokers
| Feature | Nicotine User (Smoker/Vaper) | Non-Nicotine User |
|---|---|---|
| Anaesthetic Dose | Often requires a higher dose of agents like propofol and opioids [1.4.1, 1.4.8]. | Standard dose requirements. |
| Cardiovascular Risk | Increased heart rate, blood pressure instability, and higher risk of perioperative heart attack [1.2.6, 1.4.8]. | Stable hemodynamics, lower cardiovascular risk. |
| Respiratory Risk | Higher risk of bronchospasm, laryngospasm, and postoperative pneumonia [1.2.4, 1.2.5]. | Lower risk of airway complications. |
| Wound Healing | Delayed healing due to vasoconstriction and reduced oxygen delivery [1.2.1, 1.6.7]. | Normal healing process. |
| Infection Risk | Weakened immune response leads to a higher risk of surgical site infections [1.6.3, 1.6.4]. | Lower risk of postoperative infection. |
| Postoperative Pain | May experience lower pain thresholds and require more opioids after surgery [1.7.4, 1.7.7]. | Standard postoperative pain management. |
Postoperative Recovery: The Lingering Impact
Nicotine's negative influence extends far beyond the operating room. The vasoconstrictive properties of nicotine severely impair blood flow to healing tissues, which is a critical component of recovery [1.2.1]. Reduced blood and oxygen supply means surgical incisions heal more slowly, increasing the risk of wound disruption (dehiscence) and unsightly scarring [1.2.2, 1.6.2]. This poor healing environment also makes nicotine users more susceptible to surgical site infections [1.6.4]. Studies have shown that a history of smoking is linked to a higher rate of postoperative antibiotic use, suggesting a greater likelihood of infection [1.4.3]. Quitting smoking 4-6 weeks before surgery and remaining smoke-free for 4 weeks after can reduce the likelihood of wound complications by as much as 50% [1.2.5, 1.5.6].
Conclusion: The Critical Importance of Preoperative Cessation
The evidence is overwhelming: nicotine, in any form, profoundly and negatively affects anaesthesia and surgical outcomes. It complicates drug administration, destabilizes cardiovascular and respiratory function, and severely hampers postoperative recovery. The American Society of Anesthesiologists and other health bodies strongly recommend quitting as far in advance of surgery as possible—ideally at least four weeks prior—to mitigate these risks [1.2.5, 1.5.2]. Even stopping one day before surgery can provide benefits by improving immediate oxygen availability [1.2.1, 1.2.6]. Patients must be transparent with their surgical and anaesthesia teams about all nicotine use, including vaping and pouches, to allow for the safest possible care plan [1.2.2]. The period leading up to surgery represents a crucial opportunity to cease nicotine use, not only for a safer procedure but for long-term health benefits [1.5.1].
For more information on smoking cessation resources, consider visiting The American College of Surgeons Quit Smoking page.
