Key result
In veterans undergoing elective surgery, pulmonary complications mediated 22% of smoking-associated 6-month mortality, followed by cardiovascular complications (4%) and surgical site infections (2%).
Why the study?
Does current smoking increase postoperative mortality mediated by perioperative complications in veterans undergoing elective surgery?
Cohort (n=322,373)
Yes
Does current smoking increase postoperative mortality mediated by perioperative complications in veterans undergoing elective surgery?
Pulmonary complications are the primary mediator of smoking-associated postoperative mortality, suggesting that targeted prevention and early treatment of these complications could reduce mortality in smokers undergoing elective surgery.
Pulmonary complications predominate as mediators of smoking-related postoperative mortality in veterans; extends mechanistic evidence but hypothesis-generating and should not yet change practice.
OBJECTIVE: To assess the mediation of smoking-associated postoperative mortality by postoperative complications. DESIGN: Observational cohort study. SETTING: Using data from the Veterans Affairs (VA) Surgical Quality Improvement Programme, a quality assurance programme for major surgical procedures in the VA healthcare system, we assessed the association of current smoking at the time of the surgery with 6-month and 1-year mortality. PRIMARY AND SECONDARY OUTCOME MEASURES: Using mediation analyses, we calculated the relative contribution of each smoking-associated complication to smoking-associated postoperative mortality, both unadjusted and adjusted for age, race/ethnicity, work relative value unit of the operation, surgeon specialty, American Society of Anesthesiologists class and year of surgery. Smoking-associated complications included surgical site infection (SSI), cardiovascular complications (myocardial infarction, cardiac arrest and/or stroke) and pulmonary complications (pneumonia, failure to wean and/or reintubation). RESULTS: There were 186 632 never smokers and 135 741 current smokers. The association of smoking and mortality was mediated by smoking-related complications with varying effects. In unadjusted analyses, the proportions of mediation of smoking to 6-month mortality explained by the complications were as follows: SSIs 22%, cardiovascular complications 12% and pulmonary complications 89%. In adjusted analyses, the per cents mediated by each complication were as follows: SSIs 2%, cardiovascular complications 4% and pulmonary complications 22%. In adjusted analyses for 1-year mortality, respective per cents mediated were 2%, 3% and 16%. CONCLUSIONS: Pulmonary complications, followed by cardiovascular complications and SSIs were mediators of smoking-associated 6-month and 1-year mortality. Interventions targeting smoking cessation and prevention and early treatment of pulmonary complications has the likelihood of reducing postoperative mortality after elective surgery.
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Singh et al. (2013) conducted a cohort in Veterans undergoing elective surgery (n=322,373). Current smoking at the time of surgery vs. Never smokers was evaluated on Mediation of smoking-associated 6-month and 1-year mortality by postoperative complications. In veterans undergoing elective surgery, pulmonary complications mediated 22% of smoking-associated 6-month mortality, followed by cardiovascular complications (4%) and surgical site infections (2%).
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