Urine nicotine assessment in plastic surgery patients
Steven C. Bonawitz, MD.
Central Maine Plastic Surgery, Lewiston, ME, USA.
The effect of tobacco use on surgical outcomes has been clearly and consistently documented in the medical literature. Not only is the risk of general complications increased but also specific wound related complications are also significantly increased and there are medico legal implications as well. These risks are particularly significant in light of the elective nature of most procedures that plastic surgeons perform.
Urine testing for nicotine and cotinine, a metabolite of nicotine, has been available for several years and this represents a simple, non-invasive method to evaluate smoking habits and to screen patients for surgery. Furthermore, the documentation of smoking status may be a useful tool to help patients quit and may also allow physicians to protect themselves from liability created by patients who refuse to follow their advice.
This study was conducted to assess the reliability of reported smoking behavior in plastic surgery patients and correlate both the results of urine nicotine testing with surgical outcomes.
Routine nicotine testing was ordered on all patients scheduled for surgery in a single surgeon plastic surgery practice. Smoking history was recorded and all patients were counseled pre-operatively regarding risks of tobacco use and regarding cessation. Cessation was made a requirement for any elective procedure involving a flap or skin undermining as well as any in patients undergoing secondary reconstructive surgery. Cessation was confirmed prior to scheduling surgery in patients with a stated past history. Urine samples were routinely obtained at the PAT date or on the date of surgery on all patients regardless of history to establish baselines, to assess patient compliance and to include the evaluation of secondary exposure.
A total of 235 patients underwent 257 procedures. Only data from the first procedure on any patient during the study period was included for analysis. Urine nicotine reports were available for 200 procedures. By self-report, 50.5% of patients listed themselves as never having smoked while 41% were past smokers and 8.5% reported themselves as active smokers.
Testing confirmed measurable nicotine levels in 2% of never smokers, 13% of past smokers and 94% of current smokers. Overall 85% of patients tested negative for nicotine and 15% were positive with 11.5% demonstrating levels consistent with active use. The complication rates and reoperation rates for the entire series were 12.5% and 6% respectively. Complication and reoperation rates were 30% and 17.4% in patients with urine nicotine levels of active smokers and 10% and 4.7% respectively for patients who tested negative for nicotine.
The urine nicotine test is an effective method for documenting smoking status in plastic surgery patients and appears to have predictive value for complication and reoperation rates in this population.