Smoking is associated with delayed wound healing, and is a modifiable risk factor. This message has been repeated in different presentations at the 12. Wound Specialist Day at the UniversitätsSpital Zürich and at the XVII Course of Diabetic Foot at the UCM , two events I have attended this week and in which I have learned from great experts that I admire. Both the famous Swiss meeting and the prestigious course organized annually by the University Podiatric Clinic have insisted on the need to educate and motivate patients to promote change if we want to succeed in prevention and healing.
Ok, that is what is recommended, but what do we do in our clinical practice? do we ask all our patients if they are smokers? do we really give importance to that information? On the other hand, are we interested in the physical exercise they do, the type of diet they follow or the shoes they wear?
First of all, if I want to effectively convince a patient to stop smoking, it is essential that I understand why it is necessary.
In smokers, the amount of oxygen released to the tissues is reduced, the function of the immune cells is altered, with less antibacterial activity, and the proliferation of fibroblasts and production of collagen is reduced.1
This detrimental effect of smoking on wound closure has been observed in a retrospective series of more than 40,000 patients undergoing different types of reconstructive surgery, with an increased number of post-surgical complications.2 In chronic wounds, regardless of their predominant etiopathogenic trigger, the cytotoxic components of smoking directly and indirectly worsen the ischaemia and pro-inflammatory environment, with an increased risk of infection. I have used the adjective “predominant” to highlight that, although on many occasions the cause of a wound is easily identifiable, we cannot forget that there are different local and systemic factors that are influencing, more or less directly, the healing process. Among the risk factors that we cannot modify is age, while smoking, as we have said, is modifiable.
Without a doubt, quitting smoking is difficult for anyone. Starting to exercise regularly and eating a healthy diet are also not easy for the general population. The likelihood of achieving these healthy changes is greatly reduced if the person is depressed, has difficulty moving, is obese, has diabetes, is in pain, has no social support or financial means (=typical profile of the patient with hard-to-heal wounds).
Education, with clear repeated messages will not have any beneficial effect on the patient if we do not motivate them to change. We have to work on an active listening attitude to understand and adapt the management strategy to each patient, negotiating realistic, easily achievable short-term goals. It is essential to establish a trusty relationship, with constant encouragement and support.
References
- McDaniel JC, Browning KK. Smoking, chronic wound healing, and implications for evidence-based practice. J Wound Ostomy Continence Nurs. 2014 Sep-Oct;41(5):415-23
- Goltsman D, Munabi NC, Ascherman JA. The Association between Smoking and Plastic Surgery Outcomes in 40,465 Patients: An Analysis of the American College of Surgeons National Surgical Quality Improvement Program Data Sets. Plast Reconstr Surg. 2017 Feb;139(2):503-511.
