In our efforts to prevent and treat wounds, we may overlook an important factor in early prevention-smoking cessation. Evidence in the literature supports smoking cessation programs for the prevention of many associated risk factors, such as emphysema, chronic obstructive pulmonary diseases, cancer, cardiovascular disease, cerebrovascular disease, peripheral vascular disease, and venous and arterial disease. Recently, health care insurance providers have initiated incentives and cessation programs for smokers. Moreover, a paradigm shift toward individual and community responsibility for the initiation and maintenance of prevention and cessation programs is emerging.1

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In a recent survey of corporate wellness programs, smoking cessation was the most prevalent program offered.1 Mulligan et al1 hypothesized this was due to national focus on this problem, legislative initiatives, health care claim cost emphasis, or the efforts of commercial vendors and pharmaceutical companies. Conversely, the least prevalent component among the respondents was health education classes.1 It clearly makes sense to begin the prevention programs at the individual, workplace, and community levels, using the biosocial behavioral model; this method saves lives and contributes to the health of the community. When it comes to preventing diseases related to tobacco use, including the co-contributions to chronic wounds, we have a lifetime of work to accomplish.

Wound Pathophysiology and Smoking

Tissue hypoxia has been regarded as a major mechanism for tobacco-related impairment of wound healing. Smoking for 10 minutes can decrease the tissue oxygen concentration for as long as 1 hour, with the implication that smokers who consume 1 pack of tobacco a day would live under tissue hypoxia throughout the day.2 Reduced tissue oxygenation is believed to be the result of reduced tissue blood flow and decreased proportion of oxyhemoglobin, among others. The fact that smoking decreases cutaneous blood flow in various parts of the body has major implications for wound healing.

Surgeons have long remarked the deleterious effect of smoking on wound healing,2 and plastic surgeons are often reluctant to perform cosmetic surgeries on patients who refuse to quit smoking.2 Postoperative patients who smoke show delayed wound healing and increased complications, such as infection, wound dehiscence,3-5 anastomotic leakage,6 wound and flap necrosis, epidermolysis,2,7,8 and a decrease in the tensile strength of wounds9 following a variety of surgeries, such as plastic,10 gastrointestinal,11 colorectal,6 abdominal,5 orthopedic,12 dental surgeries,13 coronary bypass surgery,14 and breast cancer surgery.7 Fewer studies have addressed the relationship between chronic wounds and smoking,15 but an association has been found between smoking and a higher incidence of pressure ulcers in patients with spinal cord injuries.16

Conclusions

Further investigations on the tobacco-related pathophysiologic aspects of wound care and the influence of smoking on wound healing are needed. Like the old tobacco advertising campaign said, "We've come a long way baby." But we have much farther to go.

Richard "Sal" Salcido, MD

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References