Nicotine Products Consideration in the Perioperative Setting: A Narrative Review

Authors

  • Ross Groeschl Resident Physician, Grant Medical Center, Columbus, OH
  • Robert Mendicino Director of Ohiohealth Grant Medical Center Residency, Columbus, OH

DOI:

https://doi.org/10.55067/jifaf.v2i8.64

Keywords:

Nicotine, tobacco, electronic cigarettes, cigarettes, chewing tobacco, nicotine replacement therapy, nicotine pouch

Abstract

Nicotine-containing products, including combustible tobacco, smokeless tobacco, electronic cigarettes (e-cigarettes), and nicotine replacement therapies (NRT), are widely used and have significant implications in the perioperative setting for orthopedic surgery. Smoking has been linked to numerous surgical complications such as delayed wound healing, infection, cardiovascular and pulmonary complications and impaired bone healing. This narrative review aims to provide an overview of the different nicotine-containing products, their nicotine content, and the potential effects observed with their use in orthopedic surgery. A comprehensive literature search was conducted to identify studies reporting on dosage, health effects, and perioperative outcomes associated with various forms of tobacco and nicotine products. The findings reveal that combustible tobacco products contain varying levels of nicotine, ranging from 7.2 to 26.3 mg per gram of tobacco. Smokeless tobacco products have nicotine contents ranging from 7.1 to 23.1 mg per gram. Smokeless tobacco users exhibit better surgical outcomes in terms of bone healing compared to smokers. Nicotine content in e-cigarette liquids varies widely, from 0 to 134.7 mg per milliliter. Limited evidence exists regarding the effects of e-cigarettes on surgical outcomes, but animal studies suggest similar soft tissue healing rates compared to combustible cigarettes due to comparable nicotine levels. NRT, available as gum, nasal spray, lozenges, patches, and inhalers, aims to replace tobacco use and gradually reduce nicotine intake. Dosages range from 0.5 mg per spray to 42 mg in high-dose patches. Understanding the nicotine content, absorption, and route of administration of NRT products is crucial for perioperative management. In conclusion, different nicotine-containing products have varying nicotine levels and potential implications for surgical outcomes. Further research is needed to elucidate the specific effects of e-cigarettes and NRT on bone healing and to establish optimal perioperative management strategies for nicotine users undergoing orthopedic surgery.

References

Scherer G, Mütze J, Pluym N, Scherer M. Assessment of nicotine delivery and uptake in users of various tobacco/nicotine products. Curr Res Toxicol. 2022;3:100067. Published 2022 Mar 11. doi:10.1016/j.crtox.2022.100067

Grønkjær M, Eliasen M, Skov-Ettrup LS, et al. Preoperative smoking status and postoperative complications: a systematic review and meta-analysis. Ann Surg. 2014;259(1):52-71. doi:10.1097/SLA.0b013e3182911913

Turan A, Mascha EJ, Roberman D, et al. Smoking and perioperative outcomes. Anesthesiology. 2011;114(4):837-846. doi:10.1097/ALN.0b013e318210f560

Hawn MT, Houston TK, Campagna EJ, et al. The Attributable Risk of Smoking on Surgical Complications. Ann Surg. 2011;254(6):914–920. doi:10.1097/sla.0b013e31822d7f81

Nolan MB, Warner DO. Safety and Efficacy of Nicotine Replacement Therapy in the Perioperative Period: A Narrative Review. Mayo Clinic Proceedings. 2015;90(11):1553–1561. doi:10.1016/j.mayocp.2015.08.003

Sørensen LT. Wound Healing and Infection in Surgery. Ann Surg. 2012;255(6):1069–1079. doi:10.1097/sla.0b013e31824f632d

Kozlowski LT, Mehta NY, Sweeney CT, Schwartz SS, Vogler GP, Jarvis M, West RJ. Filter ventilation and nicotine content of tobacco in cigarettes from Canada, the United Kingdom, and the United States. Tobacco Control. 1998;7:369-375.

Lawler TS, Stanfill SB, deCastro BR, et al. Surveillance of Nicotine and pH in Cigarette and Cigar Filler. Tob Regul Sci. 2017;3(Suppl 1):101-116. doi:10.18001/TRS.3.2(Suppl1).11

(n.d.). Highlights for the 2021 National Survey on Drug Use and Health. Substance Abuse and Mental Health Services Administration. https://www.samhsa.gov/data/sites/default/files/2022-12/2021NSDUHFFRHighlights092722.pdf

NIDA. 2023, January 23. What is the scope of tobacco, nicotine, and e-cigarette use in the United States?. Retrieved from http://nida.nih.gov/publications/research-reports/tobacco-nicotine-e-cigarettes/what-scope-tobacco-use-its-cost-to-society on 2023, April 2

Kim JH, Patel S. Is It Worth Discriminating Against Patients Who Smoke? A Systematic Literature Review on the Effects of Tobacco Use in Foot and Ankle Surgery. J Foot Ankle Surg. 2017;56(3):594-599. doi:10.1053/j.jfas.2017.02.006

Scolaro JA, Schenker ML, Yannascoli S, Baldwin K, Mehta S, Ahn J. Cigarette smoking increases complications following fracture: a systematic review. J Bone Joint Surg Am. 2014;96(8):674-681. doi:10.2106/JBJS.M.00081

Lipari RN, Van Horn SL. Trends in Smokeless Tobacco Use and Initiation: 2002 to 2014. In: The CBHSQ Report. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2013-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK436371/

Richter P, Spierto FW. Surveillance of smokeless tobacco nicotine, pH, moisture, and unprotonated nicotine content. Nicotine Tob Res. 2003;5(6):885-889. doi:10.1080/14622200310001614647

Benowitz N. Nicotine and smokeless tobacco. CA-A Cancer Journal for Clinicians. 1988;38:244–247.

Rodu B, et al. Nicotine Levels in American Smokeless Tobacco Products. R Street Institute, Brad Rodu, 7 Nov. 2012, https://www.rstreet.org/commentary/nicotine-levels-in-american-smokeless-tobacco-products/.

W-Dahl A, Toksvig-Larsen S. No delayed bone healing in Swedish male oral snuffers operated on by the hemicallotasis technique: a cohort study of 175 patients. Acta Orthop. 2007;78(6):791-794. doi:10.1080/17453670710014563

Raymond BH, Collette-Merrill K, Harrison RG, Jarvis S, Rasmussen RJ. The nicotine content of a sample of e-cigarette liquid manufactured in the United States. Journal of addiction medicine. 2018;12(2):127-131.

Boakye E, Osuji N, Erhabor J, et al. Assessment of Patterns in e-Cigarette Use Among Adults in the US, 2017-2020. JAMA Network Open. 2022;5(7):e2223266. doi:10.1001/jamanetworkopen.2022.23266

Marynak KL, Gammon DG, Rogers T, Coats EM, Singh T, King BA. Sales of Nicotine-Containing Electronic Cigarette Products: United States, 2015. Am J Public Health. 2017;107(5):702-705. doi:10.2105/AJPH.2017.303660

Voos N, Goniewicz ML, Eissenberg T. What is the nicotine delivery profile of electronic cigarettes? Expert Opin Drug Deliv. 2019 Nov;16(11):1193-1203. doi: 10.1080/17425247.2019.1665647. PMID: 31495244; PMCID: PMC6814574.

Troiano C, Jaleel Z, Spiegel JH. Association of Electronic Cigarette Vaping and Cigarette Smoking With Decreased Random Flap Viability in Rats. JAMA Facial Plast Surg. 2019;21(1):5-10. doi:10.1001/jamafacial.2018.1179

Kennedy P, Saloky K, Yadavalli A, Barlow E, Aynardi M, Garner M, et al. Nicotine exposure via electronic cigarettes significantly impedes biomechanical healing properties of tendon healing in a rat model. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2021;37(10):3170-3176.

Wadgave U, Nagesh L. Nicotine Replacement Therapy: An Overview. Int J Health Sci (Qassim). 2016 Jul;10(3):425-35. PMID: 27610066; PMCID: PMC5003586.

Benowitz NL, Zevin S, Jacob P 3rd. Sources of variability in nicotine and cotinine levels with use of nicotine nasal spray, transdermal nicotine, and cigarette smoking. British Journal of Clinical Pharmacology. 1997 Mar;43(3):259-267. DOI: 10.1111/j.1365-2125.1997.00566.x. PMID: 9088580; PMCID: PMC2042749.

Azzopardi D, Ebajemito J, McEwan M, Camacho OM, Thissen J, Hardie G, et al. A randomised study to assess the nicotine pharmacokinetics of an oral nicotine pouch and two nicotine replacement therapy products. Sci Rep. 2022 Apr 28;12(1):6949.

Donigan JA, Fredericks DC, Nepola JV, Smucker JD. The Effect of Transdermal Nicotine on Fracture Healing in a Rabbit Model. Journal of Orthopaedic Trauma. 2012 Dec;26(12):724-727.

Daffner SD, Waugh S, Norman TL, Mukherjee N, France JC. Effect of serum nicotine level on posterior spinal fusion in an in vivo rabbit model. The Spine Journal. 2015;15(6):1402-1408.

Benowitz NL, Hukkanen J, Jacob P III. Nicotine chemistry, metabolism, kinetics and biomarkers. Handb Exp Pharmacol. 2009;192:29–60.

Marynak KL, Wang X, Borowiecki M, et al. Nicotine Pouch Unit Sales in the US, 2016-2020. JAMA. 2021;326(6):566–568. doi:10.1001/jama.2021.10366

McEwan M, Azzopardi D, Gale N, Camacho OM, Hardie G, Fearon IM, et al. A Randomised Study to Investigate the Nicotine Pharmacokinetics of Oral Nicotine Pouches and a Combustible Cigarette. Eur J Drug Metab Pharmacokinet. 2022 Mar;47(2):211-221.

Skott M, Andreassen TT, Ulrich‐Vinther M, Chen X, Keyler DE, LeSage MG, et al. Tobacco extract but not nicotine impairs the mechanical strength of fracture healing in rats. Journal of orthopaedic research. 2006;24(7):1472-1479.

Hastrup SG, Chen X, Bechtold JE, Kyle RF, Rahbek O, Keyler DE, et al. Effect of nicotine and tobacco administration method on the mechanical properties of healing bone following closed fracture. Journal of Orthopaedic Research. 2010;28(9):1235-1239.

Downloads

Published

2023-08-01

How to Cite

1.
Groeschl R, Mendicino R. Nicotine Products Consideration in the Perioperative Setting: A Narrative Review. J Int Foot Ankle [Internet]. 2023 Aug. 1 [cited 2024 Jun. 19];2(8). Available from: https://internationalfootankle.org/journal/index.php/JIFAF/article/view/64

Issue

Section

Articles