Electronic cigarettes in the perioperative period of cardiothoracic surgery: views of Australian clinicians and patients

Smoking cessation has health benefits, particularly before surgery. Diagnosis, hospitalisation and surgery for tobacco-related illnesses such as coronary artery disease or lung cancer are 'teachable moments' in health promotion, an opportunity to promote smoking cessation among patients. However, many smokers find it difficult to quit. Electronic nicotine delivery systems (ENDS), commonly referred to as electronic cigarettes or e-cigarettes, may reduce harm in the perioperative period and offer an alternative method of tobacco reduction or cessation in the short and longer term for patients undergoing surgery. However, they are controversial, due to the unknown health effects of long-term use, their efficacy as a cessation aid, and views that electronic cigarettes will either renormalise smoking or be a gateway to tobacco use in younger people. Compared to other developed countries, such as Canada, New Zealand and the United Kingdom, Australia has taken a more precautionary approach to the regulation of electronic cigarettes, thus there is limited research in clinical settings. The thesis examines the awareness and opinions of cardiothoracic clinicians about current clinical smoking cessation guidelines and the impact of smoking and of cessation in the perioperative period. It also examines their views on electronic cigarettes, and the potential role to reduce postoperative complications caused by tobacco smoking and create a sustained quit attempt. Furthermore, the thesis examines the awareness, use and beliefs about electronic cigarettes of patients diagnosed with coronary artery disease or lung cancer awaiting cardiothoracic surgery and the potential role of electronic cigarettes as a smoking cessation aid in the perioperative period. The thesis contains three studies based on empirical research in six hospitals in Sydney, New South Wales, consisting of surveys and interviews with 62 patients awaiting cardiothoracic surgery, and indepth interviews with 52 cardiothoracic clinicians - surgeons, anaesthetists, nurses and physiotherapists. Study I explores the knowledge and reported delivery of Australian clinical guidelines for smoking cessation care in the perioperative period of surgery by cardiothoracic clinicians. It reveals inconsistent implementation of clinical guidelines due to the diversity of clinicians' views in delivering smoking cessation, and institutional inadequacies in cessation training, resources and engagement, as categorised using the Behaviour Change Wheel "Capabilities, Opportunity, Motivation and Behaviour" (COM-B) analysis framework. Two studies explore the opinions of cardiothoracic clinicians and patients towards electronic cigarettes as a potential alternative to tobacco use in the perioperative period. Study II demonstrates a lack of clinician knowledge about electronic cigarettes yet reveals an overall view that, compared to continued tobacco smoking in the perioperative period, electronic cigarette use is regarded as the "lesser of two evils", and a potential bridge to quit for patients who are unable to stop smoking before cardiothoracic surgery. Similar views are expressed by patients awaiting cardiothoracic surgery who smoke or had recently ceased (Study III), particularly those who have previously been unsuccessful with other cessation attempts or are struggling with urges to smoke. The studies reveal the views and needs of patients awaiting surgery who continue to smoke, and are using, or are interested in using, electronic cigarettes to reduce or quit smoking. Both clinicians and patients alike have a similar pragmatic view that, compared to ongoing smoking, electronic cigarette use could reduce tobacco harm around the time of surgery when other smoking cessation methods have been unsuccessful. The studies also highlight the actions needed by local health authorities, hospitals and clinicians to provide more consistent evidence-based smoking cessation care for patients awaiting cardiothoracic surgery. Importantly, findings from this thesis support a review of current Australian perioperative clinical smoking cessation guidelines to encourage clinicians to provide consistent, tangible cessation support, and be prepared to have an informed discussion with patients on using electronic cigarettes to stop smoking and on the benefits and risks of electronic cigarette use in the perioperative period.