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ORIGINAL ARTICLE
Year : 2020  |  Volume : 8  |  Issue : 4  |  Page : 172-179

Perception of knowledge toward surgery-Related adverse effects of cigarette smoking among Al-Ahsa population, Saudi Arabia


1 Department of Surgery, College of Medicine, King Faisal University, Al-Ahsa, Saudi Arabia
2 Department of Surgery, King Fahad University Hospital, Khobar, Saudi Arabia

Date of Submission06-Sep-2021
Date of Acceptance27-Sep-2021
Date of Web Publication30-Sep-2021

Correspondence Address:
Fatimah Abdullah AlAbbad
Al Hasa 6365, 36356-4625
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ssj.ssj_83_21

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  Abstract 


Introduction: Tobacco smoking has been proven to be a major risk factor for morbidity and mortality. The connections between smoking and postoperative adverse effects are very much recorded across surgical specialties. It has been established that smoking cessation has a major impact in optimizing the surgical outcomes of smokers. This study aims to obtain the perception of knowledge regarding surgery-related adverse effects of cigarette smoking among adult population of Al-Ahsa in Saudi Arabia.
Methodology: To assess the knowledge of surgery-related adverse effects of cigarette smoking, an online survey was distributed randomly to all Al-Ahsa population in Saudi Arabia. The participants asked about their biographical data and questions regarding surgery-related adverse effects of cigarette smoking. Responses were analyzed as means and standard deviations for the quantitative variables, and percentages for qualitative categorical variables. The results shows that most of participants have agreed that smoking can increase the risk of future heart and lung problems (79%) and think it is necessary to stop smoking after surgery (69%), while more than a half of all participants did not know that smoking can increase pain (60.8%), infection after surgery (56.2), surgical complications with anaesthesia (51.3%). In this study, only 16.5% agreed that the ideal smoking cessation period before surgery is 4 to 6 weeks.
Results: The results suggest that the awareness of smoking related postoperative adverse effects is poor. That is why we recommend starting and implanting a strong pre-operative smoking cessation program to provide the needed information and educational materials, advising smoker to quit and offering referral for behavioral change.
Conclusion: The awareness of smoking-related postoperative adverse effects is poor. It is important for health-care providers to raise their patient's awareness and knowledge before the surgery.

Keywords: Awareness, Saudi Arabia, smoking, surgical adverse effects, tobacco


How to cite this article:
Alquaimi MM, Alammar ZA, Alghannam ZM, AlAbbad FA, Al Mulhim AA, Boumarah KA. Perception of knowledge toward surgery-Related adverse effects of cigarette smoking among Al-Ahsa population, Saudi Arabia. Saudi Surg J 2020;8:172-9

How to cite this URL:
Alquaimi MM, Alammar ZA, Alghannam ZM, AlAbbad FA, Al Mulhim AA, Boumarah KA. Perception of knowledge toward surgery-Related adverse effects of cigarette smoking among Al-Ahsa population, Saudi Arabia. Saudi Surg J [serial online] 2020 [cited 2022 May 27];8:172-9. Available from: https://www.saudisurgj.org/text.asp?2020/8/4/172/334513




  Introduction Top


Tobacco smoking has been proven to be a major risk factor for morbidity and mortality.[1] It harms almost all organs, causing many diseases and reducing smokers' overall health in general.[2] The prevalence of smoking in Saudi Arabia[1],[2],[4] is high, estimated cigarette smoking to be around 25% of Saudi adults.[3]

The connections between smoking and postoperative adverse effects are very much recorded across surgical specialties.[4] Smoking before any surgery increases the risk of many complications such as pulmonary complications as atelectasis and pneumonia, cardiovascular complications such as myocardial ischemia, and wound-related complications such as infection, impairs tissue healing, and other complications at the surgical site.[5],[6] In addition, surgical patients who smoke have a greater risk of postoperative intensive care admission.[7] A study's done in Abha City, Kingdom of Saudi Arabia, showed that about one-fourth of smokers developed complications during anesthesia. More than a fourth of the participants developed respiratory adverse effects, and found with other postoperative complications.[3]

It has been established that smoking cessation has a major impact in optimizing the surgical outcomes of smokers. Postoperative respiratory complications can be significantly reduced by prolonged smoking abstinence, as antimicrobial and inflammatory alveolar macrophage function can be restored in 6 months of smoking cessation. Cardiovascular, respiratory, and wound-related complications can be reduced by 6–8 weeks of smoking cessation. Finally, it has been shown that the incidence of impaired wound healing can be reduced by 3 weeks of smoking cessation.[2] This reflects why it is crucial for smokers to quit smoking prior to their elective surgeries.

Elective surgery might be considered a “teachable moment” for patients. “Teachable moments” are health experiences that provide motivation to reduce risky behaviors and adopt positive behaviors.[8] Elective surgery is considered an excellent chance for patients to quit smoking as they may be more motivated to stop smoking and open to smoking cessation advice.[4] A systematic review demonstrated that smoking behavior and postoperative morbidity are significantly influenced by preoperative smoking interventions therefore, the rule of surgeons and anesthesiologists in advising their patients is influential.[9] In addition, a study that was conducted at King Khalid University Hospital, Riyadh, Saudi Arabia, showed that only 58.8% of patients were advised to stop smoking before the surgery, most of which were advised to stop for less than a week.[7]

Since researches on the awareness of population toward the adverse effect of smoking on the surgical outcomes are quite deficient, it is crucial to identify the gaps to improve patient's outcome and the health-care system. Therefore, this study aims to measure the perception of knowledge of postoperative effects of cigarette smoking among Al-Ahsa population in Saudi Arabia.


  Methods Top


The Research and Ethics Committee, of the College of Medicine, King Faisal University (KFU), approved this cross-sectional survey study. Participants gave informed consent via a questionnaire that was distributed to the general population of Al-Ahsa Saudi Arabia. All Saudi Al-Ahsa citizens were studied (males and females) aged 18 years old and above.

The exclusion criteria excluded all health-care providers, participants aged <18-year-old, non-Saudi participants, and Saudi participants from outside Al-Ahsa. The total sample size was 632.

The questionnaire used in this study was structured based on relevant previous studies. The validity and reliability of the proposed survey were studied and edited by a panel of reviewers, which was followed by a cognitive interview technique, using online interviews with a group of 12 participants. The main structure of the questionnaire consists of two parts: (1) participants' biographical data and (2) knowledge assessment part, which assesses the perception of smoking-related health risk and the surgery-related adverse effects of cigarette smoking. The questionnaire was randomly distributed, using the means of electronic surveys. The knowledge assessment part was arranged into two scores: smoking health risk score and smoking surgical complication score. Smoking health risk score is an accumulative score for a total of 9 points, as every correct answer for the statements of smoking-related health risk is equal to 1 point. The smoking health risk scores was further divided into 2 groups: high score (7–9 points) and a low score (3–0 points).

Smoking surgical complication score is an accumulative score for a total of 8 points, as every correct answer for the statements of surgery-related adverse effects of smoking is equal to 1 point. The smoking surgical complications' score was divided into two groups: high score (6–8 points) and a low score (0-3 points).

Knowledge assessment for smoking health risk was done by using a knowledge assessment scores; ”Smoking Health Risk Score” is a score for a total of 9 points as each statement in the knowledge assessment gives 1 point for each agree “yes” answer, and the same is applicable for a “smoking surgical complications score” for 8 points in total. The smoking health risk scores were divided mainly into two groups: high score (7–9 points) and a low score (3–0 points). The smoking surgical complications' score was also divided into two groups: high score (6–8 points) and a low score (3–0 points).

The collected data were analyzed using SPSS and reported as means and standard deviations for the quantitative variables, and percentages for qualitative categorical variables. Fisher's exact or Chi-square tests were used to assess the relationship between qualitative variables. The significance was assessed at P < 0.05 for interpretation of tests' results, and 95% was presented as a confidence interval. All data were analyzed using Statistical Package for the Social Science (SPSS), version 17.0 (SPSS Inc., Chicago, IL, USA).


  Results Top


Biodemographic data

In this study, there were 632 responses, 324 (51.3%) were male and 308 (48.7%) were female. Almost a third of the participants belonged to the age group 41 and above, and the rest were 40 years of age and below. The majority were married and only 181 (28.6%) were single.

Of all participants, the income varies from less than 5000 riyals in 296 (46.8%) to more than 10000 riyals in around a third of the participants. In terms of level of education, nearly half of the participants were university graduated or had a higher education, 151 (23.9%) had a secondary school education, and only 48 (7.6%) had a below secondary school education either primary education or intermediate education [Table 1].
Table 1: Responses related to bio-demographic data

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Smoking habit data

Smoking prevalence in our study was reported to be 17.9% (112), while 73.5% (461) were nonsmokers and 8.6% (54) were reported to be ex-smoker. For smokers' participants, the majority (40.2%) have smoked 11–20 cigarettes. Furthermore, almost two-third of all smokers (67%) have been a smoker for more than 10 years, while only 8% have been a smoker for less than 5 years, and a quarter have been a smoker for 5–10 years.

For all participants, 235 (41.5%) are living with a smoker at the same house and 44.7% of them smoke inside the house. Furthermore, 204 (36%) of all participants are exposed to another smoker outside the house. Moreover, 79 (23.2%) of smoking-exposure participants have an everyday exposure to smoking regardless of participants smoking status. However, around half of the smoking-exposure participants are having less than an hour of smoking exposure, and 18.8% of smoking-exposure participants are having more than 3 h of smoking exposure [Table 2].
Table 2: Responses related to smoking habit data

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Smoking with surgical procedures and surgery-related adverse effects of cigarette smoking data

[Table 3] shows that the majority of smokers' group (71.9%) did not stop smoking before the surgery, and only 12 smokers (35.3%) have been asked by a physician to stop smoking few days prior to surgery. Nevertheless, 4 out of 9 smokers (44.4%), who have stopped smoking before the surgery, have been advised by their physician to stop smoking before the surgery, and the rest (55.6%) have already known the surgical adverse effects of smoking.
Table 3: Smoking with surgical procedures and adverse effects of smoking

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[Figure 1] shows that people who have heard about surgical adverse effects due to cigarette smoking are only 208 participants (32.9%), and the most have heard about surgical adverse effects via social media (43.1%) even though only 34.1% of social media followers have followed health-care providers' accounts in the social media. The rest of the participants have heard about surgical adverse effects from health-care professionals (28.1%), a person I know underwent a surgery (14.7%), and from books (12.0%).
Figure 1: Sources of information taken for surgery-related adverse effects of cigarette smoking

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[Figure 2] shows that nearly half of all participants agreed that health-care professionals is one of the most trusted sources of information for surgery-related adverse effects of cigarette smoking, in spite of the fact that only 12.8% of participants have reported the social media to be one of the most trusted sources of information. Further, participants have reported books and a person I know underwent a surgery to be one of the most trusted sources of information (22.7% and 16,7%, respectively).
Figure 2: Most trusted sources of information for surgery-related adverse effects of cigarette smoking

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Knowledge assessment for smoking health risk and smoking surgical complications data

[Figure 3] shows that lung cancer (56.5%) is the most agreed answer for smoking health risk, while peptic ulcer (35.9%) is the least agreed answer for smoking health risk as well as the most disagree answer for smoking health risk (13.6%). Furthermore, half of the participants did not know that peptic ulcer is a smoking health risk (50.5%) compared to lung cancer which is only applicable in 7.9% of all participants. In addition, coronary heart diseases, increased carbon monoxide level, and hypertension are the most agreed answers after the lung cancer for smoking health risk (76.7%, 63.6%, and 61.6%, respectively). Moreover, more than a third of all participants are found to have an 'I don't know' answer for esophageal cancer (34.2%), and (9.3%) of all participants did not agree that esophageal cancer can be a smoking health risk.
Figure 3: Knowledge assessment (smoking health risks)

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[Figure 4] shows that most of the patients have agreed that smoking can increase the risk of future heart and lung problems (79%), and think it is necessary to stop smoking after surgery (69%). However, more than a half of all participants did not know that smoking can increase pain after surgery (60.8%), increase risk of infection after surgery (56.2), increase surgical complications with anesthesia (51.3%), and also the ideal smoking cessation period before surgery is 4–6 weeks (55.7%). Finally, there were more people who did not agree that the ideal smoking cessation period before surgery is 4.6 weeks (27.8%) compared to people who agreed with the smoking cessation period statement (16.5%).
Figure 4: Knowledge assessment (smoking surgical complications)

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Knowledge assessment scores and biodemographic/behavior factors data

[Table 4] shows smoking health risk score, there are similar results overall for high scores across all age groups range from 60.2% to 72.5% of all participants, and females tend to have higher scores (72.1%) in compared to males (61.2%). Furthermore, 67.7% of nonsmoker people have higher scores than smoker people (56.8%), even though the ex-smoker group got the best outcome of high scores (73.7%).
Table 4: Crosstab between knowledge assessment scores and biodemographic/behavior factors

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For smoking surgical complications' score, more than half of all adult participants have low score in all age groups (minimally 61.8%, maximally 75.7%) unlike in the smoking health risk score, which is only applicable from 27.5% up to 39.8% of all adult participants. Further, females also have better awareness by getting higher scores (41.3%) compared to males (25.9%). Generally, most of smokers and nonsmokers group have a low score, despite that nonsmokers' group (36.0%) has better results for high score in comparison to smokers' group (25.0%).

[Table 5] shows a significant relationship between gender and knowledge assessment for both “smoking health risk” and “smoking surgical complications (P = 0.27 and P = 0.0001, respectively). Females are more likely to have a high score for smoking health risk (OR: 1.637, 95% CI: 1.055–2.541) and for smoking surgical complications (OR: 2.017, 95% CI: 1.367–2.978) in compared to males. However, no significant relationship was found between smoking status and smoking health risks' score (P = 0.094) or smoking surgical complications' score (P = 0.052).
Table 5: Relation between knowledge assessment scores and biodemographic/behavior factors

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  Discussion Top


Tobacco smoking is identified as a preventable leading cause of death worldwide.[4] Smoking-related postoperative adverse effects are well highlighted across surgical specialties [4T]. Smoking cessation, on the other hand, has been established to have a major impact in optimizing surgical outcomes.

In this study, there were 112 (17.9%) smokers out of 632 participants (110 males and only 2 females with a ratio of 55:1. Almost half of the participants (47.2%) were university graduates which indicates that almost half of the participants are well educated.

In Abha city, a male-to-female smoker ratio of 31.8:1 was found in Ejaimi et al. paper [2T].[3] Besides that, Al-Nozha et al. found that the ratio of smoker male to female was 2.6:1.[10]

About 40.2% of the smoker participants smoked 11–20 cigarettes and nearly two-third of them (67%) have been a smoker for more than 10 years. This study findings are in accordance with Ejaimi et al., who reported a smoking of 10–20 cigarettes per day in 40.7% of their smoker participants [2T].[3] Al-Nozha et al., on the other hand, reported a mean of 23.3 cigarettes smoked per day for more than 30 years' duration.[10]

For all participants, 41.5% are living with a smoker at the same house. About 44.7% of them smoke inside and 36% of all participants were exposed to another smoker outside their house. Al-Zalabani et al. found that the prevalence of secondary-hand smoke exposure reaches up to 32.7%, 49.3%, and 25%, inside, outside, and both inside and outside the house, respectively, in a study conducted among 3400 students in AL-Madinah city, Saudi Arabia.[11]

The majority of the smokers 71.9% did not stop smoking before their surgery, and only 12 smokers (35.3%) have been asked by a physician to stop smoking few days prior to surgery. Four out of 9 smokers (44.4%), who have stopped smoking before the surgery, have been advised by their physician to stop smoking before the surgery. This high number of not quitting smoking before the operation may be attributed to a defect in educating the patients or the way of explanation and advising by their physician prior to surgery.

Ejaimi et al. showed that quitting smoking was tried by 50% of their participants and the main reason for stopping smoking was a doctors' advice (53%) [2T].[3] Philips et al. stated that implantation of intensive smoking cessation programs in preoperative period results in high success rate. About 73% of the participants were able to quit smoking before surgery and cessation rated at 6, 12, and 24 months postoperatively were 55.3%, 55.6%, and 51.7%, respectively.[12]

Regarding preoperative interventions, Zaballos et al. also revealed that most anesthesiologists (85%) ask about smoking status. However, only 31% of them informed their patients about health risks of smoking and 23% advised to quit before surgery.[13]

A study was conducted by Hajjar et al., to explore the awareness of both surgeons and patients about the role of smoking cessation in improving surgical outcomes, showed that 69.6% of surgeons advised smoker patients to stop smoking for more than 2 weeks before surgery.[7]

In this study, only 32.9% heard about surgical adverse effects due to cigarette smoking. The majority (43.1%) have heard about it through social media, while only 28.1% heard about it from a health-care provider.

About 49.4% believed that health-care professionals are one of the most trusted sources of information for surgery-related adverse effects of cigarette smoking. This indicates the importance of physician's role in explaining and encouraging their patients to stop smoking prior to the surgery. Thus, surgery can be an exceptional motivation for smoker patients to facilitate tobacco abstinence.

Lung cancer was the most agreed on answer for smoking health risk, while peptic ulcer was the least agreed. Moreover, coronary heart diseases, increased carbon monoxide level, and hypertension were second most agreed on answers. Besides that, most of the patients have agreed that smoking can increase the risk of future heart and lung problems (79%) and think it is necessary to stop smoking after surgery (69%). More than a half of all participants did not know that smoking can increase pain after surgery (60.8%), increase risk of infection after surgery (56.2), and increase surgical complications with anesthesia (51.3%).

Wong et al. reported that 4 weeks at least of smoking cessation reduces respiratory complications and 3 weeks at least reduces wound-healing complications postoperative.[14] Montbriand et al. revealed that current smokers had significantly higher pain intensity (P < 0.05) at 1-month postsurgery than never smokers and past smokers. Besides that, both current and past smokers report a less than expected decline in daily opioid consumption (P < 0.05) at 3 months than current smokers.[15]

In this study, 55.7% did not know the ideal smoking cessation period before surgery is 4–6 weeks, 27.8% did not agree, and only 16.5% agreed upon this period.

A study done by Matsuoka et al. showed that there was no relationship between the length of preoperative smoking cessation period and the frequency of postoperative complications and stated that the delay of surgery to allow patients to stop smoking is unnecessary.[16]

On the other hand, Quan et al. in a retrospective study of 2469 patients, revealed that smokers who stopped smoking ≥4 weeks before surgery had lower pulmonary problems than those with a shorter period of smoking cessation.[17]


  Conclusion Top


The awareness of smoking-related postoperative adverse effects is poor. It is important for health-care providers to raise their patient's awareness and knowledge before the surgery. We recommend starting and implanting a strong preoperative smoking cessation program to provide the needed information and educational materials, advising smokers to quit, and offering referrals for behavioral change.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Moradi-Lakeh M, El Bcheraoui C, Tuffaha M, Daoud F, Al Saeedi M, Basulaiman M, et al. Tobacco consumption in the Kingdom of Saudi Arabia, 2013: Findings from a national survey. BMC Public Health 2015;15:611.  Back to cited text no. 1
    
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Katznelson R, Beattie WS. Perioperative smoking risk. Anesthesiology 2011;114:734-6.  Back to cited text no. 2
    
3.
Ejaimi G, Abu Saq I, Alfaifi W, Al-Zahrani F. (PDF) Awareness of cigarette-smoker surgery patients in Abha City, Saudi Arabia toward surgery-related adverse effects of smoking. Res Gate 2017;84:151-6.  Back to cited text no. 3
    
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Theadom A, Cropley M. Effects of preoperative smoking cessation on the incidence and risk of intraoperative and postoperative complications in adult smokers: A systematic review. Tob Control 2006;15:352-8.  Back to cited text no. 4
    
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Hadi M, Azrina M, Zamzila A, Ariff O. Smoker Desaturation during General Anaesthesia: A Case Report. Irep.iium.edu.my. 2009; 019,076.  Back to cited text no. 5
    
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Warner DO. Helping surgical patients quit smoking: Why, when, and how. Anesth Analg 2005;101:481-7.  Back to cited text no. 6
    
7.
Hajjar WM, Al-Nassar SA, Alahmadi RM, Almohanna SM, Alhilali SM. Behavior, knowledge, and attitude of surgeons and patients toward preoperative smoking cessation. Ann Thorac Med 2016;11:132-40.  Back to cited text no. 7
[PUBMED]  [Full text]  
8.
Webb AR, Robertson N, Sparrow M. Smokers know little of their increased surgical risks and may quit on surgical advice. ANZ J Surg 2013;83:753-7.  Back to cited text no. 8
    
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Lee SM, Landry J, Jones PM, Buhrmann O, Morley-Forster P. The effectiveness of a perioperative smoking cessation program: A randomized clinical trial. Anesth Analg 2013;117:605-13.  Back to cited text no. 9
    
10.
Al-nozha M, et al. Smoking in Saudi Arabia and its relation to coronary artery disease. J Saudi Heart Assoc 2009;21:169-76.  Back to cited text no. 10
    
11.
Al-Zalabani AH, et al. Second-Hand Smoking among Intermediate and Secondary School Students in Madinah, Saudi Arabia. Biomed Res Int 2015;2015:672393. doi: 10.1155/2015/672393. Epub 2015 Jul 26. PMID: 26273638; PMCID: PMC4529938.  Back to cited text no. 11
    
12.
Phillips JD, et al. Long-Term Outcomes of a Preoperative Lung Resection Smoking Cessation Program. J Surg Res. 2020;254:110-7. doi: 10.1016/j.jss.2020.04.005. Epub 2020 May 16. PMID: 32428728.  Back to cited text no. 12
    
13.
Zaballos M, et al. Preoperative smoking cessation counseling activities of anesthesiologists: A cross-sectional study. BMC Anesthesiol 2015 28;15:60. doi: 10.1186/s12871-015-0036-6. PMID: 25927569; PMCID: PMC4426771.  Back to cited text no. 13
    
14.
Wong J, Lam DP, Abrishami A, Chan MT, Chung F. Short-term preoperative smoking cessation and postoperative complications: a systematic review and meta-analysis. Can J Anaesth. 2012;59:268-79. doi: 10.1007/s12630-011-9652-x.  Back to cited text no. 14
    
15.
Montbriand JJ, et al. Smoking, Pain Intensity, and Opioid Consumption 1-3 Months After Major Surgery: A Retrospective Study in a Hospital-Based Transitional Pain Service. Nicotine Tob Res 2018;20:1144-51. doi: 10.1093/ntr/ntx094. PMID: 28472423.  Back to cited text no. 15
    
16.
Matsuoka K, et al. Preoperative Smoking Cessation Period Is Not Related to Postoperative Respiratory Complications in Patients Undergoing Lung Cancer Surgery. Ann Thorac Cardiovasc Surg. 2019;25:304-310. doi: 10.5761/atcs.oa.19-00080. Epub 2019 Jul 4. PMID: 31270298; PMCID: PMC6923722.  Back to cited text no. 16
    
17.
Quan H, Ouyang L, Zhou H, Ouyang Y, Xiao H. The effect of preoperative smoking cessation and smoking dose on postoperative complications following radical gastrectomy for gastric cancer: a retrospective study of 2469 patients. World J Surg Oncol. 2019;17:61. doi: 10.1186/s12957-019-1607-7. PMID: 30940207; PMCID: PMC6446305.  Back to cited text no. 17
    


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