Effects of Smoking on Circulation, Surgery, and Peripheral Arterial Disease

I remember the patient vividly.  A very pleasant elderly gentleman, a navy veteran of World War II, a retired mover, who came to the ER with his daughter because he couldn't take the pain anymore.  Years of tobacco use had taken its toll on the circulation in his legs, and for months he slept sitting up in a chair in an attempt to force blood down to his feet, but in the end, gangrene set in and the pain was all consuming.

I was consulted to see him, and the appearance of his feet was quite shocking.  The skin on his toes turned black and dried up like an old prune, and the remaining tissue was infected.  He was admitted to the hospital, and after the vascular surgery team performed a bypass procedure to restore blood flow to what was left of his foot, my residents and I salvaged the remaining healthy tissue and restored function to the foot.  Ever since that time, I kept a picture of his foot in my phone to demonstrate the ill effects of smoking to my patients who continue the habit- slightly cruel, yes, but as they say, a picture is worth a thousand words.

Any guess what percentage of US residents continue to smoke?  About 19.3%, according to the CDC.  And we are all aware of the dangers of smoking ever since the surgeon general published the first report in 1964: cancer, emphysema, heart disease, and yes, peripheral arterial disease, or PAD, which can lead to lower extremity amputation.  In fact, the two single biggest risk factors for PAD are diabetes and tobacco use.  Plus, it's a rather nasty, expensive habit- here in NYC the price of a pack of cigarettes is upwards of $11.  The exorbitant price of cigarettes is thanks to Mayor Bloomberg's aggressive anti-smoking campaign which was credited with preventing 3,813 hospital admissions for heart attacks in a 2004 study.

So what does this have to do with my NYC podiatry practice?  I made the decision a few years ago not to perform elective foot surgery on smokers, including bunion, hammertoe, and heel spur procedures.  I was frankly stymied by the high rate of non-healing bone procedures and skin incisions.  A 2009 study in the Journal of Foot and Ankle Surgery demonstrated a 42% longer bone healing time in smokers vs. non-smokers.  Of course, non-elective-surgeries, such as treatment of smoking and diabetes related infections, are still performed, although I anticipate a longer recovery.

I fully acknowledge that smoking is a tough habit to break, and is physically addictive.  But the rewards for quitting are certainly worth it, and more than can be detailed in this blog.  Need help?  Start here.

See you in the office.

Dr. Ernest L. Isaacson

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