Perioperative tobacco use behavior was not changed by the use of a decision aid, though it did substantially improve measures of decisional quality, according to a study published recently in Anesthesiology.1 The decision aid facilitated discussions between clinicians and patients about tobacco use around the time of surgery.

The study researchers explained that patients who smoke have three options regarding their smoking behavior in the surgical period: continue to smoke, attempt temporary abstinence from smoking in the perioperative period, or use the surgery as an opportunity to quit for good. 

The setting of surgery is an “excellent opportunity” to explore the use of a decision aid to facilitate discussing tobacco use between clinicians and patients who smoke, according to the study’s background information.

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Designing the Cards 

The final device consisted of three laminated, colorful cards that were contained in a sleeve that also had written patient instructions for their use. Each card had a graphic that described each choice, the reverse had two to three pros and cons for each decision, and the cards had a simple graphic illustrating the effects of smoking on the body for one card and a motivational phrase.

Testing the device

A two-group pilot study evaluated the final decision aid in current cigarette smokers in preoperative care for elective surgery, with the decision aid compared with usual care. Both the decision aid and usual care were delivered by the practicing clinicians who regularly staff the preoperative evaluation center at the Mayo Clinic Rochester, where the study was conducted.

Usual care, which was received by 63 patients, was a standard patient education brochure in clinical use that outlined the risk of smoking in the perioperative period, the benefits of quitting, and resources available to support quitting. This was delivered by the personnel who brought them into the examination room.

For the 66 patients who received the decision aid, the personnel who brought them into the examination room gave them the decision aid. Then the personnel read them the instructions printed on the package sleeve about making a decision about how to handle smoking at the time of surgery. The patient was instructed to look at the information and choose a card to give to their doctor about which decision was right for that patient.

The median time from the preoperative evaluation center to surgery was one day (interquartile range, 1-2 days), with a mean of 2.6 days.

Decisional quality and decisions

The quality of the patient decision was increased by the decision aid according to all measures. The decision aid group had a medium to large effect size, as measured by the Decisional Conflict Scale (Cohen’s d = 0.76), which assesses uncertainty in decision-making, and by the COMRADE scale (Cohen’s d = 0.78), which assesses decision-making and risk communication. The OPTION scores indicated significantly higher patient involvement in the decision-making process in the decision aid group (Cohen’s d = 1.20).

However, the distribution of choices made by the patients was not significantly different between those in the decision aid group and those receiving usual care. Adhering to a decision for self-reported abstinence or “quit for good” was not different between the groups.

Clinical utility?

Since the decision aid did not appear to effect smoking behavior, the authors questioned its potential clinical utility in the discussion. 

They stated that, since using the decision aid did not reduce the number of patients choosing some period of abstinence compared with usual advice to quit, the decision aid was at least not inferior. 

The authors concluded that it remains to be determined if combining the decision aid with support for patients wishing to maintain a period of abstinence could affect behavior.


1. Warner DO, et al. Anesthesiology. 2015; 123:18-28.