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OVERVIEW

Tobacco Smoking and Solid Organ Transplantation


Chris Corbett,1,2 Matthew J. Armstrong,1,2 and James Neuberger1,3
Smoking, both by donors and by recipients, has a major impact on outcomes after organ transplantation. Recipients
of smokers organs are at greater risk of death (lungs hazard ratio [HR], 1.36; heart HR, 1.8; and liver HR, 1.25),
extended intensive care stays, and greater need for ventilation. Kidney function is significantly worse at 1 year after
transplantation in recipients of grafts from smokers compared with nonsmokers. Clinicians must balance the use of
such higher-risk organs with the consequences on waiting list mortality if the donor pool is reduced further by exclusion of such donors. Smoking by kidney transplant recipients significantly increases the risk of cardiovascular
events (29.2% vs. 15.4%), renal fibrosis, rejection, and malignancy (HR, 2.56). Furthermore, liver recipients who
smoke have higher rates of hepatic artery thrombosis, biliary complications, and malignancy (13% vs. 2%). Heart
recipients with a smoking history have increased risk of developing coronary atherosclerosis (21.2% vs. 12.3%), graft
dysfunction, and loss after transplantation. Self-reporting of smoking is commonplace but unreliable, which limits its
use as a tool for selection of transplant candidates. Despite effective counseling and pharmacotherapy, recidivism rates
after transplantation remain high (10Y40%). Transplant services need to be more proactive in educating and implementing effective smoking cessation strategies to reduce rates of recidivism and the posttransplantation complications
associated with smoking. The adverse impact of smoking by the recipient supports the requirement for a 6-month
period of abstinence in lung recipients and cessation before other solid organs.
Keywords: Smoking, Transplant, Nicotine, Tobacco, Cigarettes.
(Transplantation 2012;94: 979Y987)

moking is well recognized to increase the risks of a wide


range of pathologies, including cardiovascular disease,
stroke, peripheral vascular disease, peptic ulcer disease, lung
disease, and cancer (1). Smoking has also been shown to be a
major risk factor for bacterial and viral infections (2) as well
as the development of chronic kidney disease (3). Most notably, smoking increases the risk of all-cause mortality and
contributes to approximately 5 million premature deaths
per year (4). In 2000, smoking accounted for 4.83 million
deaths worldwide (5). Based on prevalence figures of 30%,
the World Health Organization has estimated that smoking
will kill 8 million people a year by 2030 (6).
The adverse effects of smoking on outcomes after surgical procedures (7), particularly solid organ transplantation,
are well documented. After liver transplantation, smoking

M.J.A. is in receipt of a Wellcome Trust Clinical Research Fellowship.


All other authors declare no funding or conflicts of interest.
1
Liver Unit, Queen Elizabeth Hospital, Birmingham, United Kingdom B15 2TH.
2
National Institute of Health Research Biomedical Research Unit and
Centre for Liver Research, University of Birmingham, Birmingham,
United Kingdom B152TT.
3
Organ Donation and Transplantation, NHS Blood and Transplant, Bristol,
United Kingdom.
Address correspondence to: Chris Corbett, M.B.B.S., M.R.C.P., National Institute of Health Research Biomedical Research Unit and Centre for Liver
Research, University of Birmingham, 5th Floor IBR Building, Birmingham,
United Kingdom B152TT.
E-mail: chris.corbett@nhs.net
C.C. wrote the article. M.J.A. and J.N. reviewed and edited the final article.
Received 4 April 2012. Revision requested 26 April 2012.
Accepted 7 June 2012.
Copyright * 2012 by Lippincott Williams & Wilkins
ISSN: 0041-1337/12/9410-979
DOI: 10.1097/TP.0b013e318263ad5b

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& Volume 94, Number 10, November 27, 2012

increases all-cause mortality, with cardiovascular and sepsis


accounting for the majority of deaths (8). In kidney and
heart recipients, smoking is associated with graft loss (9) and
delayed graft function (10).
Smoking cessation should always be advocated by
clinicians and indeed is mandatory for 6 months before lung
transplantation (11). As will be discussed in detail below, use
of organs from donors who have smoked has a negative
impact on the outcomes after transplantation (12).
This review summarizes the documented effects of
tobacco smoking on solid organ transplantation, with particular focus on the impact of donor and recipient smoking
on posttransplantation morbidity and mortality. The impact
of smoking cessation and the efficacy of interventions to
reduce smoking rates are also reviewed.
An evidence-based approach was used for this review.
MEDLINE search was performed to February 2012 using the
following terms: smoking (or tobacco), transplant, smoking
detection, and smoking cessation. Literature for this review
was selected from a total of 153 publications.

PATHOLOGIC EFFECTS OF
TOBACCO SMOKING
Tobacco smoking affects multiple organ systems in the
human body, impairing both psychologic and physical wellbeing and are summarized in other reviews and Figure 1.

CURRENT GUIDELINES ON SMOKING AND


ORGAN TRANSPLANTATION
In 1998, the American Society for Transplant Physicians,
the American Thoracic Society, the European Respiratory
www.transplantjournal.com

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& Volume 94, Number 10, November 27, 2012

FIGURE 1. Physiological and psychological effects of smoking on humans. MAO-B, monoamine oxidase B; FEV-1, forced
expiratory volume in one second; COPD, chronic obstructive pulmonary disease; NASH, nonalcoholic steatohepatitis; PSC,
primary sclerosing cholangitis; UC, ulcerative colitis.

Society, and the International Society for Heart and Lung


Transplantation published consensus guidelines recommending that candidates for lung transplantation must have been free
of substance addiction (including alcohol, tobacco, and narcotics)for at least 6 months. These guidelines also recommended
appropriate biochemical monitoring in at-risk patients (13)
(Table 1).
Similar to alcohol-associated liver disease patients listed for liver transplant, the guidelines recommended that
such at-risk candidates should sign a smoking cessation contract and perhaps attend a smoking cessation program.
The International Society for Heart and Lung Transplantation guidelines were modified in 2006 to recommend
that active smoking should be a relative contraindication to
transplantation and state that active tobacco smoking during the 6 months before surgery is a risk factor for poor
outcomes (14). Guidelines for liver and kidney transplantation issued by the British Transplantation Society (15)
state that patients are strongly advised to stop smoking
before any transplant and that formal smoking cessation
programs should be offered and accessed in primary care.

SMOKING AND ORGAN DONORS


The lungs, hearts, and kidneys from donors who have
smoked are associated with worse recipient survival and
increased morbidity. This increased risk associated with the
use of organs from such donors raises medical and ethical

issues. The risks associated with these organs must be balanced against the risk of dying or becoming untransplantable
if these organs are not used (16) and potential candidates
must be appropriately consented.
Lung Transplantation
A retrospective study by Bonser et al. (17) of 1295
United Kingdom lung transplant recipients found that 39%
of the transplanted lungs were from donors with a history of
smoking. Three-year survival after transplantation in recipients of positive smoking history lungs was worse with an
adjusted hazard ratio (HR) of 1.36 (95% CI [95% confidence
interval], 1.11Y1.67) compared with nonsmokers lungs. Declining these organs, however, would have increased waitlist
mortality, so the overall patient survival would be reduced.
Statistical modeling confirmed that the potential recipient
offered a lung donated from a smoker has a better chance of
survival if the lungs are used rather than wait for the next
suitable offer.
In contrast, two smaller studies assessing 424 and
173 recipients failed to find a statistically significant impact
from the use of lungs from smokers on late mortality. There
was an increased odds of an intensive care stay for more than
2 days compared with nonsmokers donor lungs (95% CI,
1.3Y3.1; P=0.001) (12). Ventilation times were raised in
those who received organs from donors with 920 pack-years
(HR, 0.41; 95% CI, 0.22Y0.78; P=0.01) (18).

Copyright 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

Corbett et al.

* 2012 Lippincott Williams & Wilkins

TABLE 1.

Smoking and acceptance onto waiting lists

Transplantation

Cessation

Effect on listing

Lung [13]

Contraindication
Tobacco smoking
(also includes
alcohol; narcotics;
other illegal
substances)

Kidney [15]

Tobacco smoking

Heart [14]

Tobacco smoking

Liver [15]

981

Tobacco smoking

Duration of
abstinence

Management

Q 6 months

Biochemical
(in high risk)
monitoring
and smoking
cessation
signed contracts
Strongly advised;
Not specified Education; Some
not a contraindication
centres adopt
urine sampling

Relative
Contraindication

Risks of recipient
smoking compared to non
smoking recipients
Increased risk of CKD HR
1.69 (1.27Y2.24)

Allograft loss HR
1.43 (1.16Y1.76)
Death HR 2.26 (1.91Y2.66)
Transplant failure
33.3% vs. 21.2%
Cancer HR 1.12 (1.02Y1.21)

Ideally
Formal smoking
Death HR 1.6 (1.09Y2.34)
6 months
cessation programs
should be offered Renal dysfunction HR
1.97 (1.06Y4.26)

Strongly advised;
Not specified Not specified
not a contraindication

Skin cancer HR
2.25 (1.29Y3.93)
Solid organ cancer HR
4.53 (2.33Y8.78)
Biliary complications HR
1.92 (1.07Y3.43)
Hepatic Artery Thrombosis RR
2.49 (1.16Y5.33)
10-yr rate of cancer
12.7% vs. 2.1%

CKD, chronic kidney disease; HR, hazard ratio; RR, risk ratio.

One major concern with studies looking at the effects


of smoking in donors is that it was not possible fully to
define the amount and duration of smoking and all three
studies class smoking as never or ever. It must also be
recognized that surgeons carefully evaluate the lungs before
retrieval and implantation so the lungs used represent a selected cohort. Certainly, research is needed to discover above
which threshold the donor pack-year consumption begins to
compromise treatment benefit.
Kidney Transplantation
Living kidney transplants donors who actively smoke
or have a past history of tobacco use have a larger percent
increase in creatinine (57% vs. 40%; PG0.001) following
donation compared with donors who have never smoked.
At 1 year, recipients of kidneys from donors who were
smokers showed both significantly less improvement (j57%
vs. j81%; P=0.015) in postoperative serum creatinine and
lower glomerular filtration rate compared with recipients of
nonsmoking donor kidneys. A dose effect is seen: the greater
the donor tobacco exposure, the smaller the improvement in
recipient creatinine. Although smoking cessation by the
donors can improve outcomes, kidneys from donors with
no history of smoking provide the best outcomes (19).
A history of smoking in kidney donors is associated
with both decreased graft survival (HR, 1.05; P=0.028) and
recipient survival (HR, 1.06; P=0.021) (20).

These findings have not been replicated in the United


Kingdom.
Heart Transplantation
We are aware of only one study looking at donor smoking
on the outcomes of heart transplantation. This small (n=112)
Taiwanese study showed that 25% of donors were smokers and
that the donors smoking history had a significantly detrimental
effect on the recipients survival with a HR of 1.8 (95% CI,
1.09Y2.95) (21).
Liver Transplantation
A 2011 German study of extended donor criteria livers
showed that any smoking in the donor was associated with
an increased risk of death after liver transplant of 1.249
(95% CI, 1.011Y1.544; P=0.04) (22). There was however, no
difference in graft survival after liver transplant.

RECIPIENT SMOKING
Effects of Smoking on the Immune System of
Transplanted Patients
Potential immunologic pathways have been investigated in mouse models to explain how smoking might
contribute to organ rejection. Indoleamine 2,3-dioxygenase

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(IDO) expression is seen to be inhibited by smoking (23).


IDO is expressed by antigen-presenting cells and metabolizes tryptophan to serotonin and kynurenine, both of which
promote T-cell apoptosis. Tryptophan catabolism also
induces and expands the pool of regulatory T cells, which
play a key role in immune tolerance. Therefore, smoking
may precipitate allograft rejection by suppressing either IDO
expression or regulatory T-cell generation, both of which are
essential for graft survival.
Lung Transplantation
Prior smoking in lung recipients has been shown to be
associated with a higher risk of chronic kidney disease (24).
The decline in glomerular filtration rate is more rapid in
former smokers than nonsmokers.
Kidney Transplantation
Several studies have looked at the adverse effects of
smoking on the transplanted kidney as well as the morbidity
and mortality of the recipient. Smoking after transplant is
associated with an increased risks (9, 10, 25Y27) compared
with nonsmokers of death-censored allograft loss (HR, 1.43;
95% CI, 1.16Y1.76; P=0.001), death (HR, 2.26; 95% CI,
1.91Y2.66; PG0.001), and transplant failure (33.3% vs. 21.2%;
P=0.25). This cohort also has greater rates of diabetes (25%
vs. 13.5%; P=0.33), cardiovascular events (29.2% vs. 15.4%;
P=0.16), and vascular renal problems such as fibrous intimal thickening of small arteries (fourfold probability of a
primary increase; P=0.004). Cancer risk is elevated by 1.12
(1.02Y1.21; P=0.016) after a 10 pack-year history and by 2.56
(1.51Y4.32; P=0.001) with a 25 pack-year history (28).
Rates of smoking in kidney transplant candidates
range between 24% (29) and 33% (30), with 90% continuing
to smoke postoperatively.
Heart Transplantation
Reported rates of smoking in heart transplant recipients vary between 17% (31) and 27% (32). The higher rate
was observed when urinary samples were covertly tested for
urinary cotinine. Smoking (unquantified) was found to reduce life expectancy from 16.28 to 11.89 years, increase rates
of coronary artery disease (21.2% vs. 12.3%; PG0.05), and
increase malignancy (16.3% vs. 5.8%; PG0.001). Smoking
significantly raised the rate of all-cause and cardiac death
with an HR of 1.6 (P=0.016) (33).
Smoking in heart transplant recipients is also associated with noncardiac morbidity: thus, there is an increased
risk of postoperative renal dysfunction (HR, 1.97; 95% CI,
1.06Y4.26; P=0.04) (34). Smokers are also at higher risk of
longer postoperative intubation as well as recovery unit stay
with increased all-cause mortality (35).
The rates of both skin cancer (HR, 2.25; P=0.004) and
other solid organ cancers (HR, 1.12; PG0.001) are increased
in smokers. This leads to an increased risk of death with a
life expectancy of 5 years for skin cancer and 0.3 years for
solid organ tumors (36).
Liver Transplantation
Smoking is associated with an increased overall mortality, cardiovascular-related mortality, and sepsis-related
mortality in a retrospective study of 136 patients from
Scotland (8). Active smokers had a 92% higher rate of biliary
complication rates compared with lifetime nonsmokers

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& Volume 94, Number 10, November 27, 2012

(HR, 1.92; 95% CI, 1.07Y3.43), but no difference was noted


in the rate of complication resolution (37).
Smokers also had a higher rate of hepatic artery thrombosis, but cessation of smoking for 2 years before grafting reduced vascular complications (13.5% vs. 4.8%) (38).
Self-reported smokers had a similar 1-year survival to
patients who denied smoking (39), but those who reported
smoking had a higher mean length of hospital stay and significantly higher hospital charges. Smokers were also found
to have a higher incidence of ascites and encephalopathy at
referral to the transplantation program. There was, however,
no elevation in Model for End-Stage Liver Disease score or
Childs-Pugh-Turcotte score.
At 10 years, the cumulative rate of malignancies was
12.7% in active smokers compared with 2.1% in nonsmokers (P=0.019) (40). Tobacco use is also associated with
a higher incidence of posttransplantation de novo noncutaneous neoplasms (41) as well as solid organ (10.5% at
10 years) and hematologic malignancy (3.2% at 10 years),
especially in those transplanted for primary sclerosing cholangitis and alcoholic liver disease (42).
The literature is not all in agreement: a retrospective
study of 2260 US patients who were assessed for liver transplant showed that smoking was not associated with increased
mortality risk (HR, 0.89) at any time point (43). This study,
although large, was a single center study and smoking cessation was not mandated or confirmed by cotinine (nicotine
metabolite) levels. Smoking behavior was also not quantified
and thus entered as a single covariate in the survival models.
Factors predictive of mortality included a prior cardiac history, cardiac complications perioperatively, and pretransplant
Model for End-Stage Liver Disease score.

EFFICACY OF SMOKING CESSATION


PROGRAMS AND RATES OF RECIDIVISM
Detection of Smoking
There are several ways to detect smoking (Table 2).
& Urinary cotinine is cheap and easy to use. It is a metabolite
of nicotine with a longer half-life than nicotine (19 vs. 2 hr).
Its use as a marker for smoking is not perfect because the
levels become undetectable after approximately 4 days.
& Saliva and hair testing for cotinine is more expensive but
can give positive results up to 10 days after smoking.
& Carboxyhemoglobin blood levels are also employed to
detect smoking but can be elevated by road traffic or
domestic emissions.
Rates of Smoking in Transplant Recipients
After liver transplant, use of cotinine levels has shown
that self-reporting use of tobacco is very accurate (as a
positive control). Seventeen percent of patients in one study
were using nicotine replacement and 97% of those had
positive cotinine levels (44).
Assessing recidivism has also been assessed using the
above methods. Cotinine has shown rates of smoking of 11%
in lung recipients among those who chose not to report it (45).
Carboxyhemoglobin has also been used in the same way.
One study describes that 4 of 22 smokers after heart transplant
who had previously denied smoking only admitted to it when
shown the results of tests (46).

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171

Retrospective

Prospective
Prospective

Prospective

Prospective

Prospective
Prospective
Prospective
Prospective

Di Martini 2005 [49]


Ehlers 2004 [50]

Vos 2010 [45]

Basile 2004 [31]

Botha 2008 [32]


Nagele 1997 [46]
Yavuz 2004 [48]
Banas 2008 [47]

Heart
Heart
Renal
Renal

Heart

Lung

Liver (ALD)
Liver

Liver

Liver

Organ
transplant

Covert urinary cotinine


Self-report and Co-Hb
Self-report
Self-report

Self-report, urinary
cotinine and
exhaled CO
Self-report

Self-report
and serum cotinine
Self-report
Self-report

Self-report

Detection
method

ALD, alcoholic liver disease; CO, carbon dioxide; COPD, chronic obstructive pulmonary disease.

380
84
226
264 post-allograft

103

267

172
202

301

Prospective

Van der Heide


2009 [40]
Bright 2010 [44]

Number

Study type

Smoking cessation and recidivism

Author (year). ref

TABLE 2.

87.5% (40.9% never)

74%
42%
13%

0%

62% former,
38% never
34% never

10%

17%

17%

8% never

83% (11% had


positive cotinine)

53%

Non-smokers

Active at
assessment

Smoking rates

19% G1 year

47% 91 year before

Roughly 33%

Cessation
before
transplant

17.6% in long-term
ex-smokers
40% in short-term
ex-smokers
27%
26%
12%

40%
15% (20% of
ex-smokers)
11% (23% in COPD)

20%

12%

Recidivism
after
transplantation

* 2012 Lippincott Williams & Wilkins

Corbett et al.

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Rates of recidivism are difficult to predict as most studies assess


smoking via self-reporting and patients may be reluctant to
admit to smoking (40, 47Y49). Self-reported smoking may be
open to reporter bias, but Ehlers et al. (50) also observed
that there was a decrease in self-reported risky health behaviors leading to the suggestion that transplantation might be
a point in time where interventions might be more successful due to patient being more motivated and amenable.
An Italian study assessed patients using a Minnesota
Multiphasic Personality Inventory. Those who scored badly
in self-control and difficult adaptation scales were at a higher
risk of reabuse, and as such, they may require more stringent
and prolonged psychological support pretransplant (31).
Beneficial Effects of Stopping Smoking
Smoking cessation in the general population is of
proven benefit: cessation is associated with an increase in
FEV-1 of 47 mL (~2%) in people with chronic obstructive
pulmonary disease and also slows the rate of decline in lung
function (31 vs. 62 mL/year) (51). The change in FEV-1 is
not, however, associated with respiratory symptoms.
The Lung Health Study looked at interventions with
(nontransplanted) smokers and the beneficial effects on
mortality. They found that usual smoking cessation care was
only successful in a minority (5.4%) of patients (52). The
rate of smoking cessation increased to 21.7% if group sessions were added. This translated into a significantly lower
mortality of the intervention group compared with the usual
care group. The HR for mortality between the two groups
was 1.18 (95% CI, 1.02Y1.37).
A 2011 Spanish study of 339 liver transplant recipients
showed that, of the 135 smokers (40%), stopping smoking
postoperatively might have a protective effect against the
development of cancer (53). Smokers, ex-smokers, and
nonsmokers were matched against controls to observe risks
of developing and dying of a smoking-related malignancy
(lung, head and neck, esophageal, and renal tract). A relative
risk of 8.55 (95% CI, 3.45Y15.76) was seen in smokers
postoperatively. Among previous smokers, this risk was
lower with a risk ratio of 4.44 (95% CI, 1.92Y8.74).
In renal transplant recipients, Kasiske and Klinger (54)
showed that patients who smoked but quit Q5 years before
transplantation had better outcomes than those who had
never smoked. The reasons for this were unclear but have been
postulated to be due to drug adherence and lifestyle changes.
Efficacy of Treatments
Three meta-analyses and a Cochrane review have
proven the efficacy of the various smoking cessation therapies (55Y58). The Cochrane review suggested that provision
of more intense levels of support, although beneficial in facilitating the likelihood of quitting, is not essential to the
success of nicotine replacement therapy. A summary of the
various interventions and their likelihood of abstinence are
included in Table 3.
Focusing on smoking cessation in the last few years
may have helped reduce rates of smoking in renal transplant
patients. Before 1990, 38% of patients continued to smoke
after transplantation. After 2000, this drops to 13% (26).
There is very little information on the efficacy of such
interventions in the transplanted population, but extrapolation

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& Volume 94, Number 10, November 27, 2012

of the data from nontransplanted patients would suggest that


smoking cessation by whatever means is essential. It is not clear
whether the costs of such smoking cessation programs should
fall on the transplant unit or primary care where such programs
already exist, but there should be guidance from transplant
clinicians for more targeted approaches in primary care.

SHOULD ACTIVE SMOKERS BE DENIED


ACCESS TO TRANSPLANTATION?
A survey in 2000 (59) found that transplant programs
considered tobacco as an absolute contraindication in
the following groups: renal 8%, liver 20%, heart 77%, and
lungs 96%.
All smokers should be encouraged and supported to
stop smoking. This becomes even more important when that
patient is being considered for a transplant. Given the extent
of the surgery and the consequences of immunosuppressive
drugs, it is imperative that the patients are educated as to the
consequences of continuing to smoke.
Some have advocated denying the active smoker access
to a life-saving transplant based on the need to allocate
scarce organs to those who will benefit most. In 1997, the
American Medical Association (60) listed unacceptable criteria for denying transplantation. These include the patients
(or insurers) ability to pay, the contribution of the patient
to society, or the previous use of medical resources. They
also mentioned that perceived obstacles to treatment or the
patients contribution to their condition, such as personality
or alcohol abuse, are not acceptable reasons to deny access to
transplantation. However, the degree of likely benefit is a
valid reason to deny a person access to transplantation. This
is because continued smoking does put the patient at an
added (and most would argue) preventable cause of graft
loss and premature death, and it would be ethical to deny
active smokers access to transplantation (61). There are
parallels in other situations: liver transplantation is contraindicated by ongoing alcohol use despite full support to
become and remain abstinent; kidney transplantation has
been denied to morbidly obese patients (62). Smoking, like
nonadherence to immunosuppression or excessive alcohol
consumption, will potentially damage the graft and reduce
patient survival. Therefore, it has been argued that organs
should be allocated preferentially to those who will benefit
most or at least take all necessary measures to ensure good
graft function.
In a nontransplant situation, research has shown that
self-reporting of smoking can be a valid way of assessing
rates of smoking in an open environment. Among selfreported regular smokers, 97.2% of men and 94.9% of
women had urinary cotinine levels consistent with active
smoking. Among nonsmokers, 2.5% of men and 2.7% of
women had detectable cotinine levels (63). The situation
with respect to transplantation assessment is not likely to be
as reliable given the potential ramifications of admitting to
smoking, which would be potentially life-threatening if more
stringent rules were set in place. Self-reporting of smoking
therefore lacks sufficient reliability in transplantation yet
remains the only available mainstream method of assessment
at present. Depending on the honesty of patients is unrealistic
given the addictive nature of tobacco (specifically nicotine).

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Corbett et al.

* 2012 Lippincott Williams & Wilkins

TABLE 3.

985

Smoking cessation therapies

Author, date, ref


Silagy 1994 [55]

Type

Intervention

Meta analysis of 53 trials and


17703 patients

Gum
Transdermal patch
Nasal Spray
Inhaled Nicotine
All trials
Stead 2008 [56]
Cochrane review of 132 trials and
Gum
40,00 patients
Transdermal patch
Nasal Spray
Inhaled Nicotine
Oral tablets/lozenges
Any form of NRT
Strassmann 2009 [57] Meta analysis of 6 trials and
Nicotine replacement
7372 COPD patients
therapy and counselling
vs. standard care
Nicotine replacement
therapy and counselling
vs. counselling
Nicotine replacement
therapy and counselling
vs. counselling 3.30)
Counselling vs. usual care
Eisenberg 2008 [58] Meta analysis of 69 trials
Varenicline
covering 32908 patients
Nicotine Nasal Spray
Bupropion
Nicotine patch
Tablets
Gum
Inhaled Nicotine

Odds ratio (RR)


of abstinence

RR of abstinence

1.61 (1.46Y1.78)
2.07 (1.64Y2.62)
2.92 (1.49Y5.74)
3.05 (1.56Y1.87)
1.71 (1.56Y1.87)
1.43 (1.33Y1.53)
1.66 (1.53Y1.81)
2.02 (1.49Y3.73)
1.90 (1.36Y2.67)
2.00 (1.63Y2.45)
1.58 (1.50Y1.66)
5.08 (4.32Y5.97)

2.80 (1.49Y5.26)

1.53 (0.71Y3.30)

1.82 (0.96Y3.44)
2.41 (1.91Y3.12)
2.37 (1.12Y5.15)
2.07 (1.73Y2.55)
2.07 (1.69Y2.62)
2.06 (1.12Y5.13)
1.71 (1.35Y2.21)
2.17 (0.95Y5.43)

RR, risk ratio; NRT, nicotine replacement therapy; COPD, chronic obstructive pulmonary disease.

Transplanting an undisclosed smoker while denying surgery to


honest patients is unjust, as is relying on any test where the
results can be manipulated by temporary cessation of smoking.
Perhaps, as with alcohol cessation agreements before liver
transplant, there may be a role for random urine cotinine
screening of recidivism. If centers decide that this direction is
agreeable, it would only be ethical with patient involvement
and consent. Involvement of family members is also likely to be
key to maintenance of abstinence, as witnessed with alcohol
consumption.

CONCLUSION
Smoking remains a preventable but addictive and
common health risk with a proven mortality and morbidity
(respiratory disease, cancers, and atherosclerotic problems)
in the general population. There are, however, greater
implications in the transplant population with increased risk
of perioperative problems such as sepsis and prolonged
hospital stay. Later complications are varied and include
graft dysfunction and possible graft loss.
Denial of transplantation to smokers, however, would
be ethically hard to defend on the grounds of distributive

justice and that self-reporting (the commonest method of


assessment) is open to abuse. The employment of cotinine
screening would minimize such abuse and increase the reliability of detection. The ethical conundrum remains,
however, until screening tools are optimized.
Patients who are being assessed for solid organ transplant should have free access to smoking cessation counseling
and pharmacologic therapy, as the benefits of cessation such
as improved lung function and reduced cancer risk are compelling. Maintaining long-term abstinence remains a challenge,
however, as 10% to 20% return to smoking after transplantation despite the efficacy of current cessation therapies.

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