80
J Gandhara Med Dent Sci
October - December 2026
How to cite this article
INFLUENCE OF ACTIVE CIGARETTE SMOKING ON POSTOPERATIVE OUTCOMES AFTER
ELECTIVE GENERAL SURGERY: A PROSPECTIVE COHORT STUDY
Muhammad Imran
1
, Marya Saleem
2
, Javeria Arshad
2
Imran M, Saleem M, Arshad J.
Inuence of Active Cigarette Smoking
on Postoperative Outcomes After
Elective General Surgery: A
Prospective Cohort Study. J Gandhara
Med
Dent
Sci.
2026;13(4):80-84.
Date of Submission:
08-09-2026
Date Revised:
18-09-2026
Date Acceptance:
18-09-2026
2
Senior Registrar, Department of General
Correspondence
1
Muhammad Imran, Assistant
Professor, Department of General
Surgery, Surgical Unit, Services,
Institute of Medical Sciences/Services
Hospital, Lahore, Pakistan
:
+
92-331-6935535
:
Muhammadimran504@yahoo.com
Hospital, Lahore, Pakistan
Surgery, Surgical Unit, Services,
Institute of Medical Sciences/Services
ABSTRACT
OBJECTIVES
This study aimed to assess the association between active cigarette smoking
and
postoperative
morbidity
and
hospital
stay
among
adults
undergoing
elective non-cardiac general surgery at a tertiary-care hospital in Pakistan.
METHODOLOGY
This prospective observational cohort study enrolled 280 adults aged 18–60
years undergoing elective general surgical procedures at Services Institute
of
Medical
Sciences/Services
Hospital,
Lahore,
from
November
2024
to
December 2025. Participants comprised 180 active smokers and 100 non-
active
smokers.
Smoking
exposure
was
quantied
in
pack-years.
Patients
received
standard
perioperative
care
and
were
followed
through
30
days
after discharge. Outcomes included pulmonary complications, surgical-site
or wound-related complications, postoperative fever, cardiovascular events,
and total hospital stay. Associations were assessed using chi-square testing,
logistic
regression
for
overall
complications,
and
independent-samples
testing for length of stay.
RESULTS
Overall
postoperative
complications
occurred
in
67/180
smokers
(37.2%)
and
13/100
non-smokers
(13.0%),
corresponding
to
an
odds ratio of
3.96
(95%
CI
2.0–7.7;
p<0.001).
Pulmonary
complications
were
the
most
frequently
reported
adverse
event
among
smokers.
Among
smokers
with
more
than
11
pack-years,
55/121
(45.5%)
developed
at
least
one
complication. Mean total hospital stay was 14.90 days in smokers and 7.58
days in non-smokers (reported p<0.001).
CONCLUSION
Active
smoking
was
associated
with
substantially
greater
postoperative
morbidity and longer hospitalisation after elective general surgery. Routine
preoperative tobacco assessment, pack-year documentation, and structured
cessation support should be incorporated into elective surgical pathways.
KEYWORDS:
Smoking;
Tobacco
Use,
Elective
Surgery,
Postoperative
Complications, Surgical-Site Infection, Pulmonary Complications, Hospital
Stay, Smoking Cessation
INTRODUCTION
Tobacco smoking remains a major preventable cause of
morbidity
and
mortality
and
is
highly
relevant
to
surgical care. Pakistan continues to carry a substantial
burden
of
tobacco
use,
particularly
among
adult
men,
and cigarette smoking is common among working-age
patients
who
present
for
elective
operation.
1,2
For
surgeons and anaesthetists, smoking status is not simply
a lifestyle characteristic; it is a modiable perioperative
exposure that can inuence pulmonary function, tissue
oxygenation,
wound
healing,
infection
risk,
and
recovery
after
surgery.
The
mechanisms
linking
smoking
with
adverse
postoperative
outcomes
are
biologically
plausible
and
well
described.
Nicotine
produces sympathetic stimulation and vasoconstriction,
while
carbon
monoxide
reduces
oxygen-carrying
capacity
and
shifts
the
oxyhemoglobin
dissociation
curve.
Tobacco
smoke
impairs
mucociliary
clearance,
increases
airway
reactivity,
promotes
mucus
production,
and
alters
innate
and
adaptive
immune
responses.
Smoking
also
aects
platelet
function,
endothelial
physiology,
collagen
synthesis,
an
d
microvascular
perfusion.
Together,
these
eects
can
increase
susceptibility
to
pulmonary
complications,
surgical-site
infection,
delayed
wound
healing,
and
cardiovascular
stress.
3
Large
contemporary
surgical
datasets
show
that
current
smoking
is
associated
with
increased
postoperative
complications
across
a
wide
range
of
specialities.
4,5,6,7,8
International
prospective
evidence
from
elective
surgical
systems
likewise
demonstrates
worse
outcomes
among
current
smokers
and supports systematic identication of smoking status
before
surgery.
9
Earlier
intervention
studies
and
systematic
reviews
have
shown
that
preoperative
smoking
cessation
can
reduce
postoperative
ORIGINAL ARTICLE
http://doi.org/10.37762/jgmds.13-4.997
81
J Gandhara Med Dent Sci
October - December 2026
complications,
particularly
when
abstinence
begins
several
weeks
before
surgery.
7,10,11
The
perioperative
period
therefore
represents
a
clinically
important
teachable
moment
in
which
patients
may
be
more
receptive
to
cessation
advice.
The
importance
of
smoking-related
complications
may
be
amplied
in
resource-constrained
hospitals.
Additional
pulmonary
infection, wound morbidity, or prolonged inpatient stay
increases
antibiotic
use,
nursing
workload,
bed
occupancy, and overall cost. Pakistan's surgical system
already
faces
pressure
related
to
access,
timeliness,
workforce, and resource distributio.
4
Local studies have
documented
surgical-site
infection
as
an
important
postoperative
problem,
but
smoking-specic
evidence
in
general
surgical
populations
remains
limited.
5
A
further methodological issue
is that smoking exposure
should not
be treated only
as
a binary
variable. Pack-
years provide a simple measure of cumulative cigarette
exposure
and
may
help
identify
patients
with
heavier
lifetime
tobacco
burden.
Although
pack-years
cannot
capture
all
dimensions
of
smoking
intensity
or
recent
cessation,
documenting
them
can
improve
risk
communication
and
provide
a
more
informative
baseline
for
perioperative
counselling.
The
present
study was therefore undertaken to assess the association
between
active
cigarette
smoking
and
postoperative
complications
among
adults
undergoing
elective
non-
cardiac
general
surgery
at
Services
Hospital
Lahore.
Secondary
objectives
were
to
describe
cumulative
tobacco
exposure
among
active
smokers
and
to
compare hospital stay between smokers and non-active
smokers.
The
study
was
intended
to
generate
locally
relevant
evidence
that
could
support
routine
tobacco
screening
and
structured
preoperative
cessation
pathways.
METHODOLOGY
was
calculated
using
the
OpenEpi
web-based
sample
size calculator, using the recent prevalence of smoking
in Pakistan to be 13.4%.
6
A total of 180 patients were
enrolled
in
the
study.
In
order
to
make
a
comparison
between
smokers
and
non-smokers,
100
patients
with
no smoking history were also enrolled in the study. A
structured
tobacco
use
history
was
taken
from
every
participant at the time of the preoperative consultation.
The
enrollment
was
focused
on
cigarette
smokers,
as
this
was
the
predominant
form
of
tobacco
use
in
our
society. Participants were classied as active smokers if
they
reported
current
cigarette
use
at
the
time
of
surgical
listing.
Those
who
had
completely
abstained
from
all
tobacco
products
for
a
minimum
of
four
consecutive
weeks
before
their
surgical
date,
or
who
had
never used
tobacco,
were
classied
as
non-active
smokers.
Cumulative
tobacco
burden
was
quantied
using the pack-year index, calculated by multiplying the
number of cigarette packs consumed daily by the total
years
of
active
smoking.
7
All
participants
received
uniform
perioperative
care
in
line
with
the
hospital’s
standard
surgical
protocols,
including
antibiotic
prophylaxis,
infection
control
practices,
and
standardised
anaesthetic
management.
No
modifications to the standard of care were made on the
basis
of
smoking
status.
Each
active
smoker
received
brief
verbal
counselling
at
the
preoperative
visit
regarding
the
additional
risks
that
continued
smoking
posed
to
their
surgical
recovery,
with
abstinence
strongly
recommended.
No
formal
pharmacological
cessation
support
program
was
in
place
at
the
study
institution during the study period. A reality that itself
reects
the
broader
gap
in
cessation
services
within
Pakistan's
public
surgical
sector.
Participants
were
followed from the day of admission through to 30 days
post-discharge.
Wound
assessment
was
conducted
using the Southampton Wound Assessment Scale, and
surgical
site
infections
were
identied
using
the
National
Nosocomial
Infections
Surveillance
(NNIS)
system criteria of the United States Centres for Disease
Control and Prevention.
Respiratory complications were
defined
as
new
pulmonary
consolidation
on
chest
imaging
or
the
initiation
of
antibiotic
therapy
for
clinically
suspected
postoperative
lower
respiratory
tract
infection.
Postoperative
fever
was
dened
as
temperature
exceeding
38C
on
at
least
two
separate
occasions, each at least 24 hours apart. Cardiovascular
complications
were
dened
as
new
electrocardiographic
changes
or
a
conrmed
acute
cardiac event during admission. Total hospital stay was
measured
in
days
and
disaggregated
into
preoperative
and postoperative components. Data
were recorded on a
standardised proforma and entered into Microsoft Excel
2021.
Analysis
was
performed
using
IBM
SPSS
Statistics
version
26.0.
Continuous
variables
were
Inuence of Active Cigarette Smoking on Postoperative Outcomes After
A
prospective
observational
cohort
study
was
conducted
at
the
Department
of
General
Surgery,
Surgical
Unit,
Services
Institute
of
Medical
Sciences/Services
Hospital,
Lahore,
Pakistan.
The
duration
of
the
study
was
12
months,
from
November
2024
to
December
2025.
The
study
was
approved
by
the
hospital’s
Institutional
Ethics
(Ref
No.
IRB/2022/709/SIMS,
Dated:
15-11-2022)
Committee
prior
to
commencement,
and
procedures
were
conducted
in
accordance
with
the
principles
of
the
Declaration of Helsinki. Adults aged 18-60 years listed
for
elective
non-cardiac
general
surgical
procedures
were screened consecutively. Patients were excluded if
they
had
established
chronic
pulmonary
disease
or
cardiac disease, were immunocompromised because of
illness
or
medication,
or
were
undergoing
cardiac
surgery. A total of 280 participants were analysed: 180
active smokers
-active
sample
The
non
and
100
smokers.
82
J Gandhara Med Dent Sci
October - December 2026
reported as means; categorical variables as frequencies
and
percentages.
The
chi-squared
test
was
used
to
assess associations between categorical variables. Odds
ratios with 95% condence intervals were estimated by
binary logistic regression. Length of stay was compared
using
the
independent
samples
t-test.
A
two-tailed
p-
value
below
0.05
was
considered
statistically
significant throughout.
RESULTS
Two hundred eighty participants met the eligibility
criteria and were included, comprising 180 active
smokers and 100 non-active smokers.
DISCUSSION
Our
prospective
study
has
shown
that
active
tobacco
smoking is
an important
and independent predictor
of
postoperative
morbidity
among
male
patients
undergoing
elective
general
surgical
procedures
at
a
tertiary
care
hospital
in
Pakistan.
According
to
our
results,
smokers
experienced
complications
at
more
than three times the rate of non-smokers (OR 3.96; 95%
CI:
2.07.7;
p
≤
0.0007),
with
hospital
stay
nearly
Table 1: Baseline Characteristics of the Study Population
Characteristic
Active Smokers
(n=180)
Non-Active Smokers
(n=100)
Mean age, years
42.8
38.5
Male, n (%)
177 (98.3)
84 (84.0)
Mean BMI, kg/m
22.8
24.3
Married, n (%)
166 (92.2)
79 (79.0)
Urban residence, n (%)
107 (59.4)
71 (71.0)
Table 2: Cumulative Cigarette Exposure Among Active Smokers
Pack-Year Category
n (%age)
15 pack-years
39 (21.7)
610 pack-years
20 (11.1)
>11 pack-years
121 (67.2)
Table 3: Association Between Smoking Status and Overall
Postoperative Complications
Group
Complic
ation
No
Complication
Odds ratio
(95% CI)
p-value
n (%age)
Active
smokers
67 (37.2)
113 (62.8)
3.96 (2.0-7.7)
<0.001
Non-active
smokers
13 (13.0)
87 (87.0)
Table 4: Specic Postoperative Complications Reported by
Smoking Group
Complication type
Active smokers, n
Non-active smokers, n
Pulmonary complication 20
3
Wound-related / surgic
al-site complication
11
4
Postoperative fever
12
5
Cardiovascular event
4
1
Table 5: Hospital Stay by Smoking Status
Admission
Phase
Active
Smokers,
Mean Days
Non-Active
Smokers,
Mean Days
Mean
Dierence,
Days
p-value
Preoperative
stay
5.38
3.11
2.27
Postoperative
stay
9.52
4.47
5.05
Total hospital
stay
14.90
7.58
7.32
<0.001
doubled.
These
ndings
align
with
a
growing
international
body
of
evidence.
Gräsbeck
et
al.,
in
a
machine learning-based analysis of more than 300,000
surgical
patients
in
Finland,
reported
that
active
smoking
was
a
consistent
and
signicant
predictor
of
complications
across
all
surgical
specialities.
8
Similarly,
a
multinational
secondary
analysis
by
Glaszbey
et
al.
conducted
across
442
hospitals
in
29
countries
conrmed
that
current
smokers
undergoing
elective surgery had signicantly elevated complication
rates
and
longer
hospital
stays
compared
to
non-
smokers.
9
Our
ndings
provide
locally
grounded
Pakistani data that have, until now, been largely absent
from
the
perioperative
literature.
The
near-exclusive
male composition of the smoker cohort (98.0%) directly
reects
the
deeply
entrenched
gender
asymmetry
of
tobacco use in Pakistan. As Zahra et al. have reported in
a national study examining tobacco exposure patterns in
Pakistan,
active
tobacco
use
remains
overwhelmingly
concentrated
among
men,
with
important
implications
for
household
and
occupational
exposure
as
well
as
direct
health
risk.
10
This
demographic
pattern
has
a
direct
consequence
for
preoperative
surgical
risk
assessment: male patients of working age presenting for
elective
surgery
in
Pakistan
should
be
systematically
screened
for
tobacco
use
using
structured
histories
including
pack-year
quantication,
as
this
group
constitutes the predominant smoking population within
Pakistan’s surgical caseload. Respiratory complications
were the most frequently observed adverse outcome in
the
smoker
group,
occurring
in
20
smokers
(13.3%)
compared
with
only
3
non-smokers
(2.7%).
This
finding
is
mechanistically
consistent
with
the
well-
documented
eects
of
chronic
tobacco
exposure
on
airway
physiology.
This
has
been
reported
by
Vágvölgyi
et
al.,
who
showed
that
smoking
disturbs
normal physiology and substantially increases the risk
of postoperative atelectasis and pneumonia
in patients
undergoing
surgical
procedures.
11
In
Pakistani
public
hospitals, where access to high-dependency respiratory
care
and
intensive
monitoring
is
constrained,
the
prevention
of
pulmonary
complications
carries
particular operational importance. Each avoidable case
of postoperative pneumonia occupies a surgical bed for
additional days and displaces capacity for other elective
Inuence of Active Cigarette Smoking on Postoperative Outcomes After
83
J Gandhara Med Dent Sci
October - December 2026
admissions.
Wound-related complications and
surgical
site
infections
(SSIs)
represented
the
second
most
prevalent complication category in this study,
with 11
smokers aected compared to 4 non-smokers. Existing
evidence
consistently
conrms
the
SSI-promoting
effects of tobacco in diverse surgical settings. A similar
result
reported
by
Ahmad
et
al.,
in
a
recent
Pakistani
study
examining
SSI
risk
following
orthopaedic
surgery, found that active smoking was among the most
significant
modiable
predictors
of
surgical
site
infection,
corroborating
the
relevance
of
tobacco-
attributable
wound
risk
in
the
Pakistani
surgical
population specically.
12
In an elderly surgical cohort,
Ma
et
al.
similarly
identied
current
smoking
as
a
leading modiable factor increasing SSI risk following
hip fracture
surgery,
with
an
independent contribution
to
wound-related
morbidity
that
persisted
after
adjustment for comorbidities.
13,16
These ndings, taken
together with the high baseline SSI rates documented at
Pakistani public hospitals, underscore the compounding
nature
of
tobacco-attributable
wound
risk
in
resource-
constrained
settings.
A
clear
dose-response
gradient
was
observed between
cumulative pack-year
exposure
and complication risk. Patients with more than 11 pack-
years of tobacco exposure carried a complication odds
ratio of 3.9 (95% CI: 1.88-8.24; p ≤ 0.0002) relative to
non-smokers, compared with lower odds in those with
1-5
and
6-10
pack-years.
This
graded
relationship
is
consistent
with
ndings
reported
by
Quan
et
al.,
who
demonstrated
in
a
retrospective
study
of
2,469
patients
undergoing radical
gastrectomy
for
gastric cancer that
increasing smoking dose was independently associated
with
escalating
rates
of
postoperative
complications,
and that preoperative cessation attenuated this risk in a
dose-dependent
fashion.
14
The
majority of our
smoker
cohort
(67.3%)
had
accumulated
more
than
11
pack-
years,
reecting
the
long-duration,
high-volume
smoking
patterns
prevalent
among
working-age
Pakistani
men.
Pakistani
surgeons
must
therefore
anticipate
that
most
smokers
they
encounter
will
fall
into
the
highest-risk
exposure
category,
and
should
quantify
pack-year
burden
routinely
rather
than
treating
smoking
as
a
binary
variable.
The
near-doubling
of
total hospital stay in active smokers (14.90 versus 7.58
days;
p
≤
0.0001)
has
direct
and
substantial
implications
for
bed
management
and
resource
utilisation
in
Pakistan's
overburdened
public
surgical
sector.
The
multinational
data
of
Glaszbey
et
al.
similarly
reported
signicantly
prolonged
inpatient
stays
among
current
smokers
across
442
hospitals,
confirming that smoking-attributable bed-day extension
is
not
a
local
phenomenon
but
a
reproducible
and
quantiable
operational
burden
on
surgical
systems
worldwide.
9,17
A mean excess of 7.32 inpatient days per
smoker
translates,
across
the
volume of elective cases
managed
annually
at
major
Pakistani
tertiary
centres,
into
considerable
additional
antibiotic
expenditure,
nursing
time,
consumable
use,
and
surgical
bed
occupation.
Even
a
modest
reduction
in
smoking-
attributable
complications
through
preoperative
cessation
support
would
produce
meaningful
gains
in
surgical
throughput
and
patient
welfare
at
scale.
The
case
for
structured
preoperative
tobacco
cessation
in
Pakistan
is
compelling
but
currently
unaddressed
by
national
policy.
No
formal
perioperative
cessation
guidelines
exist
within
Pakistan’s
public
surgical
framework,
and
pharmacological
cessation
aids
are
largely
unavailable
through
the
public
sector.
The
capacity
of
nursing
sta
to
engage
patients
in
postoperative
wound
care
and
complication
surveillance forms one part of this gap: Huzaifa et al.,
in a study of nurses at public sector teaching hospitals
in
Peshawar,
documented
signicant
deciencies
in
knowledge and practice regarding postoperative wound
care, underscoring the need to strengthen allied health
capacity at the point of postoperative care delivery.
15,18
The surgical preoperative consultation itself represents
a
readily
accessible
and
well-timed
opportunity
for
at
least brief structured cessation advice, and the evidence
presented
in
this
study
provides
the
locally
grounded
empirical
foundation
that
policymakers
and
hospital
administrators
require
to
justify
integrating
tobacco
assessment
and
cessation
into
Pakistan’s
elective
surgical pathways.
LIMITATIONS
The
study
was
conducted
at
a
single
tertiary-care
institution and
may not represent other surgical settings.
Smoking
status
was
self-reported
and
was
not
biochemically
veried.
Never-smokers
and
recent
quitters
were
combined
in
the
non-active
group.
Procedure-specic
risk
was
not
reported.
Standard
deviations for length-of-stay measures were absent.
CONCLUSIONS
This
prospective
study
conrms
that
active
tobacco
smoking is a powerful, dose-dependent, and modiable
risk
factor
for
adverse
postoperative
outcomes
in
elective general surgery. Smokers faced more than three
times
the
odds
of
complications
compared
to
non-
smokers, with respiratory morbidity and wound-related
events
dominating
the
complication
prole,
and
their
total hospital
stay
was
nearly
doubled. These ndings
carry
direct
clinical
and
policy
implications
for
Pakistan, where male tobacco prevalence remains high
and
preoperative
cessation
support
is
largely
absent
from
public
surgical
pathways.
Routine
quantication
of tobacco burden in pack-years should be incorporated
Inuence of Active Cigarette Smoking on Postoperative Outcomes After
84
J Gandhara Med Dent Sci
October - December 2026
into
all
preoperative
assessments,
and
brief
cessation
counselling
should
be
delivered
at
every
surgical
consultation.
National
health
authorities
are
urged
to
develop
evidence-based
perioperative
tobacco
guidelines that reflect the scale of smoking-attributable
surgical risk.
CONFLICT OF INTEREST:
None
FUNDING SOURCES:
None
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Muhammad
Imran
-
Concept
&
Design;
Data
Acquisition;
Data
Analysis/Interpretation;
Drafting
Manuscript;
Critical
Revision; Final Approval
Marya
Saleem
-
Concept
&
Design;
Data
Acquisition;
Data
Analysis/Interpretation;
Drafting
Manuscript;
Critical
Revision; Supervision; Final Approval
Javeria Arshad
-
Concept & Design; Data Acquisition; Data
Analysis/Interpretation; Drafting Manuscript; Critical Revision;
Supervision;
Final
Approval
AUTHORS CONTRIBUTION
The authors accept responsibility for all aspects of the work
and will ensure that any concerns regarding the accuracy or
integrity of any part are properly investigated and resolved.
Inuence of Active Cigarette Smoking on Postoperative Outcomes After
