Impact of Smoking Status on Morbidity and Mortality after Lung Cancer Resection: An Analysis of the Society of Thoracic Surgeons General Thoracic Surgery Database

BACKGROUND: Tobacco exposure is the leading cause of lung cancer, with some surgeons and centers requiring smoking cessation before lung resection. The impact of continued smoking on outcomes remains uncertain. We evaluated morbidity and mortality after resection among patients who currently smoke compared with those who formerly smoked. STUDY DESIGN: We analyzed lung cancer resections (2018 to 2023) in the Society of Thoracic Surgeons General Thoracic Surgery Database. Smoking status was defined using Society of Thoracic Surgeons operational definitions as current (within 1 month of operation) or former (abstinence more than 1 month). Patients who never smoked were excluded. Primary outcomes were operative or 30-day mortality and postoperative pulmonary complications. Multivariable regression identified predictors of outcomes. This research was determined to be exempt research with a waiver of informed consent from Advarra IRB (Mod01760092, Version 1.1, Approval date July 17, 2023). RESULTS: Of 85,124 patients, 28% (n = 24,093) currently smoked and 72% (n = 61,031) formerly smoked. Patients who currently smoked were younger (65.6 vs 69.6 years; p < 0.001), had fewer comorbidities, and included higher proportions of patients who identify as Black (11.5% vs 7.5%; p < 0.001). Pulmonary complications were more frequent among patients who currently smoke (34.6% vs 30.5%; p < 0.001), but mortality did not differ by smoking status (1.0% vs 1.0%; p = 0.52). Male sex, current smoking, greater pack-years, thoracotomy, and more extensive resection independently predicted pulmonary complications. CONCLUSIONS: Patients who currently smoke experienced higher pulmonary morbidity but no increase in mortality. Surgeons should not use smoking status alone when determining whether a patient is a candidate for lung cancer resection. Risk assessment should integrate smoking status in combination with a comprehensive range of preoperative factors to guide shared decision-making and ensure access to lung cancer operations.