Nutrition 411: Smoking Cessation, Nutrition, and Wound Healing

  According to the Centers for Disease Control and Prevention (CDC),¹ smoking is the leading preventable cause of death in the United States, where every year it is the reason for one out of five deaths.

  What is it about smoking that causes such negative health outcomes? The byproducts of smoking — carbon monoxide and nicotine — pose a double threat to the body. Once inhaled, they increase heart rate, blood pressure, and the body’s demand for oxygen. It doesn’t take long to feel the effect; just 10 seconds after inhaling smoke, the brain is bathed in nicotine and carbon monoxide hinders red blood cells from carrying adequate amounts of oxygen. The lungs cannot work to full capacity because smoking narrows the small airways of the lungs, making smokers more prone to lung collapse, infection, chronic coughing, and breathing complications. Despite efforts to squelch smoking with mandatory smoke-free public buildings and clean-air laws, an estimated 46 million adults 18 years and older still choose to light up.¹   Smoking is cause for concern in the healthcare arena because it can lead to poor surgical outcomes and increased length of time in intensive care, in recovery from surgery, and in hospital.² The economic and psychological costs of increased hospitalization, medical care, and lost productivity are enormous: $3,000.00 annually per smoker, according to CDC statistics.¹ The US Surgeon General’s Report,³ The Health Consequences of Smoking, states, “The evidence is sufficient to infer a causal relationship between smoking and increased risks for adverse surgical outcomes related to wound healing and respiratory complications.”

  Wound healing progresses more slowly in smokers and renders patients more susceptible to infections. Smoking has been found to block immune responses and increase production of free radicals, the main culprits in oxidative stress. This is damaging to every body cell, including skin cells, the active players in wound healing. Thus, maintaining optimal levels of antioxidants (eg, vitamins A, C, E and selenium and carotenoids), as well as other vitamin and minerals, is vital for wound healing. However, smoking depletes nutrients. According to Vardavas et al,⁴ smokers have lower levels of wound healing nutrients, such as vitamin C, carotenoids (eg, a-carotene, betacarotene, and cryptoxanthin), and B vitamins (such as folic acid) than nonsmokers. Plus, the poor eating habits of the average smoker (ie, a diet high in red meat and alcohol and lower in nutrient-rich fruits, vegetables, whole grains, beans, and lean protein) may add to lower serum levels of vital nutrients.⁴ Malnourished or nutrient-deficient patients are susceptible to chronic wounds (regarded as skin defects that last longer than 6 weeks or frequently reoccur). Chronic wounds are in a constant inflammatory state that is further compounded by smoking, which releases inflammatory cells that, over time, can damage healthy cells in the body. Thus, first and foremost, patients who smoke need to be educated as to the benefits of smoking cessation and the tools available to help them quit. In addition, medical nutrition therapy must be a vital component of their on-going healthcare.

Benefits of Smoking Cessation on Wound Healing

  The obvious way to improve wound healing outcomes among smokers is for them to quit. One of the major conclusions of the US Surgeon General’s report is that quitting smoking, regardless of age, has immediate as well as long-term effects. Smoking cessation before and after surgery is ideal for adequate recovery and speedy wound healing. Because it is not easy to quit the smoking habit, hospitals are facilitating the process by offering smoking cessation programs and creating smoke-free environments, which can help patients quit smoking before surgery. In a 2006 systematic review² of 12 prospective cohort studies, smoking cessation before surgery was found to be beneficial for avoiding postsurgical complications. Not surprisingly, longer periods of cessation yielded better outcomes from a recovery and healing standpoint.

Smoking Cessation and Weight Gain

  Although numerous positive health outcomes are associated with smoking cessation (see Table 1), an unintended side effect of quitting is weight gain. One reason may be that as quitters move from one oral habit to another, they can actually feel hunger, whereas smoking may have filled that gap before. Smoking cessation has been shown to lead to weight gain of 1.8 kg (almost 4 lb) in a follow-up period of 2 years.⁷

  In an epidemiological study,⁷ 946 subjects were followed for 3 years after smoking cessation to assess changes in body mass index (BMI) and risk for impaired fasting glucose (IFG), a precursor to diabetes mellitus (DM) and a common result of weight gain. The findings revealed that after smoking cessation, BMI significantly increased in quitters compared to current smokers and persons who never smoked. Not only food contributed to weight gain; both quitters and current smokers had a higher amount and frequency of alcohol consumption than persons who never smoked. Plus, the risk for IFG increased in conjunction with higher BMIs. This is an important consideration in wound healing, because elevated blood sugars lead to inflammation, which can exacerbate wounds and extend healing time. Thus, when caring for patients who already have or want to quit smoking, weight management must be a priority in the care protocol. Referring patients to a registered dietitian for adequate meal planning, food accountability, and overall nutrition support is important throughout the smoking cessation process and beyond.

The Nutrition Factor

  Wound healing requires a great deal of energy, obtained through a combination of macronutrients (protein, carbohydrates, and fat) and micronutrients (vitamins and minerals). Because smokers tend to be undernourished,⁴ it is important for them to increase their calorie intake, focus on the overall nutritional value of their food, and take a nutritional supplement, if necessary. Fueling the body well, particularly for surgical patients, is imperative to recovery. Ideally, the optimal mix of foods for efficient wound healing should focus on lean protein (eg, skinless chicken, turkey, pork loin, fish, tofu, beans, and legumes); vitamins (eg, vitamin A from leafy greens, broccoli, and sweet potatoes; and vitamin C from citrus fruits and orange, red, and yellow vegetables); and minerals (eg, such as zinc — available from whole grains, seafood, and lean red meat).   See Table 2 for recommended serving sizes for each food group.

  To ensure good wound healing with a synergy of nutrients, people should be encouraged to follow the tenets of ChooseMyPlate.gov – the icon for the 2010 Dietary Guidelines for Americans⁸:
    • Enjoy your food, but eat less.
    • Avoid oversized portions.
    • Make half of your plate fruits and vegetables.
    • Make at least half of your grains whole grains.
    • Switch to fat-free or low-fat (1%) milk.
    • Watch the sodium and compare brands and read labels (stick with less than 500 mg per serving).
    • Drink water instead of sugary drinks.

Victoria Shanta Retelny, RD, LDN, is the author of The Essential Guide to Healthy Healing Foods and the owner of a nutrition communications consulting practice in Chicago, IL. Visit her website and blog at www.victoriashantaretelny.com. This article was not subject to the Ostomy Wound Management peer-review process.

Coming next month: Surgical wounds: nutrition for healing after open-heart surgery.

1. Centers for Disease Control and Prevention Fact Sheet. Available at: www.cdc.gov/tobacco/data_statistics/fact_sheets/adult_data/cig_smoking/index.htm. Accessed December 17, 2011.

2. Theadom A, Cropley M. Effects of preoperative smoking cessation on the incidence of intraoperative and postoperative complications in adult smokers: a systematic review. Tobacco Control. 2006;15:352–358.

3. 2004 Surgeon General’s Report —The Health Consequences of Smoking. Available at: www.cdc.gov/tobacco/data_statistics/sgr/2004/pdfs/executivesummary.pdf. December 18, 2011.

4. Vardavas C, Linardakis MK, Hatzis CM, et al. Smoking status in relation to serum folate and dietary vitamin intake. Tob Induc Dis. 2008;4(1):8.

5. Cleveland Clinic. Nutrition Guidelines to Improve Wound Healing. Available at: http://my.clevelandclinic.org/healthy_living/nutrition/hic_nutrition_guidelines_to_improve_wound_healing.aspx. December 15, 2011.

6. Wild T, Rahbarnia A, Kellner M, et al. Basics in nutrition and wound healing. Nutrition. 2010;26:862–866.

7. Kamaura M, Fujii H, Mizushima S, Tochikubo O. Weight gain and risk of impaired fasting glucose after smoking cessation. J Epidemiol. 2011;21(6):431–439.

8. USDA. Selected Messages for Consumers. Available at: www.choosemyplate.gov/print-materials-ordering/selected-messages.html. Accessed January 3, 2012.