Jul 25, 2017
Dr. Michael Fitzgerald was recently interviewed about how smoking impacts bone health on HealthLink On Air. To listen to the podcast click the link below.
July 14th, 2017
Amber Smith: “Upstate Medical University. I’m Amber Smith. This is HealthLink On Air. In the studio, I have with me today Dr. Michael Fitzgerald. He was born in Syracuse. He earned his medical degree at Upstate Medical University and now he is an orthopedic surgeon here, specializing in hand, wrist, elbow, and shoulder care. Today he is speaking with us about something more broad, the effects if cigarette smoking on bone health. Thank you for being here.”
Dr. Fitzgerald: “Thank you for having me.”
Amber Smith: “Well, we’ve heard about the damage smoking does to the lungs and the heart, but the bones are something else, so what does cigarette smoking do to our bones?”
Dr. Fitzgerald: “Well, cigarette smoking, as we all know, doesn’t have just one effect. It affects all aspects of the body and the bones are no different, so depending on how we are treating the bones whether it’s bones, soft tissue, muscle, or tendons, cigarette smoking can have a very impactful effect on healing, on blood flow, on just even patients’ outcome in general whether they have more pain or not, and so it is something that as orthopedic surgeons we pay attention to and we are very concerned about and it can have a detrimental effect on what we do for the patients.”
Amber Smith: “Does it set the bones up for fracture or injury.”
Dr. Fitzgerald: “Well, it doesn’t necessarily set them up for fracture injury, per se. I guess you could, in some situations, say that. It’s more so we see it in the healing phase, so after bones are fractured or after muscles or tendons are injured, they need the ideal environment to heal and smoking, with almost over 4,000 different chemicals within the cigarette, makes that environment more difficult for the body to heal itself.”
Amber Smith: “So when we talk about cigarettes, are we talking about electronic cigarettes as well?”
Dr. Fitzgerald: “Well, a lot of the literature and the research that’s been done has been looking at smoking specifically. There is some literature on chewing tobacco and things like that. In my search of the literature, there’s not a ton of information about electronic cigarettes just yet which, to me, makes it a little bits scary because there’s not much known about it or the effects of it, so using it you’re putting yourself at risk because we don’t know that much about it.”
Amber Smith: “And what about second-hand smoke if you live with a smoker?”
Dr. Fitzgerald: “From what I’ve seen, there is not as much research about it, but you can, at least, infer that there is going to be similar effects of that smoke, depending on how much you’re around it that it would have on the primary smoker, not as much but still some effect.”
Amber Smith: “You mentioned 4,000 or so chemicals in tobacco cigarettes. Nicotine and carbon monoxide are just two of the chemicals. What do they do that affects the bones specifically or is there something about them?”
Dr. Fitzgerald: “So nicotine has a lot of different effects on the body. We know that it is a vasoconstrictor, so it can decrease blood flow to different parts of the body. We also know from a bone healing standpoint that it can actually decrease the activity of osteoblasts which are the cells that help produce bone, as well as many other effects on the body and musculoskeletal system. Carbon monoxide in and of itself decreases the ability of the blood to carry oxygen. You’ve heard of carbon monoxide poisoning, so in theory you are putting something that is very, very detrimental to your health in your system and, again, for bone healing, for soft tissue healing, the body needs oxygen, and so you are putting something in there that’s stealing that oxygen away from the environment.”
Amber Smith: “Now, collagen; I’ve heard that that’s production of collagen is lower in smokers?”
Dr. Fitzgerald: “Yes.”
Amber Smith: “What is collagen and why does that matter”
Dr. Fitzgerald: “So collagen is basically a component that makes up your skin, your soft tissue, so it’s very vital in your healing. There has been a couple of studies that have been done that have looked at smokers and nonsmokers in a unique way to see how much collagen they can produce by looking at factors that serve as the collagen production and what they found was that in smokers, they make a considerably less amount of collagen which they’ve extrapolated out to say that smokers have decreased ability to heal.”
Amber Smith: “Interesting. Alright. Well, this is Upstate’s HealthLink On Air. I’m your host, Amber Smith, talking with Dr. Michael Fitzgerald, an orthopedic surgeon at Upstate. So tell me, do you, when you have patients seeking care from you and they’re smokers, what kind of a conversation do you have with them?”
Dr. Fitzgerald: “It kind of all depends on what they’re there for. We have the information on everyone that comes in about whether they are smoking or not and, if they are smokers, we have a little discussion about it and usually, depending on what I’m doing for them, we discuss how this can affect not only their current state but their future outcomes and it’s been shown that almost in every subspecialty of orthopedics that smoking can have a detrimental effect on multiple different surgeries, and so whether they’re having surgery or not, we discuss how smoking can affect it how it would be beneficial for them to at least decrease it if not quit altogether.”
Amber Smith: “Okay, alright. Are they generally receptive to that or do you get some skeptics?”
Dr. Fitzgerald: “For people who have fractures that need to be fixed or fractures that haven’t healed that need a second or third surgery, smoking can be a big deal, so I really stress to patients how important it is to quit and usually these patients are in quite a bit of pain. I use that as a motivator for them, that if they decrease their smoking their pain is going to subside sooner and they are pretty receptive to that, usually”.
Amber Smith: “Interesting, so how is it that smoking affects the pain?”
Dr. Fitzgerald. “So it’s not really known how smoking affects the pain, per se. There are probably multiple pathways for that. We do know that smoking can decrease blood flow. We do know that it increases, what is called, platelet aggregation or clotting factors in the body. It also, as I said, decreases the ability for the body to make bone and it disrupts certain cascades throughout the body that can alter the healing pathway and probably all of those mechanisms combined make smokers in certain situations have worse outcomes and more pain in the long-run”.
Amber Smith: “So it just delays the healing or does it make healing impossible?”
Dr. Fitzgerald: “It definitely delays the healing in a lot of cases and in some cases definitely makes the bone not heal, which is what we call non-union, and so we see that smokers in a lot of scenarios have an increased risk of non-union or not healing of the bone”.
Amber Smith: “Interesting. Now what about bone density. Does smoking have an effect on that?”
Dr. Fitzgerald: “It seems like it may. There are some studies that look at women, especially, that show that post-menopausal women, who we know have problems with bone density already, if they are concurrent smokers, have worse problems with this, so there is some literature that shows that, if you’re a smoker, the older you get there may be worse problems with bone density”.
Amber Smith: “Hmm, okay. Now you mentioned talking with some of your patients about the need to quit smoking before surgery, or whatever. Do you think orthopedics, I mean, do you think that should be their job? Should orthopedic surgeons have a role….”
Dr. Fitzgerald: “I think sometimes there is a stereotype in that orthopedic surgeons look at the bones and that’s all we do, but it is our job as all physicians to look at the patient as a whole and I think smoking is part of that. It is even more important because smoking can have such an impact on multiple aspects of the body and so I think we do have a pretty big role to make sure that, not only do we mention it, but we talk to our patients about how it can affect their outcome. There are a couple of studies that have been done that show that even if an orthopedic surgeon takes 60 to 90 seconds to talk to the patient about their smoking and how they can quit, that it actually does make a difference, so I think that mentioning it and telling them you have something wrong with your bones or your soft tissues and your smoking can make it worse or make you have a worse outcome, a lot of people will listen and take it to heart”.
Amber Smith: “So maybe because it’s a concrete issue staring at them right at that moment, because I can’t image that a primary care provider hasn’t had a similar conversation in the past……?”
Dr. Fitzgerald: “Exactly. I think sometimes it’s hard when there’s not, like you said, a concrete reason, there is not pain, there is no motivation to quit smoking, sometimes it’s harder but when you have someone with a broken wrist or a rotator cuff tear, that is in pain, if you tell them that by quitting smoking this may allow you to heal quicker or feel better sooner, that’s a pretty good motivating factor for them”.
Amber Smith: “So if they have been smoking all their life and then they fracture something and they quit right before surgery is that really going to have an effect?”
Dr. Fitzgerald: “Yeah, there is some good literature that shows that if they quit before or even quit soon thereafter that they can have better outcomes versus people who continue to smoke throughout their recovery process. So even if they smoked their whole lives and they can quit around the time of their surgery they actually can have better outcomes”.
Amber Smith: “So I just thought of something. I mean no one plans a fracture, and that just happens, do you have to quit cold-turkey because you’re going to be having surgery the next day?”
Dr. Fitzgerald: “No. For a lot of people that is very tough for them to do, especially people who have been smoking for years. I think there are some statistics out there that state it takes about 8 to 10 times for someone to quit fully, if they have been smoking for a while. I even tell patients, even if they can cut down some, that it will be more beneficial. It is hard for people, especially in times of stress, and any fracture is stressful, for them to take away their stress reliever. I don’t make them or tell them that they have to but I encourage them just to cut down. Maybe if they’re a pack-a-day smoker, cut down to ½ pack and see if they can tolerate that.
Amber Smith: “Neat. Well thank you. My guest has been orthopedic surgeon, Dr. Michael Fitzgerald. I am Amber Smith for Upstate’s Podcast and Talk show, Health Link on Air.”
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