We can still safely offer surgery, but we have to decide on an individual basis.
For decades, the operating room door has been conditionally closed to lung cancer patients who smoke — a rule rooted in caution but not always in evidence. Researchers at the University of Cincinnati, analyzing outcomes from more than 85,000 patients, have found that while smoking raises the risk of post-operative complications, it does not raise the risk of death after surgery. The finding invites medicine to trade a blunt prohibition for a more honest, individualized conversation — one that weighs the whole person, not just the cigarette.
- A long-held surgical rule — quit smoking or forgo lung cancer surgery — is now being challenged by data from one of the largest patient cohorts ever studied on the question.
- Current smokers faced meaningfully higher pulmonary complication rates after surgery, yet their short-term mortality was identical to those who had quit, creating a tension between risk and refusal.
- Advances in robot-assisted surgery are quietly reshaping who can safely go under the knife, with smaller incisions reducing recovery time and complication rates for even high-risk patients.
- Surgeons are being urged to replace blanket pre-operative cessation mandates with case-by-case assessments that factor in age, mobility, overall health, and available surgical technique.
- For patients who cannot or will not quit before their cancer surgery, the emerging clinical message is neither automatic clearance nor automatic denial — but a more transparent, individualized risk dialogue.
A surgical team at the University of Cincinnati has challenged one of medicine's more entrenched pre-operative rules: that lung cancer patients must quit smoking at least a month before surgery, or be turned away. Analyzing data from more than 85,000 patients in the Society of Thoracic Surgeons database — covering surgeries between 2018 and 2023 — they found a result that complicates the old calculus.
Current smokers did face higher rates of pulmonary complications after surgery, 34.6 percent compared to 30.5 percent among those who had quit. But when it came to mortality, both groups landed in exactly the same place: a one percent short-term death rate. That equivalence, the researchers argue, changes what surgeons are ethically and clinically justified in refusing.
Dr. Robert Van Haren, who led the work alongside medical school graduate Hannah Kim and a team of cardiothoracic specialists, was careful not to minimize smoking's harms. The data clearly shows it raises complication risk. But he argued that a blanket denial of surgery — for patients who cannot or will not quit — may be doing more harm than the smoking itself. The goal, he said, is individualized assessment: weighing a patient's age, physical condition, and the surgical approach available, rather than applying a single rule to everyone.
Technology has made that flexibility more defensible. Robot-assisted surgery, now widely used, operates through smaller incisions than traditional open thoracotomy, reducing tissue trauma and lowering the likelihood of complications like pneumonia. The result is a broader pool of patients — including active smokers — who can be offered surgery with a reasonable safety profile. For those patients, the conversation with their surgical team is no longer a closed door, but an open and honest reckoning with their specific circumstances.
A team of surgeons at the University of Cincinnati has upended a long-standing surgical principle: the idea that patients who smoke must quit at least a month before lung cancer surgery, or they shouldn't have the operation at all. What they found instead is more nuanced—and potentially opens doors that have been closed.
The researchers analyzed outcomes from more than 85,000 lung cancer patients who underwent surgery between 2018 and 2023, pulling data from the Society of Thoracic Surgeons database. They compared those who were still smoking when they went into the operating room with those who had managed to quit beforehand. The results, published in the Journal of the American College of Surgeons, revealed something unexpected: while current smokers did face a higher risk of pulmonary complications after surgery—34.6 percent versus 30.5 percent among those who had quit—their mortality rates were identical. Both groups had a one percent death rate in the short term.
Dr. Robert Van Haren, an associate professor of clinical surgery at UC College of Medicine and a surgeon at UC Health, emphasized that this doesn't mean smoking is harmless. "Smoking is obviously very bad and is associated with developing cancer and heart disease," he said. "And in our study, it shows it does increase the chance of post-operative complications." But the absence of a mortality difference changes the calculus. If a patient cannot or will not quit smoking before their cancer surgery, the data suggests they shouldn't automatically be denied the operation.
The traditional model—demanding cessation a month out or refusing surgery—may have been unnecessarily restrictive. Van Haren and his colleagues argue for a shift toward individualized decision-making. "We really want patients not to smoke and to quit smoking before surgery," Van Haren acknowledged. "However, if some patients are unable or unwilling to quit smoking, we still can safely offer surgery for treatment of their lung cancer." The key is careful, case-by-case assessment rather than a blanket rule.
Interestingly, the current smokers in the study tended to be younger and had fewer existing health conditions than those who had quit. This suggests that age and overall health status matter as much as smoking status when predicting surgical outcomes. Van Haren noted that surgeons already weigh multiple factors—whether a patient can walk or is confined to a wheelchair, whether the cancer requires a full thoracotomy or can be addressed with less invasive techniques.
Technology has shifted the landscape considerably. Robot-assisted surgery, now increasingly common, allows surgeons to work through smaller incisions than traditional open surgery. This means faster recovery, less tissue trauma, and lower rates of complications like pneumonia. "We are doing a lot of surgery robotically with smaller incisions so that it allows patients to recover better and have less chance of developing problems," Van Haren explained. These advances mean that more patients—including those still smoking—can be candidates for surgery with reasonable safety profiles.
The study's lead author was Hannah Kim, a recent medical school graduate, working alongside a team of cardiothoracic surgeons, researchers, and biostatisticians. Their work suggests that the field may need to reconsider rigid pre-operative protocols in favor of more flexible, individualized approaches. For lung cancer patients who smoke and feel they cannot quit, the message is neither a blanket yes nor a categorical no—but rather an invitation to a more honest conversation with their surgical team about their specific situation, their age, their overall health, and the technical options available.
Citas Notables
If some patients are unable or unwilling to quit smoking, we still can safely offer surgery for treatment of their lung cancer.— Dr. Robert Van Haren, University of Cincinnati College of Medicine
We have to be careful and make that decision on an individual basis rather than looking at one factor in making our decision about surgery.— Dr. Robert Van Haren
La Conversación del Hearth Otra perspectiva de la historia
So the finding is that smokers don't die more often after lung cancer surgery. That seems counterintuitive. Why would complications go up but mortality stay flat?
It's worth sitting with that tension. Complications like pneumonia are real and more frequent—that's the 34.6 versus 30.5 percent gap. But those complications aren't killing people at higher rates. Modern medicine can manage them. A patient might spend extra days in the hospital, need antibiotics, have a tougher recovery. That's serious. But it's not fatal in the short term.
And the researchers are saying surgeons have been too rigid about the one-month smoking cessation rule?
Exactly. If you tell someone they can't have cancer surgery unless they quit smoking, and they can't quit, you've just denied them treatment. But the data says: if we operate on them anyway, they'll likely survive the surgery itself. The complications are manageable. So why turn them away?
What changed to make this safer now than it would have been ten or twenty years ago?
Robot-assisted surgery. Smaller incisions mean less tissue damage, faster healing, fewer infections. A thoracotomy—cutting open the chest—is brutal. Robotic surgery lets surgeons do the same work through ports the size of a dime. That's a game-changer for anyone with compromised lungs, smoker or not.
So the message isn't "smoking is fine." It's "we can work with you where you are."
That's it. They still want people to quit. But if someone can't or won't, the surgeon can now say: let's look at your age, your overall health, what technique we'd use, and make a real decision together. Not a categorical no based on one factor.
Does this apply to other surgeries, or is lung cancer special?
That's the question the field will be asking now. This is specific to lung cancer resection in this study. But the principle—that individualized risk assessment might be better than rigid rules—could ripple outward.