Smokers with lung cancer are often told surgery is off the table unless they quit first. A large national analysis led by University of Cincinnati thoracic surgeons suggests that it is not always true: people who are still smoking at the time of lung cancer resection face higher rates of breathing complications after surgery, but do not see higher short-term death rates. The results challenge blanket rules that keep some patients off the operating table simply because they have not quit smoking.
The peer-reviewed study, published in the Journal of the American College of Surgeons, analyzed 85,124 lung cancer resections performed between 2018 and 2023 and recorded in the Society of Thoracic Surgeons General Thoracic Surgery Database. Pulmonary complications occurred in 34.6% of patients who were smoking at the time of surgery, compared with 30.5% of those who had quit, while operative or 30-day mortality was about 1% for both groups. The authors conclude that smoking status should be just one factor among many in individualized surgical decision-making.
Robert Van Haren, the study's corresponding author and an associate professor of clinical surgery at the University of Cincinnati, said in a University of Cincinnati news release, "We really want patients not to smoke and to quit smoking before surgery. However, if some patients are unable or unwilling to quit smoking, we still can safely offer surgery for treatment of their lung cancer." The release also notes that robot-assisted techniques and smaller incisions have expanded who can safely tolerate resection.
Study details and predictors
The analysis found that current smokers in the database tended to be younger and to have fewer recorded comorbidities than former smokers. Multivariable modelling identified male sex, current smoking, greater pack-years, thoracotomy, and more extensive resections as independent predictors of postoperative pulmonary complications, the authors report in the Journal of the American College of Surgeons.
What this means for patients and surgeons
The findings do not change the basic public-health message that quitting smoking reduces cancer risk, but they do suggest that automatic exclusion from surgery based on smoking alone may be inappropriate in many cases. Perioperative guidance commonly suggests a window of about four weeks of abstinence when feasible to reduce complication risk, as outlined in JAMA Surgery. Lung cancer remains the leading cause of cancer death in the U.S., accounting for roughly one in five cancer deaths, according to the American Cancer Society.
Equity and access concerns
Because current smokers in the registry were more likely to be younger and to include a higher share of Black patients, clinicians warn that rigid "quit-or-deny" policies could disproportionately block access to curative surgery for people who already face barriers to care. The study and subsequent coverage in outlets such as Cleveland.com raise questions about how to balance surgical risk with equitable access.
Surgeons emphasize that decisions should be individualized: smoking remains a modifiable risk, but the choice to operate depends on overall fitness, tumor factors, and surgical approach. Patients are encouraged to talk with their care teams about preoperative optimization, including smoking-cessation support and pulmonary prehabilitation, as recommended in JAMA Surgery perioperative guidance.
