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Smoked for Years but Stopped a Few Months Back: Dilemma Regarding the American Society of Anesthesiologists Physical Status.

Dear Editor,
' Tobacco is the only legal drug that kills many of its users when used
exactly as intended by manufacturers'
-World Health Organization

The American Society of Anesthesiologists physical status (ASA-PS) classification is the universally accepted, time-tested and probably the gold standard risk categorisation used by anaesthesiologists worldwide. It has been also shown to predict postoperative morbidity and mortality (1). However, few limitations of this gold standard classification have been noted (2). In 2014, the ASA House Of Delegates revised/modified the ASA-PS with the inclusion of examples (3). This is definitely helpful for easy allocation of ASA-PS class and has shown to be effective in increasing the correct assignment of the preoperative surgical patients (4). This modified ASA-PS gives importance to the smoking status. However, there are limitations and ambiguity on this common problem, which leads to the dilemma regarding the 'current smoker' status.

The definition of current smoker itself is a dilemma. The Ministry of Health, New Zealand Government, indicates that a 'current smoker' is an individual who has smoked >100 cigarettes (including hand-rolled cigarettes, cigars and cigarillos) throughout their life and has smoked in the last 28 days. The same authority also defines another category, that is, 'ex-smoker', as an individual who has smoked >100 cigarettes throughout their life but has not smoked in the last 28 days (5). Conversely, the World Health Organization (WHO) does not use the term 'current smoker' in their frequently asked questions sections of the Smoking and Tobacco Use Policy. The policy involves the use of terms such as 'smoker' (daily and occasional), which refers to an individual who smokes any tobacco product either daily or occasionally. WHO categorises an individual who smokes any tobacco product at least once a day as a daily smoker and an individual who smokes but not every day as an occasional smoker. The WHO also categorises a 'tobacco user' as an individual who smokes any tobacco product (6). Another survey authority under the banner of Centre for Disease Control and Prevention (CDC), the National Health Interview Survey, uses current smoking definition by screening for lifetime smoking [greater than or equal to] 100 cigarettes only (7). A study has shown that differences in the definition also affect the estimate of prevalence of current smokers (8).

According to a report of WHO Global Health Observatory data, over 1.1 billion people smoked tobacco in 2015. The prevalence of smoking tobacco appears to be increasing in the WHO Eastern Mediterranean Region and African Region (9). In India, the prevalence of smoking is 15.3 %, 27.3% and 22.1% in the age group of 25-44, 45-64 and >65 years, respectively (10). These data clearly shows us the gravity of the situation. Therefore, contact with a person who has a history of smoking or tobacco use is extremely prevalent in the preanaesthesia evaluation clinic. Unfortunately, the term 'current smoker' results in a dilemma especially when the patient says that they smoked for years but stopped a month. A cross-sectional survey at the primary care level in United Kingdom showed that misclassification of ex-smokers as non-smokers is likely to occur for those who quit smoking at an early age and/or a long time ago (11). Consequently, these individuals, who actually has significant smoking history even in the recent past, can be classified as ASA-PS I patients, i.e., non-smoker, instead of ASA-PS II. Moreover, the pulmonary system of a person who has smoked for years is likely to have a residual effect even if smoking cessation has reduced the incidence of postoperative pulmonary complications.

Therefore, it appears to be prudent to change the status of 'current smoker' to a status of 'current or ex-smoker' or 'smoker/tobacco user', when the definition is limited to a lifetime cigarette use of only >100 cigarettes to identify them as a smoker. This will probably end the ambiguity and help anaesthesiologists in better assessing the ASA-PS.

Peer-review: Externally peer-reviewed.

Conflict of Interest: The author have no conflicts of interest to declare.

Financial Disclosure: The author declared that this study has received no financial support.


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(2.) Daabiss M. American Society of Anesthesiologists physical status classification. Indian J Anaesth 2011; 55: 111-5. [CrossRef]

(3.) American Society of Anesthesiologists. ASA Physical Status Classification System. Illinois: American Society of Anesthesiologists; 2014 Oct 15. [Last accessed 2018 Dec 13]. Available from:

(4.) Hurwitz EE, Simon M, Vinta SR, Zehm CF, Shabot SM, Minhajuddin A, et al. Adding Examples to the ASA-Physical Status Classification Improves Correct Assignment to Patients. Anesthesiology 2017; 126: 614-22. [CrossRef]

(5.) Ministry of Health - Manatu Hauora. Definitions of smoking status. New Zealand: Ministry of Health; 2015 June 04 [cited 2018 Dec 12] Available from

(6.) World Health Organization. WHO policy on non-recruitment of smokers or other tobacco users: frequently asked questions. Geneva: World Health Organization; 2008. [cited 2018 Dec 13]. Available from:

(7.) National Health Interview Survey. Overview of tobacco-related topics. Atlanta: CDC/National Center for Health Statistics; 2017 Aug 29. [Last accessed 2018 Dec 13]. Available from:

(8.) Ryan H, Trosclair A, Gfroerer J. Adult current smoking: differences in definitions and prevalence estimates-NHIS and NSDUH, 2008. J Environ Public Health 2012: 918368. [CrossRef]

(9.) World Health Organization. Global Health Observatory data. Prevalence of tobacco smoking. Geneva: World Health Organization; 2015 May 12. [Last accessed 2018 Dec 13]. Available from:

(10.) Singh A, Ladusingh L. Prevalence and determinants of tobacco use in India: evidence from recent Global Adult Tobacco Survey data. PLoS One 2014; 9: e114073. [CrossRef]

(11.) Marston L, Carpenter JR, Walters KR, Moms RW, Nazareth I, White IR, et al. Smoker, ex-smoker or non-smoker? The validity of routinely recorded smoking status in UK primary care: a cross-sectional study. BMJ Open 2014; 4: e004958. [CrossRef]

Habib Md Reazaul Karim [iD]

All India Institute of Medical Sciences, Raipur, India

Cite this article as: Karim HMR. Smoked for Y'ears but Stopped a Few Months Back: Dilemma Regarding the American Society of Anesthesiologists Physical Status. TurkJ Anaesthesiol Reanim 2019; 47(6): 515-6.

Corresponding Author: Habib Md Reazaul Karim E-mail:

Received: 14.01.2019 Accepted: 04.02.2019 Available Online Date: 02.09.2019

Doi: 10.5152/TJAR.2019.28863
No portion of this article can be reproduced without the express written permission from the copyright holder.
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Article Details
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Author:Karim, Habib Md Reazaul
Publication:Turkish Journal of Anaesthesiology and Reanimation
Article Type:Letter to the editor
Date:Dec 1, 2019
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