Intersection of Smoking, E-Cigarette Use, Obesity, and Metabolic and Bariatric Surgery: A Systematic Review of the Current State of Evidence

• Smoking significantly increases risk of complications after bariatric surgery, including leaks, ulcers, blood clots, and poor wound healing, which is why programs require quitting before surgery.
• E-cigarette and vaping safety in the perioperative period is still limited; vaping should not be assumed safe.
• Smoking cessation requirements can create barriers to surgical access, raising equity questions.
• This is part of a comprehensive research program on substance use and bariatric surgery outcomes.
• This provides clear evidence that quitting is essential for safe surgery and best outcomes.

Why This Review Was Needed

Millions of Americans qualify for bariatric surgery, and at the same time e-cigarette and vaping use has become widespread. Surgeons know that smoking raises surgical risk, but patients increasingly ask whether vaping is a safer alternative, and the evidence had never been gathered in one place.

How the Review Was Done

Following PRISMA guidelines, the authors searched PubMed, ScienceDirect and EMBASE for studies published from 1990 to 2020 on smoking, tobacco, e-cigarettes or vaping and bariatric surgery. Of 3,251 articles screened, 48 were included.

What the Review Found

• Tobacco use around the time of surgery was associated with more complications and higher mortality.
• Smoking was not consistently linked to weight loss: seven studies found more weight loss in smokers, six found no relationship, and one linked quitting before surgery with weight gain afterward.
• No published study had examined how e-cigarettes or vaping affect outcomes after bariatric surgery.

What This Means for Patients

If you smoke, quitting before surgery is one of the most important things you can do for your safety. Smoking is linked to leaks, marginal ulcers after gastric bypass, blood clots and poor wound healing. Do not assume vaping is safe; there is simply no data yet. Our Pre-Operative Checklist and article on pre-op readiness explain how to prepare.

Clinical Pearls

• Combustible tobacco use is associated with higher complication and mortality rates after bariatric surgery.
• Smoking does not reliably affect the amount of weight lost.
• There is no evidence on the safety of e-cigarettes in bariatric patients.

Strengths and Limitations

The review followed a structured, multi-database search over three decades. The included studies varied widely in design and definitions, which prevented pooling the results, and no data existed on vaping.

Expert Commentary

I ask every patient to stop smoking before surgery, and this review is why. The complications we worry about most, leaks and ulcers, are more common in smokers. When patients ask if they can switch to vaping instead, my honest answer is that we do not know it is safe, so the best choice is to stop nicotine altogether.

— Dr. Nestor de la Cruz-Muñoz