Did you realize that 20% of Americans still smoke? That is an amazing number considering that cigarette smoke has some 6000 identifiable constituents! Some of the constituents include: ammonia, arsenic, benzene, formaldehyde, toluene, and vinyl chloride. I don’t know about you, but that sounds appetizing! But what does this mean for the anesthetist working in the clinical setting? For starters, smoking increases the likeliness of an irritable airway and a greater potential for hypoxia. There are a few steps you can take to try and mitigate the effects smoking can bring to the table. A thorough pulmonary examination is a great start. Listen to the lungs and ask if there is a history of wheezing, coughing, and expectoration. Observe their passive breathing and note if there is clubbing of the nails. Are they short of breath just sitting in the pre-op area? This can be an indication of pulmonary disease and prompt the need for further evaluation. As a side note, if they have pulmonary disease it is very likely that they cardio-vascular disease as well. While doing your H&P, don’t hesitate to focus on this area as well. Next, take a look at the medications they are on. If they use inhalers, ask them about the last time they used them and how frequently they use them. This is another good indicator for potential problems during the procedure. Have them use their inhaler before the procedure. It never hurts to have the airways as open as possible prior to a procedure. Chuck Biddle, CRNA, has a great list of considerations for the smoker that include, abstinence for 24 hours if possible, bronchodilators, nicotine patch if possible, pre-oxygenate, and there may be a need for increased analgesia during the procedure. Also be aware that their FRC (functional residual capacity) may be diminished. This may lead to a state of hypoxia sooner than normally expected in a non-smoker. Be prepared! And finally, as anesthesia providers we have a unique opportunity to educate our patients about the deleterious effects of smoking. For a brief period of time the patient is a captive audience, don’t hesitate to seize this opportunity for education.