Smoking relapse after bariatric surgery: insights from a statewide registry

Nicotine use after bariatric surgery can lead to serious complications. Although smoking cessation prior to surgery is often mandatory, the incidence and risk factors for smoking relapse postsurgery are not well understood.

To determine the incidence of smoking relapse 1 year after bariatric surgery and to identify patient, clinical, and smoking-related risk factors for relapse.

Statewide quality improvement collaborative of academic and community hospitals, Michigan, United States.

Using a statewide bariatric-specific data registry, we conducted a retrospective review of 15,421 former smokers who underwent bariatric surgery between 2014 and 2023. Smoking status was assessed via 1-year follow-up survey; of 28,720 eligible former smokers, 15,421 (53.7%) responded and comprised the analytic cohort. Multivariable logistic regression identified independent risk factors for smoking relapse.

The cohort had a mean age of 46.5 years and was predominantly female (80.4%). Sleeve gastrectomy was the most common procedure (81.0%). At 1 year, 7.4% of patients reported resuming smoking. The strongest predictor of relapse was quitting smoking within 1 year before surgery (adjusted odds ratio [aOR]: 14.55; 95% confidence interval [CI]: 8.28-25.56). Uninsured status/self-pay (aOR: 9.25; 95% CI: 1.34-63.77). Additional tobacco product use (aOR: 2.17; 95% CI: 1.07-4.39) and greater number of pack-years (aOR: 1.02 per pack-year; 95% CI: 1.01-1.04) were also associated with higher risk of relapse. More recent surgery was linked to lower odds of relapse (aOR: .75 per year; 95% CI: .64-.88). Nonresponders were younger and more likely to have recently quit and be uninsured, suggesting 7.4% is a lower bound on the true rate.

Despite smoking cessation prior to bariatric surgery, 7.4% of patients resumed smoking at 1 year. Shorter duration of smoking cessation before surgery, multiple tobacco product use, and uninsured status increased risk. Identifying at-risk patients may guide targeted postoperative support and improve long-term outcomes.