Status of Surgical Smoke: Risks, Remediation and Regulation

Each year, an estimated 500,000 healthcare workers –including surgeons, nurses, anesthesiologists and surgical technologists –are exposed to harmful surgical smoke, with potentially quite serious repercussions. More than 150 different chemical constituents have been identified in surgical smoke, some with the capacity for causing human cell damage, cancer and infectious disease.
Table 2. Reported frequency of “often” or “always” for smoke evacuator use.

As shown in Table 2, survey respondents in both 2007 and 2010 indicated a higher frequency of smoke evacuator use during laser procedures than during the comparable electrosurgery and ultrasonic scalpel procedures.16 For example, in 2010, for condyloma or dysplasia treatment (the category with the highest indicated smoke evacuation use), 84% of respondents indicated they used smoke evacuators “always” or “often” during laser ablation but only 68% used smoke evacuators during electrosurgery and ultrasonic scalpel procedures.

Of the 1,356 people who participated in the survey, 210 chose to enter comments. Of these, 49 specified obstacles to compliance with established surgical smoke control practices at their facility.

The most commonly reported obstacle was surgeons’ resistance or refusal to allow the use of smoke evacuators. Other reported obstacles were cost of the devices, bulkiness and excessive noise. Six respondents indicated that a clear regulation (such as an Occupational Safety and Health Administration [OSHA] standard requiring smoke evacuation use) was the only thing that would overcome resistance at their facility.

Another research study was conducted in 2010 by former AORN President and nursing professor Kay Ball, PhD, RN, to identify the key indicators of compliance with smoke evacuation recommendations during electrosurgical procedures.3 She found the most significant indicator was education; if nurses were provided information about the hazards of surgical smoke exposure, they were more apt to comply with smoke evacuation recommendations. Also significant to compliance was having strong leadership that supported smoke evacuation practices, having easy to follow policies on smoke evacuation, and promoting regular internal collaboration (physicians and nurses working together to ensure all smoke is evacuated).

“A first step in developing a smoke evacuation program is to make the commitment as a facility that protecting patients and staff from the potentially harmful effects of surgical smoke is a priority,” Ball wrote. “The commitment should be made with representatives from each of the professional groups providing care in the operating room: surgeons, anesthesiacare providers, perioperative staff and administration. Agreement from the entire surgical team before the program begins is important and will help ensure success. Once an agreement and commitment have been reached, a plan should be developed to introduce the program through education.”

Surgeon Leonard Schultz, MD, FACS, wrote in the AORN Journalin February 2014 that many surgeons dismiss the risks of smoke inhalation and won’t allow the use of smoke evacuation devices during procedures.17 He cites a number of factors, including:

  • Concern that an altered protocol could negatively affect the surgical result
  • Anxiety associated with any change to routines
  • A lack of knowledge about sources that recommend the removal of smoke
  • A lack of enthusiasm for smoke removal on the part of administrators or nursing personnel
  • Distraction caused by the noise generated by the smoke evacuator
  • Unavailability of devices that achieve high efficiency capture
  • Devices that require the surgeon’s involvement

“All of these factors can be overcome by education, use of quieter smoke evacuators, and use of capture devices that remove smoke without requiring staff members to set them up,” he wrote. “After educators and vendors present educational material to surgeons and other perioperative personnel, they often become strong advocates of the use of smoke evacuation.”


A number of standards organizations and agencies have weighed in on surgical smoke evacuation. Many organizations and agencies are making their recommendations more powerful with changing the verb from “should” to “shall.” For example, the American National Standards Institute states that airborne contaminants from laser surgery shall be controlled and that the electrosurgical device produces the same type of airborne contaminants as lasers do.18

However, there are as yet no current national standards with the force of governmental regulation. Under the Occupational Safety and Health Act of 1970, Employee Safety Standards (General Duty, Section 5A-1), comes as close to a regulation as any other entity. This duty states “each employer shall furnish to each of his employee’s employment and a place of employment which are free from recognized hazards that are causing or are likely to cause death or serious physical harm to his employees.”2

OSHA’s respiratory protection recognizes that laser plume and electrosurgical smoke contain toxic, mutagenic and carcinogenic elements.2 OSHA also mandates and identifies the removal of atmospheric contaminants with acceptable engineering controls and local ventilation, including smoke evacuation systems.

The National Institute of Occupational Safety and Health (NIOSH) is part of the Centers for Disease Control and Prevention in the U.S. Department of Health and Human Services. NIOSH investigates potential occupational health risks and makes recommendations to OSHA. The recommendations of NIOSH are referenced on the OSHA website on smoke evacuation. The NIOSH Hazard Control Alert on the Control of Smoke From Laser/Electric Surgical Procedures recommends evacuation and filtration of surgical smoke.19 It specifies that a smoke evacuator or room suction hose nozzle inlet must be kept within 2 inches of the surgical site and the smoke evacuator should be activated at all times when plume is present.

ECRI, formerly the Emergency Care Research Institute, a nonprofit agency in Plymouth Meeting, Pa., recommends that it is prudent to evacuate surgical smoke, and that there is no difference between smoke produced by lasers and smoke produced by electrosurgery units.20

The Joint Commission also recommends that surgical smoke be filtered and evacuated through the use of room ventilation and smoke evacuation methods.21


Surgical smoke carries the strong potential of long-term health damage from repeated exposure. The notion that it is akin to the effects of intense second-hand cigarette smoke should itself be of concern to medical personnel. There are risks of infectious disease as well.

The fact that there are relatively inexpensive and readily available devices to remove all or most of these harmful gases suggests that action needs to be taken.

This is why education is essential to drive widespread adoption and use of smoke evacuation technology. Physicians and nurse leaders are receptive to data and informed arguments in favor of greater safety in their work areas.

Longitudinal, multi-center studies are needed on the long-term health effects of inhalation of surgical smoke, which penetrates surgical masks and even respirators with fine particulates.

Surgical smoke is one of those elements of daily life in the hospital that are not well understood. Many clinicians take pride in handling the smoky, messy work of surgery with self-confidence. And yet, obscured in the smoke around this issue is a very serious risk to those who take such pride in assessing and addressing health risks affecting their patients.


  1. Ball K, “No Smoking in the OR,” Outpatient Surgery, November 2003
  2. Laser/Electrosurgery Plume, Occupational Safety and Health Administration, accessed at on Oct. 31, 2014
  3. Ball K, “Surgical Smoke Evacuation Guidelines,” AORN Journal, August 2010
  4. Pierce JS, et al, “Laser-Generated Air Contaminants from Medical Laser Applications: A State-of-the-Science Review of Exposure Characterization, Health Effects, and Control,” Journal of Occupational and Environmental Hygiene, July 2011
  5. “RP Summary: Recommended Practices for Electrosurgery,” AORN Journal, March 2012
  6. McCormick PW, “Bovie Smoke: A Perilous Plume,” AANS Neurosurgeon, 2008
  7. Nicola JH, et al, “Speed of particles ejected from animal skin by CO2 laser pulses, measured by laser Doppler velocimetry,” Physics in Medicine and Biology, March 2002
  8. Mihashi S, et al, “Some problems about the condensates induced by carbon dioxide laser irradiation,” Mutation Research, June 1981
  9. Gatti JE, et al, “The mutagenicity of electrocautery smoke,” Plastic and Reconstructive Surgery, May 1992
  10. Wenig BL, et al, “Effects of plume produced by the Nd:YAG laser and electrocautery on the respiratory system,” Lasers in Surgery and Medicine, 1993
  11. Fletcher JN, et al, “Dissemination of Melanoma Cells within Electrocautery Plume,” American Journal of Surgery, July 1999
  12. Hill DS, et al, “Surgical smoke -a health hazard in the operating theatre: a study to quantify exposure and a survey of the use of smoke extractor systems in UK plastic surgery units,” Journal of Plastic, Reconstructive & Aesthetic Surgery, July 2012
  13. Miller KA, et al, “Long-term exposure to air pollution and incidence of cardiovascular events in women,” New England Journal of Medicine, February 2007
  14. Murphy, E, “Membership Data Indicate Change Is Imminent,” AORN Journal, August 2010
  15. Ball K, “No Smoking in the OR,” Outpatient Surgery Magazine, November 2003
  16. Edwards, BE, and Reiman RE, “Comparison of Current and Past Surgical Smoke Control Practices,” AORN Journal, March 2012
  17. Schultz L, “An Analysis of Surgical Smoke Plume Components, Capture, and Evacuation,” AORN Journal, February 2014
  18. ANSI Z136.3: American National Standard for Safe Use of Lasers in Health Care, American National Standards Institute, 2011
  19. Control Bulletin 96-128,Control of smoke from laser/electric surgical procedures, National Institute for Occupational Safety and Health, Washington, DC
  20. ECRI Health Devices: Laser Smoke Evacuators, 1990
  21. Joint Commission, “Reducing the Danger of Surgical Smoke Exposure to Health Care Workers,” Environment of Care News, September 2007
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