The following piece was written by Jon Blastland for the Clinical Services Journal.

Studies have found that, on average, the smoke produced daily in the operating theatre is equivalent to the amount produced by 27-30 cigarettes.[1] Despite this startling statistic, the adoption of measures to remove surgical smoke plume from the surgical environment has been sluggish. This month, Clinical Services Journal spoke to Jon Blastland, Commercial Director at Eakin Healthcare’s Surgical therapy area, about the dangers of surgical smoke plume, the barriers to progress and how to break them.

Every operating theatre has shared characteristics. There is a surgeon present, alongside an array of instruments, protective equipment and patient monitoring devices. Each theatre will also, at some stage, produce hazardous surgical smoke plume. This is present during any surgical procedure that involves cutting or cauterizing tissue. Whether it is a routine mole removal or complex open-heart surgery, surgical smoke plume is generated.

When instruments, such as lasers or electrocautery devices, come into contact with tissue, heat is generated, which vapourises the flesh and creates a plume of smoke. This plume is a mixture of gases, vapours, and particles, and it has been shown to contain toxic gases, viruses and bacteria.[2]

Since the early 1980s surgical smoke plume has been known to be a significant chemical and biological hazard and has been shown to be as mutagenic as cigarette smoke. One study found that, on average, the smoke produced daily was equivalent to the amount produced by 27-30 cigarettes.[3]

Despite this discovery 40 years ago, the adoption of measures to remove smoke plume from the surgical environment have been slow and inconsistent. On-tip smoke plume extraction, which ensures clear visibility of the surgical field, is also rarely used.

This is concerning given the dangers that are present within the fumes. Research has shown that surgical smoke plume inhaled by theatre staff during procedures can contain over 150 different hazardous chemicals – 40 of which are carcinogenic, such as benzene, hydrogen cyanide and formaldehyde.[4] Substances present in surgical smoke plume can lead to complications, such as viral infections and respiratory illness, with further links to pregnancy complications and cancers.

Safety is paramount in the operating theatre, but surgical smoke plume remains a sizeable threat to the welfare of operating theatre teams. If we are to meet SDG 3.9; sustainably reducing death and illness from hazardous chemicals by 2030, more action needs to be taken.

But, in what form should this action take, and what is already being done?

Surgical Smoke Plume as a Threat

In a 2021 review conducted by the Association for Perioperative Practice (AfPP), Lindsay Keeley, the Patient Safety & Quality Lead at AfPP, captured the gravity of the situation. She stated:

“Exposure to surgical smoke plume is one of the most overlooked hazards in the operating theatre.”

The AfPP has been a strong voice in raising awareness about the risks associated with surgical smoke plume. The organisation has been proactive in addressing the issue: creating and distributing safety information resources, delivering impactful presentations at conferences, initiating petitions, and most recently in 2022, collaborating with the USA-based International Council on Surgical Plume (ICSP) to establish the Surgical Plume Alliance (SPA).

In spite of this work, there is evidence that hospitals are simply not using surgical smoke plume evacuation units or appropriate PPE to safeguard their staff.

This concerning observation suggests a significant gap between knowledge and implementation. Whilst the dangers of surgical smoke plume are becoming more known, not enough is being done at national level to improve the safety and wellbeing of surgical staff.

It is crucial to explore innovative solutions, such as the widespread adoption of surgical smoke plume evacuation units and the implementation of strict guidelines mandating the use of appropriate PPE. Additionally, encouraging a culture of safety within operating theatres that prioritises the well-being of healthcare professionals is also critical.

A recent AfPP Surgical Smoke Plume Survey found that 72% of perioperative practitioners have experienced symptoms associated with exposure from surgical smoke plume.[6] Furthermore, just 14% of staff said plume evacuation equipment is always used during laparoscopy or endoscopy procedures. The statistics show that theatre staff are concerned about the issue (96% of perioperative practitioners would attend training if made available), so why have these concerns not been addressed?

What are the Barriers?

There are a variety of objections to the prevention of surgical smoke plume and adoption of smoke evacuation systems that are commonplace in theatres nationwide. One objection  frequently encountered is the concern that implementing smoke evacuation systems will impose an unnecessary financial burden on the operating budget. Another commonly voiced objection is the notion that exposure to surgical smoke plume over the years has not caused any apparent harm.

It is understandable that healthcare facilities must carefully allocate their resources to various critical needs. However, it is important to recognise that the potential costs associated with smoke plume evacuation systems are not merely expenses; they represent investments in the long-term well-being and safety of both patients and healthcare staff.

Although it is true that the immediate effects of surgical smoke plume may not always be readily visible or evident, harmful substances present in surgical smoke plume can have cumulative and latent effects on the health of surgical staff.

It must be stressed that the inhalation of surgical smoke plume is not restricted to the surgeon. Anyone present in the operating theatre; including nurses and the patient, is exposed to surgical smoke plume.

The Occupational Safety and Health Association (OSHA) has estimated that more than half a million healthcare workers are exposed to surgical smoke plume every year.[7] At high concentrations, the smoke plume has been associated with eye and upper respiratory tract irritation in healthcare personnel. Furthermore, smoke plume creates visual problems for the surgeon, if on-tip smoke extraction systems are not utilised.[8] Studies have also shown that operating room nurses have twice as many respiratory problems in comparison to the general population.[9]

What’s Being Done Elsewhere?

Globally, the issue of surgical smoke plume is slowly being addressed. Fourteen states in the U.S. now require hospitals and ambulatory surgical centres to utilise smoke plume evacuation systems during procedures to protect patients and healthcare workers from the hazards of surgical smoke. Moreover, in Denmark, legislation has been in place since 2001 to ensure surgical smoke plume prompts removal at the point of surgery, not just from the operating theatre.

These steps are promising, and there is hope that the state requirements in the U.S. can kickstart national legislation on the issue in the UK. However, it is worth recognising that actions in the UK so far have been limited to recommendations from various healthcare bodies. While these recommendations serve as valuable guidance, they do not carry the weight of enforceable legislation.

To truly affect change and ensure consistent implementation, stronger calls for action are necessary. One crucial avenue for change lies with the National Institute for Health and Care Excellence (NICE) in the UK, which can provide a solid foundation for a nationwide approach. It is also important for more organisations to actively lobby and advocate for change.

What Steps Should Be Taken?

To effectively tackle the shortcomings in the UK regarding surgical smoke plume and its evacuation, a range of measures need to be established. These measures should address critical areas where improvements are necessary, and include:


Education, Training & More Accessible Resources on Dangers


Awareness needs to be raised about the dangers of surgical smoke plume, and surgical teams must be equipped with the knowledge and skills to effectively mitigate risks. This can be achieved through comprehensive educational programs, workshops, and ongoing training initiatives.

Better Access to Reporting Negative Symptoms & Negligence


Healthcare professionals must have access to a safe and confidential platform to report any adverse effects they may experience or witness. This data can then inform targeted interventions and policies to address shortcomings effectively.

Increased Presence of Smoke Plume Evacuation Systems in Theatres


Although progress has been made, it is important to ensure that these systems are more widely accessible and consistently implemented across all healthcare facilities. Furthermore, the presence of on-tip smoke plume extraction needs to increase in theatres. This requires collaboration between healthcare institutions, manufacturers, and regulatory bodies to establish clear guidelines, standards, and funding mechanisms.

Further Measures to Ensuring Smoke-Free Environments (PPE, Ventilation)


Adequate PPE, such as masks and eyewear specifically designed to filter out harmful particles and gases, should be readily available and consistently used. Additionally, optimizing ventilation systems within operating theaters can play a significant role in reducing the concentration and spread of surgical smoke plume, creating a safer environment for all involved.