You Can Smoke in the Operating Room!

Nurses in Georgia are seeking a law to protect themselves from surgical smoke inhalation in the operating room. The CDC and the Association of periOperative Registered Nurses. (AORN) state nurses are at higher risk of respiratory diseases because they're exposed to the smoke created by some surgeries. Nurses General Nursing News


  1. Are you exposed to surgical smoke?

    • 4
      36 hours per week or more
    • 3
      24-36 hours per week
    • 2
      12-24 hours per week
    • 1
      12 hours or less per week
    • 4
      Not at all
  2. Does your employer use an evacuator to remove surgical smoke from the ER??

    • 2
      Yes, 100% of the time
    • 3
      Yes, approximately 50% of the time
    • 9
  3. Have you experienced any health problems related to inhalation of surgical smoke?

    • 2
    • 5
    • 7

14 members have participated

You Can Smoke in the Operating Room!

Surgical smoke is produced by thermal destruction of tissue by use of lasers or electrosurgical devices during procedures like blood vessel cauterization. The CDC states that over 500,000 healthcare workers are exposed to surgical smoke, including surgeons, nurses and surgical techs, not to mention patients. The OR can fill with smoke in as little as 5 minutes after surgery begins.1

Smoking in the OR

There are multiple issues with smoke in the OR. It can get so thick that it obstructs the surgeon's view. It also causes bad odors, irritates the eyes, nose and throat, causes headaches, coughs and asthma.1

After being exposed to surgical smoke all day Brenda Ulmer, a nurse in Georgia who is a proponent of the Bill stated, "my chest felt tight, I felt sick in my stomach and my throat hurt.” Brenda Ulmer says "I had issues with allergies and asthma. I had to go on an inhaler.”2

Acute health effects of exposure include1:

  • Eye, nose and throat irritation
  • Headache
  • Cough
  • Nasal congestion
  • Asthma and asthma-like symptoms

Bacteria and Viruses in Smoke?

The National Institute for Occupational Safety and Health (NIOSH), a subdivision of the CDC states the surgical smoke plume may contain toxic chemicals such as carbon monoxide, polyaromatic hydrocarbons, benzene, hydrogen cyanide, formaldehyde, viable and non-viable cellular material, viruses and bacteria (NIOSH).1

No research has linked surgical smoke to cancer, but smoke inhalation has been known to induce acute and chronic inflammation (emphysema, asthma, chronic bronchitis) in animal models. It's frustrating because there's not a lot of scientific data on humans.

In a study on the risk of infection and disease, it was found that Human Papilloma Virus can be transmitted through surgical smoke. Case in point, a laser surgeon developed laryngeal papillomatosis, which was linked to viral particles present in the laser plume.3

It Doesn't Have to Be This Way

What gets me so angry about this topic is that like so many issues in health care, a little prevention could solve the problem. Evacuators or Local Exhaust Ventilation (LEV) devices remove smoke from the room efficiently and inexpensively. I looked up pricing and the Center for Construction Research and Training (CPWR) cites a retail price from $1000 - $3000. Welders use LEVs constantly to prevent inhalation of Mercury and other heavy metals.4

NIOSH recommends using local exhaust ventilation (LEV) for all procedures where surgical smoke is generated as best practice. Training should be provided for employees about the risks of inhalation of surgical smoke, and exposure should be minimized. In addition, they recommend using a properly fitted, filtering facepiece respirator (N95) rather than a surgical or laser mask.1

Who is affected?

NIOSH conducted a survey of healthcare workers. To be included in the survey, respondents had to be within five feet of surgical smoke in the seven days prior to the survey. 4,533 survey respondents reported exposure to surgical smoke: "4,500 during electrosurgery; 1,392 during laser surgery procedures. Respondents were mainly nurses (56%) and anesthesiologists (21%). Only 14% of those exposed during electrosurgery reported local exhaust ventilation (LEV) was always used during these procedures, while 47% reported use during laser surgery. Those reporting that LEV was always used were also more likely to report training and employer standard procedures addressing the hazards of surgical smoke. Few respondents reported use of respiratory protection.” 1

What about patients?

In a study of 1,312 spine surgeries in the OR with and without smoke removed demonstrated no statistically significant in infection rates. However, a study in Poland found a significantly higher level of benzene and toluene in urine after laparoscopic cholecystectomy than before it.3

History Lesson

As of November 2019, only two states have enacted laws mandating evacuation of smoke from ORs: Rhode Island and Colorado. Rhode Island was the first state to enact a law requiring LEVs. Julie Greenhalgh, RN, an OR nurse with 42 years of experience in Cranston, RI testified at the hearing for the Bill. She attributed her chronic lung disease to decades of exposure to surgical smoke. "I never smoked cigarettes and now I have constant cough, bronchitis and asthma.” She uses three inhalers a day. The Rhode Island Bill became a law on January 1, 2019.3

Colorado enacted a law on March 28, 2019 to protect CO perioperative nurses and surgical team members from the harmful effects of plume. All ORs must implement the new rules before May 1, 2021.5

In Georgia, like the other 47 states without surgical smoke laws, it's up to each hospital to decide to use surgical smoke evacuators – it's not mandatory. 2

The proposed bill in Georgia is to make evacuators mandatory inside every OR in Georgia. The cost to the patient would be $25 per procedure but could save thousands in health care costs down the line. 2

Legal Action?

According to a legal site, OSHA has regulations in place that should protect nurses.6 Health care organizations have a duty to address recognized hazards with a feasible means of abatement. Employers could be liable for unabated exposure to surgical smoke. OSHA requires an injury and illness prevention plan in some states like California and Washington. Employers in these states are required to train employees on the hazards in their workplaces. Employees and patients who suffer from cancer or infectious diseases at the workplace could bring worker's compensation or potentially tort claims.6 In other words, if you're breathing in surgical smoke day after day and you start to feel sick, you may want to talk with an attorney. I'm not normally litigious, but it often seems that healthcare organizations only change their policies for fiscal reasons.

What's Coming

I always advocate for joining an organization with a proven track record of effective lobbying. It's the only way us nurses will ever see positive change in the workplace. Organizations like the Association of perioperative Registered Nurses (AORN) are working hard to ensure the safety of perioperative nurses. The AORN website lists several states considering LEV mandates7:

  • Oregon is having a smoke-free OR day on Feb 4, 2020. AORN asks nurses to spend the day at the Oregon State Capitol to advocate for surgical smoke evacuation legislation.
  • A New Jersey assemblywoman introduced a surgical smoke Bill in NJ in September of 2019.
  • California is currently reviewing comments on surgical smoke evacuation as they work toward proposed regulations.
  • AORN is lobbying for similar bills in other states, so consider joining the cause. If we all donated $1, think what we could do? $3million dollars is a lot of lobbying money!

I'm not an OR nurse, but I know several and they are good people who don't deserve to be needlessly exposed to toxic chemicals that have the potential to cause lung disease. As a possible future patient, I wouldn't want to be lying unconscious on the operating table breathing in my own cauterized blood vessels. The impact on my respiratory system could be serious, plus it's just disgusting. I know, not my usual scientific approach, but this article really got me riled up!

I'd love to hear there's progress out there toward protecting healthcare providers from surgical smoke. I hope you'll comment and let me know your thoughts and/or experiences.


1. The National Institute for Occupational Safety and Health (NIOSH) (2019). Surgical Smoke. Retrieved from
7. AORN 2019 Health Policy News

Patient Safety Columnist / Educator

Dr. Kristi Miller, aka Safety Nurse is an Assistant Professor of nursing at USC-Upstate and a Certified Professional in Patient Safety. She is also a mother of four who loves to write so much that she would probably starve if her phone didn’t remind her to take a break. Her work experiences as a hospital nurse make it easy to skip using the bathroom to get in just a few more minutes on the computer. She is obsessed with patient safety. Please read her blog, Safety Rules! on You can also get free Continuing Education at In the guise of Safety Nurse, she is sending a young Haitian woman to nursing school and you can learn more about that adventure:

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That is just gross. That isn't cigarette smoke, that is people smoke. Just nasty.

Specializes in Education, Informatics, Patient Safety.
7 minutes ago, Asystole RN said:

That is just gross. That isn't cigarette smoke, that is people smoke. Just nasty.

Agree 100%. Thanks for reading and commenting!

Thank you for bringing to light an issue that is all but unknown to those of us that don't work in that environment.

Specializes in Peds, Med-Surg, Disaster Nsg, Parish Nsg.

Thanks for the informative and eye-opening article, Kristie.

Specializes in PeriOp, ICU, PICU, NICU.

This is a major health concern but in my right to work state I don’t see this changing anytime soon. I have chronic bronchitis and upper respiratory issues since working in the OR. I am concerned for my health and so are my coworkers. I am looking to transition out of the OR for that reason.

Specializes in Education, Informatics, Patient Safety.
9 hours ago, RosesrReder said:

This is a major health concern but in my right to work state I don’t see this changing anytime soon. I have chronic bronchitis and upper respiratory issues since working in the OR. I am concerned for my health and so are my coworkers. I am looking to transition out of the OR for that reason.

I am so sorry to hear that you are experiencing health problems. I hope you'll jump on the AORN website and advocate for safety in the OR. To me, this looks like a civil suit just waiting to happen. If an employer is aware of a negative health effect that could be mitigated and does nothing to address it, then the employer is at fault.

Smoke from the Bovie may be carcinogenic. Not healthy at all.

How much would a maxed-out suction yankeur help with the cauterizing fumes?