In 1854, the pioneering British anesthesiologist, John Snow, contributed to ending a cholera epidemic by having the authorities remove the handle from the Broad Street pump, a major source of contaminated drinking water. In modern times, anesthesiologists also have an opportunity to help reduce the scale of an epidemic by promoting smoking cessation during the perioperative period. In 1998, 47,581 Canadians died as a consequence of smoking. They died from lung cancer (13,951 deaths), ischemic heart disease (9,289 deaths), and chronic airways obstruction (6,457 deaths). In developed countries, up to 15% of the total health care budget is spent on treating the effects of smoking. Smoking is the leading cause of preventable death in Canada. The tobacco epidemic has been described as ‘‘probably the greatest health disaster in human history’’. Clearly, smoking is a major public health issue, but why does this matter to anesthesiologists? We see the problems caused by smoking in the operating room every day. Many of our patients would not need surgery if they had never smoked. The obvious examples are the cases of lung cancer and vascular disease, but the effects of smoking are systemic and pervasive. The relative risk of cataracts in smokers is 3.17 times that of nonsmokers, and the relative risk for development of bladder cancer is 3.9 times greater for male smokers and 2.4 times greater for female smokers. Fractures are more common in smokers; the relative risk for hip fractures is up to 1.84 times that of non-smokers. Smoking is also associated with a higher incidence of ST depression during anesthesia. Compared with patients who never smoked, smokers are twice as likely to suffer a myocardial infarction in the thirty days after surgery. They also have an 80% higher chance of developing pneumonia, a 40% greater risk of sepsis, and they are 30% more likely to die. With regard to risks of postoperative infections and wound healing, Sorensen found that the incidence of wound infections was 12% in smokers compared with 2% in non-smokers. In a retrospective study, Moller concluded that ‘‘smoking was the single most important risk factor for the development of postoperative complications’’. Our surgical colleagues, especially in plastic and orthopedic surgery, are well aware that smoking reduces the chances of successful surgery, especially in cases of vascular flaps and spinal fusion. The risk of abdominal wall necrosis after flap surgery increases from 1.0% in non-smokers to 4.3% in ex-smokers and 7.9% in current smokers. After spinal fusion, non-union is twice as common in smokers as in non-smokers. The adverse effects of smoking on wound healing are long-lasting. The outcome of anterior cruciate ligament repair at one year is worse in smokers, who have more pain, poorer function, and less ability to return to sports than non-smokers. Perioperative smoking is often seen as a risk factor which is not easily altered, but evidence suggests otherwise. For example, Moller was able to get 60% of preoperative patients to stop smoking and another 23% to reduce their smoking by at least 50% simply by offering weekly counselling sessions with a nurse and nicotine replacement therapy. The effect on outcome was dramatic; there was an overall decrease in complication rates from 52% to 18%. There was also a reduction in wound problems from 31% in the control group to 5% in the intervention group. On average, the intervention group J. Oyston, MB (&) Department of Anesthesia, The Scarborough Hospital, 3050 Lawrence Ave East, Toronto, ON M1P 2V5, Canada e-mail: john7@oyston.com