Key Takeaways
- Smoking reduces blood flow and oxygen to healing tissue. Across surgery, smokers have higher rates of skin loss, infection and wound breakdown than non-smokers.
- Stopping at least four weeks before surgery lowers the risk of wound and lung complications, and each extra week adds benefit. I ask patients to be nicotine-free for at least six weeks, ideally eight, before surgery and for at least six weeks afterwards.
- Most vapes, and all nicotine pouches, patches and gum, contain nicotine. I ask for no nicotine at all in the weeks before and after surgery, including nicotine replacement. Patches and gum can help you quit, but they need to be finished before your nicotine-free period starts.
- A urine, saliva or blood test for cotinine usually shows nicotine use over the previous three to four days, and up to about a week in some people. I don’t test everyone, but I do test higher-risk patients.
- If you’ve smoked or vaped close to your surgery date, tell the team. I’ll postpone surgery until you’ve been nicotine-free for long enough, which is usually easier to deal with than a wound that heals poorly.
“Do I really have to stop smoking before surgery?” is one of the questions I’m asked most often, and close behind it come “Does vaping count?” and “Will you test me?”. The short answers are yes, yes, and possibly. This article explains why, and what the evidence says about timing.
It covers every kind of plastic surgery. Facelift surgery relies more heavily on blood supply to lifted skin than most operations, so I’ve written a separate article on nicotine and facelift surgery.
I’m Dr Scott J Turner, a Specialist Plastic Surgeon (FRACS). This is general information, and the advice for your own surgery depends on the operation and your health.
Why smoking affects healing
A healing wound depends on small blood vessels delivering oxygen to its edges. Smoking works against that in three ways:
- Nicotine narrows small blood vessels, so less blood reaches the wound.
- Carbon monoxide from burning tobacco takes the place of oxygen in red blood cells, so the blood that arrives carries less oxygen.
- Healing cells work less well, so collagen forms more slowly and the body fights infection less effectively.
The effect is well documented. A 2012 review that pooled 140 studies of almost 480,000 surgical patients found that, compared with non-smokers, smokers had about 3.6 times the odds of tissue loss (necrosis), about twice the odds of delayed healing or wound separation, and about 1.8 times the odds of wound infection. Smoking also adds strain on the lungs and heart under general anaesthetic.
How long to stop before surgery
Some changes begin within a day of stopping. What differs with time is how much protection you get.
| Time since your last cigarette | What changes |
|---|---|
| About one day | Carbon monoxide and nicotine levels fall, so your blood carries more oxygen. It isn’t long enough to protect wound healing. |
| Three to four weeks | Wound healing complications start to fall. |
| Four weeks or more | Consistently lower rates of wound, lung and overall complications. |
| Six to eight weeks | Lung function recovers further, and the benefit keeps building. |
These steps come from the guideline of the Australian and New Zealand College of Anaesthetists and from several large reviews. A 2011 review of randomised trials found that each additional week of stopping increased the benefit by about 19%, and that four weeks or more worked noticeably better than shorter periods. A 2025 review of 55 studies found that four or more weeks of stopping was linked with about a third fewer wound complications than continuing to smoke.
That’s why I ask patients to be nicotine-free for at least six weeks, ideally eight, before surgery. Stopping a few days beforehand still lowers carbon monoxide levels and isn’t harmful, but there’s little evidence it lowers wound or lung complications, because it doesn’t give your circulation and healing cells time to recover.
The same applies after surgery. Your wounds are at their most fragile in the first weeks, and new blood vessels and collagen keep forming for months. I ask patients to stay nicotine-free for at least six weeks after surgery, and longer if a wound is slow to heal.
Vaping, pouches, patches and gum
Patients are most often caught out by the difference between smoke-free and nicotine-free.
Vapes remove the smoke and carbon monoxide, but most still deliver nicotine, and nicotine is what narrows the vessels. Human outcome studies are still limited. A 2023 systematic review, based mainly on laboratory and volunteer studies, concluded that vaping should be treated like smoking around the time of surgery. A 2025 study of more than 4,600 breast reduction patients in a large US health records database, matched for other risk factors, found that people with a recorded dependence on non-tobacco nicotine products such as vapes had about twice the risk of wound separation, though not more infection. A study like this shows a link rather than proving cause. People who vape often don’t think of themselves as smokers, so please mention it when we talk.
Nicotine pouches and heated tobacco also deliver nicotine, so the same reasoning applies.
Patches, gum, lozenges and inhalers (nicotine replacement therapy) are where the evidence is mixed, and I think it’s fair to tell you that. The Australian and New Zealand College of Anaesthetists guideline says there is considerable evidence that nicotine replacement is safe around surgery, including for wound healing, particularly when the alternative is continued smoking, and it recommends nicotine replacement for smokers with moderate to high dependence. A small trial in healthy volunteers found nicotine patches didn’t raise wound infection rates compared with dummy patches. On the other hand, nicotine still narrows small vessels. A small US plastic surgery study found that 10 patients who said they were using vapes, patches or gum instead of cigarettes on the day of surgery had complication rates at least as high as those who kept smoking. Their nicotine use was self-reported, and the group was too small to be certain.
My approach is simple. I ask for no nicotine at all, including nicotine replacement, for at least six weeks, ideally eight, before surgery and six weeks after. This is more cautious than the anaesthetists’ guideline. I take that approach because plastic surgery relies so heavily on small blood vessels in the skin, and the evidence in plastic surgery patients is limited. Nicotine replacement can help you quit, but it needs to be finished before your nicotine-free period starts, so start early. Your GP can also talk to you about non-nicotine prescription medicines.
Which operations are most affected
Smoking raises healing risks in every surgical specialty that has been studied. It matters most where healing depends on blood reaching skin that has been lifted or moved.
| Operation | What healing depends on | What studies show in smokers |
|---|---|---|
| Breast lift and breast reduction | Blood supply to the nipple and to the skin where the incisions meet | In breast reduction, a 2023 review of 40 studies found about 2.6 times the odds of complications, including more infection and wound separation |
| Abdominoplasty | A large flap of skin stretched down to a long, low incision | In one study of 132 patients, 48% of smokers had wound healing problems, compared with 15% of non-smokers |
| Facelift and neck lift | Thin lifted skin, kept alive by small vessels until new ones form | Skin loss is more likely, most often behind the ears, where the lifted skin is thinnest and under the most tension. The facelift article covers this in detail. |
| Breast augmentation | A short incision, and keeping the implant pocket free of infection | In a database of 73,608 cosmetic breast operations, smoking wasn’t a significant predictor of major complications in women, but major complications were uncommon. Infection still matters, because an infected implant may need to be removed |
| Gynaecomastia surgery | Chest skin settling over the area where tissue was removed | In a large insurance database of cosmetic breast surgery, smoking was linked with about 2.7 times the risk of major complications in men |
The figures come from different studies and patient groups, so they show the direction of risk rather than a precise number for any one person. For the wider picture, see the risks of cosmetic surgery resource.
Nicotine testing before surgery
In my experience, most people who smoke play down how much they smoke, and research shows that self-reporting isn’t always reliable. Quitting is hard, and it’s understandable to feel embarrassed about a slip. In a UK study of breast reduction patients, more than three-quarters of the smokers later admitted that they had denied smoking in the four weeks before surgery.
I don’t test every patient, but I use a cotinine test for higher-risk patients. Cotinine is what the body makes from nicotine. It can be measured in urine, saliva or blood, and it usually falls below testing thresholds about three to four days after the last nicotine use, though this ranges from about two days to a week depending on how much nicotine was used and how quickly a person’s body clears it. A French study of abdominoplasty patients found that after routine testing was introduced, with surgery cancelled if the result was positive, delayed healing was about half as common as before (20% compared with 42%). The study looked back at records, so other changes over time may have contributed.
A few practical points:
- Cotinine doesn’t show the source. A vape, a patch and a cigarette all produce it. Other markers, anabasine and anatabine, can separate tobacco from nicotine replacement. They are less reliable for vapes, because some vaping liquids contain them.
- Heavy second-hand smoke can produce low cotinine levels. If someone smokes at home, tell me.
- There’s no shortcut through the test. It reflects the past few days of nicotine, and its purpose is to lower the risk of a wound healing poorly.
If you’ve smoked close to your surgery
Tell the team, even if it’s the night before, and you can contact the practice at any point before your date. Your anaesthetist needs to know because carbon monoxide and nicotine affect your heart and lungs on the day. I need to know because it changes the risk to your wounds.
If you’ve smoked or used nicotine during your nicotine-free period, I’ll postpone your surgery until you’ve been nicotine-free for long enough. Postponing is frustrating, but it’s temporary. Skin loss or a slow-healing wound can mean months of dressings, further surgery and a permanent scar.
Getting help to stop
Stopping is hard, and willpower alone often isn’t enough. What helps most:
- Set a quit date at least six to eight weeks before surgery, and tell people around you.
- Plan for your triggers, such as coffee, driving or work breaks.
- Use Quitline on 13 7848. It’s a free, confidential service across Australia for people quitting smoking or vaping.
- See your GP early about quit medicines, and let me know your plan. Nicotine replacement needs to be finished before your nicotine-free period starts, and your GP can discuss non-nicotine prescription medicines.
Surgery can be a good moment to stop for good. A Cochrane review found that, in two small trials, intensive quit support started at least four weeks before surgery, with weekly counselling and nicotine replacement, was linked with fewer complications and about three times the chance of still not smoking a year later. The preparing for plastic surgery guide covers the rest of the checklist, and your smoking history is one of the things we go through at your first consultation.
Frequently asked questions
How long before surgery should I stop smoking?
I ask patients to be completely nicotine-free for at least six weeks, ideally eight, before surgery and for at least six weeks afterwards. Studies show that stopping at least four weeks beforehand lowers the risk of wound and lung complications, and each extra week adds benefit. Stopping a day or two before still lowers carbon monoxide levels and isn’t harmful, but it doesn’t give your wounds the protection that comes with several weeks.
Can I vape or use nicotine patches or gum before surgery?
Most vapes, and all nicotine pouches, patches and gum, contain nicotine, which narrows the small blood vessels healing skin depends on. I ask for no nicotine at all, including nicotine replacement, for at least six weeks before surgery and six weeks after. That’s more cautious than the anaesthetists’ guideline, which considers nicotine replacement safe around surgery, but plastic surgery relies heavily on small skin vessels. If patches or gum are helping you quit, start early and finish them before your nicotine-free period begins.
Do surgeons test for nicotine before surgery?
Some surgeons do. I don’t test every patient, but I do test higher-risk patients. The usual test measures cotinine, a substance the body makes from nicotine, in urine, saliva or blood. It generally detects nicotine used in the previous three to four days, and up to about a week in heavier users or people who clear nicotine slowly, and it can’t tell whether the nicotine came from a cigarette, a vape or a patch. In my practice, a positive result means postponing surgery until you’ve stopped.
What happens if I smoked before my surgery?
Tell your surgeon and anaesthetist, even if it was the night before. Recent smoking affects your heart and lungs under anaesthetic and raises the risk of wound problems. In my practice, surgery is postponed until you’ve been nicotine-free for long enough. A postponed date is usually far easier to recover from than skin loss or a slow-healing wound.
When can I smoke or vape again after surgery?
I ask patients to stay nicotine-free for at least six weeks after surgery, and longer if any wound is slow to heal, because new blood vessels and collagen keep forming for months. The best outcome is not to start again at all. If you’ve managed six to eight weeks without nicotine before surgery and six weeks after, you’re a long way towards stopping for good, and Quitline on 13 7848 can help you stay there.
