If you smoke, vape or use nicotine in any form, expect your joint replacement surgeon to ask about it, and possibly to test for it. Tobacco use is one of the most consistent risk factors for infection and wound problems after hip and knee replacement, and it is one of the few you can change before surgery.
This guide covers what the research shows, how long before surgery you need to quit, where vaping, patches and cannabis fit in (with honest notes on where the evidence is thin), how some US practices check with lab tests, and a quit timeline you can line up with a trip to Colombia.
What smoking does to joint replacement outcomes
The clearest data concern periprosthetic joint infection (PJI), an infection around the implant that usually means more surgery and months of antibiotics. A 2019 meta-analysis of 14 studies of primary hip and knee replacement found that tobacco users had about twice the odds of PJI compared with non-users, and higher odds of wound complications as well.1
| Comparison | Outcome | Odds ratio (95% CI) |
|---|---|---|
| Any tobacco use vs none | Wound complications | 1.78 (1.32–2.39) |
| Any tobacco use vs none | Joint infection | 2.02 (1.47–2.77) |
| Current smokers vs non-users | Joint infection | 2.16 (1.57–2.97) |
| Former smokers vs non-users | Joint infection | 1.52 (1.16–1.99) |
| Current vs former smokers | Joint infection | 1.52 (1.07–2.14) |
Two things stand out. Current smokers fare worse than former smokers, which is the strongest argument that quitting helps.1 But former smokers still carry more risk than people who never smoked, so quitting lowers risk without erasing it. A 2021 review of smoking as a modifiable risk in joint replacement found the same pattern for infection in later studies, while noting that some older data are muddied: in one large study former smokers had slightly higher overall complication odds than current smokers, possibly because the current smokers were younger.2
Smoking also affects more than the joint. The World Health Organization notes that smoking impairs wound healing, raises the risk of wound infection, and increases heart and lung complications around anesthesia.3 If you want to know what an infected joint looks like after surgery, see our guide to joint replacement infection warning signs.
How long before surgery you need to quit
The research points to at least four weeks smoke-free, and longer is better. Your surgeon may ask for more. The evidence:
A 2020 joint study by the WHO, the University of Newcastle and the World Federation of Societies of Anaesthesiologists concluded that people who quit about four weeks or more before surgery had fewer complications and better results six months later. The WHO also said that every smoke-free week beyond four improves outcomes by 19%, and that delaying non-urgent surgery to give patients time to quit is supported by the evidence.3 The release does not spell out exactly how that 19% was measured, so treat it as a direction rather than a precise promise.
The Cochrane review of preoperative quit programs (13 trials, 2,010 people) adds detail. Brief advice barely moved complication rates. Intensive programs, with weekly counseling starting four to eight weeks before surgery plus nicotine replacement, sharply raised quit rates and cut overall complications by more than half and wound complications by about two thirds.4 The catch: those intensive results come from only two small trials, and the authors say the best intensity is still unknown.4
Four weeks is a floor, not a target. Quitting earlier gives your body more time to recover and gives you a buffer if you slip. Structured help (counseling plus medication) works far better than willpower and a warning.
Do vaping and nicotine replacement count?
This is where patients get the most mixed messages, partly because the evidence really is incomplete. It helps to separate two questions: is it the smoke, or the nicotine?
Vaping and e-cigarettes
Vaping removes the combustion but not the nicotine. A 2024 systematic review on e-cigarettes and joint replacement found only one clinical study that looked at joint replacement patients directly, and in it just 44 people used e-cigarettes alone.5 That small group had longer operations, longer hospital stays and a readmission rate of 9.1%, but the review could not give numbers for infection, wound problems or revision in vapers, and most vapers in the data also smoked.5
The rest of the case against vaping rests on lab, animal and other-surgery research: nicotine narrows blood vessels and reduces blood flow to tissue, and in lab studies it can impair the bone cells involved in healing. Nicotine content also varies widely between devices.5 The authors concluded that vaping is not a risk-free alternative to smoking for people awaiting joint replacement.5 In plain terms: nobody has shown that vaping is as harmful as smoking for a new joint, and nobody has shown it is safe. Most surgeons who ban smoking will treat vaping the same way.
Patches, gum and lozenges
Nicotine replacement therapy (NRT) is a different situation. It is a standard quit aid, and in the intensive Cochrane trials that reduced complications, NRT was part of the program.4 That does not prove nicotine is harmless for healing, but it does suggest that using NRT to get off cigarettes beats continuing to smoke. Some surgeons are comfortable with NRT up to surgery; others want all nicotine stopped before the operation. Ask your surgeon directly and get the answer in writing, because it affects which lab test you can pass (see below).
Treat as off-limits unless told otherwise
- Cigarettes, cigars, pipes, hookah
- Vapes and e-cigarettes
- Chewing tobacco and snus
Ask your surgeon
- Nicotine patches, gum and lozenges
- Nicotine pouches
- Prescription quit medicines
- Smoked or vaped cannabis
Nicotine and cotinine testing at US practices
Some US joint replacement programs do not just take your word for it. They confirm abstinence with a urine or blood test before scheduling surgery.
- Nicotine and cotinine. Cotinine is what your body turns nicotine into. A Henry Ford Health study of 103 patients who received quit counseling before joint replacement used nicotine below 2.0 ng/mL and cotinine below 8.0 ng/mL as the "normal" thresholds. Because cotinine comes from nicotine itself, a patch or a vape can make this test positive just like cigarettes can.6
- Anabasine. Another program studied by orthopedic researchers tested urine for anabasine, a marker specific to tobacco. That kind of test can tell tobacco apart from nicotine replacement.7
The Henry Ford numbers show how hard this is. After a six-week period, 31% of counseled patients said they had quit, and 28% had lab results to prove it. The median time from counseling to normal labs was 84 days, close to three months.6 Relapse after surgery is common too: in the anabasine study, 44% of the patients surveyed started smoking again soon after the operation.7 Your new joint is still healing in those weeks, so staying quit after surgery matters as much as quitting before it.
What to expect from a Colombian surgeon
Testing policies vary by surgeon and hospital, in Colombia as in the US, and we could not find a published national rule. Do not assume that a surgeon who does not test does not care. Ask each practice directly:
- Do you require me to be nicotine-free, or only tobacco-free? Does that include vapes and patches?
- How many weeks before surgery do you want me to have stopped?
- Do you test? Which test (cotinine or anabasine), and when: before I travel or after I arrive?
- If my test is positive on arrival, what happens to my surgery date and my deposit?
- Do you want me to stay off nicotine for a set time after surgery as well?
Put the answers in your quote packet. A positive test found after you have flown in is the worst outcome for your budget and your plans.
Cannabis smoking before joint replacement
Cannabis is legal in much of the US and all of Canada, and many joint replacement patients use it for pain. Surgeons and anesthesiologists will still want to know.
In 2023, the American Society of Regional Anesthesia and Pain Medicine released the first US guidelines on cannabis and surgery. They recommend screening every patient for cannabis use, including the type of product, how it is taken, how much and how recently. Elective surgery should be postponed if a patient has altered mental status or impaired decision-making at the time of surgery. Regular users should be told that cannabis may make pain control after surgery harder; they may have more pain and nausea and need more medication, including opioids.8
For joint replacement specifically, a Cleveland Clinic-led meta-analysis of 19 studies found cannabis use was associated with higher odds of blood clots in the legs, revision surgery, pneumonia, stroke and heart complications. It did not find differences in pain scores or opioid use after hip or knee replacement.9 The researchers stress the limits: the studies did not record dose or whether use was medical or recreational, and it is unclear whether cannabis causes these problems or simply travels with other risk factors.9
Smoking cannabis also means inhaling smoke, so ask whether your surgeon wants it stopped on the same timeline as tobacco. Be honest with your anesthesiologist about how much and how often you use. Hiding it does not make it safer; it only means the team plans without the full picture.
Even if it is legal where you live, do not carry cannabis products on an international flight. Ask your surgeon about pain control instead.
A quit timeline that fits your trip
Given that lab-confirmed quitting took a median of about three months in the Henry Ford study,6 and that intensive programs start four to eight weeks before surgery,4 a realistic plan starts well before you buy a plane ticket.
- 3 to 4 months out. Set a quit date. See your doctor about counseling and quit medications, and ask the Colombian practice for their nicotine policy and testing rules in writing.
- 8 to 12 weeks out. Be fully off cigarettes and vapes. If your surgeon allows NRT, use it as directed; if not, plan a taper with your doctor so you are nicotine-free by their deadline.
- 6 to 8 weeks out. If the practice tests, ask whether you can do a test at home first. Book flights only once a clean result is in hand and the surgeon has confirmed the date.
- 2 to 4 weeks out. Keep going. Use this stretch for prehab; our prehab checklist covers the rest.
- Surgery and recovery. Plan for cravings when you are in pain, bored or stuck in a hotel room. Bring your quit tools, tell your caregiver your plan and stay off nicotine for as long as your surgeon asks.
If you are still smoking now and want a sense of what surgery would cost on a realistic timeline, you can request a quote and mention your quit date so the practices can plan around it.