It was Sir Walter Raleigh that was said to have brought tobacco to England for the first time in 1586. Yet, back then, tobacco was seen as ‘good for your health’ and was suggested to relieve toothache and used for the treatment of worms, halitosis, lockjaw and even cancer.10 However, as we well now know, tobacco (or more specifically the toxic substances it releases when burned) is detrimental to health.
Cigarette smoking is linked to fifteen types of cancer (lung, lip, pharynx, larynx, mouth, nasal cavity and nasal sinus, oesophagus, pancreas, stomach, liver, kidney, cervix, bladder, myeloid leukaemia),11 as well as coronary heart disease, stroke, chronic obstructive lung disease, peripheral vascular disease, stillbirth, low birth weight, sudden infant death, infant mortality, congenital abnormalities and miscarriage.12 Many smokers know this, however, in my experience, relatively few of these smokers are aware of the evidence that smoking prematurely ages the skin.
Smoking and ageing
Healthcare professionals have known about the effect of tobacco smoke on the skin for a long time. In the early 1970s, a study of 1,104 smokers carried out in California noted an association between cigarette smoking and skin wrinkling that was striking in both sexes.1 Smokers were observed to have as many wrinkles as non-smokers who were 20 years older. Further research was needed from this initial study, and many labs began to look into the effects of smoking on the skin.
At the beginning of the 1990s, researchers from the University of Utah assessed and compared the degree of facial wrinkling in 132 smokers and non-smokers.2 They concluded that cigarette smoking was a risk factor for the development of skin wrinkles and ‘crow’s feet’ and smoking acted as a risk factor independent of age and sun exposure. Furthermore, premature skin wrinkling increased with the amount smoked and the duration of smoking.2 In the mid-1990s, a 156-person study of smoking status and facial wrinkling was carried out in California by researchers from the Department of Veterans Affairs, the University of California, and the Kaiser Permanente Medical Group.3 After adjusting for age, average sun exposure and body mass, the risk of moderate or severe facial skin wrinkling was more than twice as high for men who smoked than those who had never smoked and three times higher for female smokers.3
These results have been broadly replicated in many more recent studies.4,13,14 The relative risk for moderate-to-severe wrinkling for current smokers compared to that of life-long non-smokers has been indicated to be 2.57 with a confidence interval of 1.83-3.06 and a P<0.0005.5 Wrinkle scores were three times greater in smokers than in non-smokers, with a significant increase in the risk of wrinkles after 10 pack-years.6 Pack-years are calculated by multiplying the number of packs of cigarettes smoked per day by the number of years the person has smoked. For example, 10 pack-years would define both as smoking one pack a day for 10 years, or two packs a day for five years.6 So what exactly are the underlying causes of smoking damage on skin?
Smoking and skin damage
One of the primary effects of smoking is a decrease in capillary blood flow to the skin caused by vasoconstriction. Nicotine causes these tiny vessels to narrow, which, in turn, creates oxygen and nutrient deprivation in the cutaneous tissues.7 This damage to the blood supply makes affected skin 12 times more likely to slough off during surgery (e.g. cosmetic surgery) for a smoker than a non-smoker.7
Smoking also releases an abundance of free radicals into the skin tissues. These first reduce the production of new collagen and then increase the concentration of the enzyme matrix metalloproteinase-1, which degrades the existing collagen.15 There is also an increase in ‘elastosis’ (degenerative change in the elastic tissue of the skin).8 These effects break down the skin’s vital scaffold leading to the development of fine lines and deep wrinkles. Ultimately, those who smoke have fewer collagen and elastin fibres in the dermis, which causes the skin to become slack, hardened and have less elasticity.16
Another effect of smoking is to increase keratinocyte dysplasia and decrease keratinocyte migration, which leads to increased skin roughness.
Another effect of smoking is to increase keratinocyte dysplasia and decrease keratinocyte migration, which leads to increased skin roughness. Smoking also decreases the production of erythrocytes, which are red blood cells.17 When the number of red blood cells are decreased, it’s similar to developing anaemia and the complexion becomes paler; in some skin tones (particularly light skinned people with fewer melanocytes) this can make the skin (especially of the face due to it being very vascular and on show) appear a very unattractive, yellow and/or grey colour.
The actual texture, smoothness and glow of the smoker’s skin degrades, especially in the exposed upper lip and chin area where those ‘cigarette lines’ appear. Smoking also leads to an increase in the development of telangiectasia – small star-shaped superficial vessel complexes that look unsightly on the cheeks and nose.9Due to these effects, the smoker’s face typically looks as follows:18
• Dry, coarse skin
• Blotchy, sallow, yellowy-grey colouring with prominent telangectasiae
• Facial wrinkles and furrows, e.g. crow’s feet at lateral canthus, vertical ear crease, smoker’s lines around lips
• Baggy eyelids and slack jawline
Once the damage has been done, it’s very difficult to reverse. Hormone-replacement therapy has been demonstrated to prevent further wrinkling and reduce wrinkle depth in post-menopausal women.5 However, in long-time smokers their skin does not appear to respond.5 Similarly, those smokers who try moisturisers, vitamins and hydration techniques to fight their poor complexions also find they make little headway. For them, treatments such as microdermabrasion, skin peels and lasers may be the only answer. Beyond the cosmetic, smoking can have many other serious effects on skin, which include the following.
Smoking delays wound healing, including skin injuries and surgical wounds. It increases the risk of wound infection, graft or flap failure, death of tissue and blood clot formation.19 The reasons for this are unclear, but involve those previously described: lack of oxygen reaching skin cells, delayed migration of keratinocytes, decreased collagen synthesis and also delayed growth of new blood vessels within the wound.19
Smoking contributes to the development and persistence of leg ulcers, particularly arterial ulcers, diabetic foot ulcers and calciphylaxis. This is because smoking reduces blood flow and thus increases the likelihood of skin breakdown in areas that already have poor perfusion such as in the lower leg in smokers.20
Smoking cigarettes doubles the risk of developing squamous cell carcinoma, compared to non-smokers.21 Thereis also an increased risk of oral leukoplakia (pre-cancer) and oral cancer; 75% of cases of oral cancer and lip cancer occur in smokers.22
Research has suggested that smokers tend to have more extensive and severe psoriasis than those that do not.23 Patients with chronic plaque psoriasis appear to smoke more than patients without psoriasis (although this is possibly linked to the stress associated with the disease).24
Peripheral vascular diseases
As mentioned, nicotine causes vasoconstriction as well as hypercoagulability, increasing the chance of blood clots occluding blood vessels. Smoking can therefore aggravate or initiate:25
• Primary or secondary Raynaud’s disease
• Ulceration, in patients with systemic sclerosis
• Buerger’s disease
In summary, smoking is a threat to the skin and many of the body’s organs and key structures. As aesthetic and cosmetic professionals we should make it our business to support the actions of all other medical professionals in helping to encourage patients to quit smoking for good.