How Smoking Affects Skin Health

• Introduction to smoking and skin health
• How smoking affects the skin
• Changes to physical appearance
  • Ageing
  • Wrinkles
  • Skin tissue composition
  • Skin tone and colour

• Poor wound healing
• General skin changes
  • Moisture
  • Skin blood flow
• Skin lesions
• Skin cancer
• Psoriasis

Introduction to smoking and skin health

Smoking is associated with a range of detrimental health effects, the most well known of which are lung cancer and cardiovascular disease. There are many lesser known health effects as well, including effects on the skin.

In many cases, these changes to skin are not life threatening, though they can change the physical appearance of the smoker. For example, smoking is associated with premature ageing and wrinkles. Smoking is also associated with very serious skin conditions, including squamous cell carcinoma of the skin (a type of skin cancer) and psoriasis. Awareness of the changes to physical appearance and the serious skin conditions associated with smoking may help motivate individuals to quit smoking.

How smoking affects the skin

The precise ways in which tobacco smoke damages or changes skin are not fully understood, though scientific studies have produced evidence about a number of possible ways. Studies suggest that tobacco smoke exposure decreases capillary and arteriolar blood flow, possibly damaging connective tissues that help maintain healthy skin. Skin fibroblasts (the cells in connective tissue that form collagen and elastin) are damaged by tobacco smoke.

There is also evidence that tobacco smoke is phototoxic. Smoke becomes more toxic in the presence of ultraviolet light (UV), such as is found in sunlight, and causes more damage to skin cells than either smoke or UV would cause on their own.

Have you quit smoking? Or are thinking about trying to quit? Use this tool to see what health benefits you have already achieved and what benefits you can expect in the future if you stick with it. For more information, see Health Benefits of Quitting Smoking Tool (tool coming soon).

Changes to physical appearance

Ageing

As people age, their skin also ages. The ageing process is influenced by a number of environmental factors. Sun exposure is the most prominent risk factor for premature ageing. Although it is much less well known, cigarette smoking is also a risk factor for premature skin ageing.

Several studies have reported that cigarette smoking causes an individual’s skin to age even more than exposure to sunlight does. Studies have also reported that the effect of exposure to tobacco smoke and sunlight at the same time is more dangerous than the combined effect of either exposure alone, and that women are at greater risk than men.

The ageing of skin can be measured by a number of features. Most obviously, skin becomes wrinkled. Wrinkling is caused by changes to skin elasticity and concentrations of skin components such as collagen and elastin. Differences in skin features between individuals who do and do not smoke can therefore be measured by physical appearance, or by analysing skin tissues for concentrations of components.

Wrinkles

Numerous studies have found that premature wrinkling is associated with smoking. There is evidence that the more an individual smokes, the more the premature ageing effect occurs, so heavy smokers will experience more premature wrinkles than those who only smoke occasionally. One study, in which eight judges individually rated the age of smokers and non-smokers from their photographs, reported that smokers were, on average, rated as being 2.7 years older than their actual age, while non-smokers were rated at 0.7 years younger than their actual age.

Another study reported that moderate smokers were almost twice as likely to wrinkle prematurely than non-smokers, and heavy smokers were almost three times more likely to wrinkle prematurely.

Other studies have examined exposure to both cigarettes and sunlight, to assess the relative importance of each of these exposures in the development of wrinkles. Evidence from these studies suggests that smoking may be a more important factor in the development of wrinkles than sun exposure.

There is evidence that individuals exposed to both tobacco smoke and sunlight prematurely winkle more than individulas exposed to tobacco smoke or sunlight alone. One study found that smokers were 5.8 times more likely to develop wrinkles than non-smokers, while those with excessive sun exposure (i.e. more than two hours per day) were only 2.65 times more likely to wrinkle than those who were not excessively exposed to sunlight. Individuals who smoked heavily (35 pack years or more) and had excessive sun exposure were 11.4 times more likely than non-smokers with less than two hours per day of sun exposure to develop wrinkles. This is a considerably greater risk than the combined individual risks of exposure (i.e. 5.8 for tobacco + 2.65 for sunlight = 8.45 times more likely). As tobacco smoke is phototoxic, this synergistic effect of combined tobacco smoke and sun exposure is unsurprising.

Another study reported that smoking more than 20 cigarettes per day was associated with an almost 10-year increase in skin ageing. The study found no significant association between sun exposure and wrinkles.

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There is some evidence that women’s skin is more affected by tobacco smoke exposure than men’s skin. One study reporting a premature ageing effect in both sexes found that smoking men were 2.3 times more likely than non-smoking men, and smoking women more than 3 times as likely as non-smoking women, to age prematurely. The study did not explore the possible reasons why women’s skin was more sensitive to the detrimental effects of tobacco smoke than men’s skin.

Skin tissue composition

As skin ages, the composition of skin tissues changes. A number of studies have examined the skin tissues of smokers and non-smokers as a measure of premature ageing. A Dutch case control study measuring the extent of elastosis (a condition in which skin loses elasticity as a result of connective tissue degeneration) and telangiectasia (a condition characterised by fine red lines in the skin caused by the dilation of small blood vessels) in smokers and non-smokers reported that the likelihood of developing either condition increased with the number of cigarettes smoked. This was true for both men and women, although the effect was most apparent in men. Another study, which used computer assisted analysis to assess elastosis in four layers of facial skin, reported significantly greater elastosis in smokers compared to non-smokers.

Skin tone and colour

In addition to wrinkles, smoking increases an individual’s risk of gauntness and facial discolouration.

 

Poor wound healing

There is evidence that smoking tobacco decreases the ability of skin to regenerate and repair wounds.This is particularly evident in patients undergoing surgery. For example, smokers who undergo face lift surgery are more likely than non-smokers to experience unsatisfactory wound healing.

There are a number of possible ways by which exposure to tobacco smoke may inhibit the skin’s ability to regenerate and repair. Nicotine, one of the toxic components of tobacco smoke, is a vasoconstrictor (an agent which causes the blood vessels to contract). When blood vessels are constricted they transport less blood through the body, and therefore reduce the supply of nutrients upon which the skin depends to regenerate. Similarly, carbon monoxide, another toxic component in tobacco smoke, reduces oxygen flow through the body, thus reducing the supply of oxygen needed by damaged cells to regenerate.

General skin changes

Moisture

Dry skin can feel uncomfortable because it is less flexible than moisturised skin. Unmoisturised skin becomes unattractive and may take on a red, flaky or scaly appearance. Dry skin is also more likely to crack or itch than well-moisturised skin.

Evidence about the effects of smoking on the moisture content of skin is limited, but the available evidence suggests that smoking reduces moisture in the skin. An Israeli study examining skin moisture found that women who smoked more than ten cigarettes per day had significantly lower mean moisture values than non-smokers.

Skin blood flow

Cigarette smoking reduces skin blood flow by increasing the release of a hormone called vasopressin.Vasopressin is produced naturally by humans. One of its functions is to reduce blood flow. Studies have shown that concentrations of vasopressin in the blood rise immediately after smoking tobacco.

Skin lesions

A review of all published studies examining the associations between skin health and smoking reported that smoking increases the risk of skin lesions in people with diabetes, lupus and AIDS.

Skin cancer

Exposure to sunlight is the predominant risk factor for squamous cell carcinoma of the skin (a type of skin cancer). There is considerable evidence that smoking also increases the risk of skin cancer. A Dutch study found that cigarette and pipe smokers were twice as likely as non-smokers to develop squamous cell carcinoma of the skin, when other risk factors (e.g. age and sun exposure) were taken into account. Interestingly, there was no significant association between cigar smoking and squamous cell carcinoma. The same study reported that current smokers were more likely to develop the condition than former smokers.

The Nurses’ Health Study, a large study conducted amongst nurses from the US, found that nurses who smoked were 50% more likely to develop squamous cell carcinoma of the skin, compared to non-smoking nurses. A number of other studies have also identified smoking as a risk factor for squamous cell carcinoma of the skin.

Psoriasis

Tobacco smoke exposure increases the risk of developing psoriasis, a rare skin condition characterised by the formation of silvery, plaque-like scales on the arms and legs (particularly at the elbows and knees). Smokers with psoriasis are less likely than non-smokers to improve following treatment.

A recent review of literature on the topic reported that women who smoked were 3.3 times more likely to develop psoriasis than non-smoking women. While no significant association between smoking and development of psoriasis in men was found, there was evidence that men who smoked at least ten cigarettes per day were more likely to have severe psoriasis. Decreased improvement rates following treatment were noted in both men and women.

More information

For more information on smoking and its health effects, and some useful tools, videos and animations, see Smoking.

References

1. Scollo MM, Winstanley MH [eds]. Tobacco in Australia [3rd edition]. Chapter 3: The health effects of active smoking [online]. Melbourne: Cancer Council Victoria. 21 November 2008 [cited 18 May 2009]. Available from URL: http://www.tobaccoinaustralia.org.au/
2. Grady D, Ernster V. Does cigarette smoking make you ugly and old? Am J Epidemiol. 1992; 135(8): 839-42.
3. Behnam SM, Behnam SE, Koo JY. Smoking and psoriasis. Skinmed. 2005; 4(3): 174-6.
4. Placzek M, Kerkmann U, Bell S, Koepke P, Przybilla B. Tobacco smoke is phototoxic. Br J Dermatol. 2004; 150(5): 991-3.
5. Kennedy C, Bastiaens MT, Bajdik CD, Willemze R, Westendorp RG, Bouwes Bavinck JN. Effect of smoking and sun on the aging skin. J Invest Dermatol. 2003; 120(4): 548-54.
6. Yin L, Morita A, Tsuji T. Skin aging induced by ultraviolet exposure and tobacco smoking: Evidence from epidemiological and molecular studies. Photodermatol Photoimmunol Photomed. 2001; 17(4): 178-83.
7. Ernster VL, Grady D, Miike R, Black D, Selby J, Kerlikowske K. Facial wrinkling in men and women, by smoking status. Am J Pub Health. 1995; 85(1): 78-82.
8. Boyd AS, Stasko T, King LE Jr, Cameron GS, Pearse AD, Gaskell SA. Cigarette smoking-associated elastotic changes in the skin. J Am Acad Dermatol. 1999; 41(1): 23-6.
9. Raitio A, Kontinen J, Rasi M, Bloigu R, Röning J, Oikarinen A. Comparison of clinical and computerized image analyses in the assessment of skin ageing in smokers and non-smokers. Acta Derm Venereol. 2004; 84(6): 422-7.
10. Koh JS, Kang H, Choi SW, Kim HO. Cigarette smoking associated with premature facial wrinkling: Image analysis of facial skin replicas. Int J Dermatol. 2002; 41(1): 21-7.
11. Leung WC, Harvey I. Is skin ageing in the elderly caused by sun exposure or smoking? Br J Dermatol. 2002; 147(6): 1187-91.
12. Freiman A, Bird G, Metelitsa AI, Barankin B, Lauzon GJ. Cutaneous effects of smoking. J Cutan Med Surg. 2004; 8(6): 415-23.
13. Wolf R, Tur E, Wolf D, Landau M. The effect of smoking on skin moisture and on surface lipids. Int J Cosmet Sci. 1992; 14(2): 83-8.
14. Waeber B, Schaller MD, Nussberger J, Bussien JP, Hofbauer KG, Brunner HR. Skin blood flow reduction induced by cigarette smoking: Role of vasopressin. Am J Physiol. 1984; 247(6 Pt 2): H895-901.
15. Rowe JW, Kilgore A, Robertson GL. Evidence in man that cigarette smoking induces vasopressin release via an airway-specific mechanism. J Clin Endocrinol Metab. 1980; 51(1): 170-2.
16. Silverstein P. Smoking and wound healing. Am J Med. 1992; 93(1A): 22-4S.
17. de Hertog SA, Wensveen CA, Bastiaens MT, Kielich CJ, Berkhout MJ, Westendorp RG, et al. Relationship between smoking and skin cancer. J Clin Oncol. 2001; 19(1): 231-8.
18. Grodstein F, Speizer FE, Hunter DJ. A prospective study of incident squamous cell carcinoma of the skin in the Nurses’ Health Study. J Natl Cancer Inst. 1995; 87(14): 1061-6.
19. Aubry F, MacGibbon B. Risk factors of squamous cell carcinoma of the skin. A case-control study in the Montreal region. Cancer. 1985; 55(4): 907-11.
20. Flynn TC, Petros J, Clark RE, Vieham GE. Dry skin and moisturizers. Clin Dermatol. 2001; 19(4): 387-92.