How Smoking Affects the Way You Look

This factsheet examines the links between smoking and a person's physical health and appearance, as well as how stopping smoking can minimise a person’s risk.

Tobacco use damages every organ in the body and causes a variety of diseases.¹ More than 7,000 chemicals and compounds are found in tobacco smoke. When a person inhales, these chemicals and substances immediately reach their lungs. The blood subsequently carries the toxicants to every organ in the body, including the skin.²

Smoking and the Skin

The skin is the largest organ in the body that hosts key inflammatory and immunological processes.³ One of the most apparent effects of smoking is on the appearance of the skin.^{4 5} Several studies have found that smoking is an independent risk factor for premature facial wrinkling and facial ageing, and the more a person smokes, the greater the risk.^{6 7}

Skin damaged by tobacco smoke typically has a greyish, wasted appearance.⁵ Smokers in their 40s often have as many facial wrinkles as non-smokers in their 60s.⁸ Skin damage caused by smoking may not be immediately visible to the naked eye, but it is still happening and can start to be detected in one’s 20s or 30s.

One explanation is that smoking impairs the skin’s ability to repair itself because it promotes the production of an enzyme called metalloproteinase (MMPs), responsible for breaking down collagen in the skin and causing it to sag.^{9 10}

Collagen is an essential scaffold protein that gives smoothness and elasticity to the skin.¹¹ Over time, while collagen is reduced, squinting in response to the irritating nature of tobacco smoke and the puckering of the mouth when drawing on a cigarette can cause wrinkling around the eyes (known as Crow’s feet) and mouth. ^{12 13}

Smoking also reduces the amount of blood flowing to the skin by constricting blood vessels near the skin’s surface, depleting the skin of oxygen and essential nutrients transported in blood.¹⁴ Together, these changes add up to what some doctors describe clinically as a “smoker’s face.”¹⁵

Smoking and Wound Healing

Smoking is associated with wound infection, wound separation, impaired healing and increased risk of complications pre-and post-operatively.^{16 17 18}
The problems that smoking can cause are so severe that some plastic surgeons have even declined to perform cosmetic surgeries on patients who refused to quit smoking.¹⁹ The Royal College of Anaesthetists advises that quitting smoking any time before surgery is beneficial.²⁰

Smoking and Psoriasis

Psoriasis is a chronic inflammatory skin condition that affects about 2% of people in the UK which, while not life-threatening, can be extremely uncomfortable and disfiguring.^{21 22} Psoriasis can appear anywhere on the body, even on the elbows, ears, skin folds, hands, feet, and nails.²³

Several studies have proven that smoking not only increases a person’s risk of developing psoriasis, but also can increase the severity of your symptoms.^{24 25} A 2012 study found that smoking was an independent risk factor for psoriasis in both men and women. The risk of developing psoriasis was highest among heavy smokers and those who had smoked for a longer duration of 30 or more years.²⁵

A more recent study also found that people who have ever smoked, currently smoke, or smoked in the past had a higher risk of developing psoriasis than nonsmokers.²⁵

Smoking and Palmoplantar Pustulosis

Palmoplantar pustulosis (PPP) is an incurable skin condition involving extreme inflammation of the hands and feet, which can occur independently or in conjunction with psoriasis. Available evidence has revealed that smoking increases the risk of PPP.^{26 27} In fact, 95% of patients with PPP are smokers, most of whom are heavy smokers.^{27 28} As a result, cigarette smoke is most likely to be involved in the disease's development.

Smoking and weight

Although stopping smoking leads to considerable improvements to health, it is often associated with weight gain.^{29 30} A 2012 meta-analysis that focused on weight gain in those who quit smoking as part of randomized clinical trials of cessation treatment, reported that the average weight gain among successful quitters was 1.1 kg at one month, 2.3 kg at two months, 2.9 kg at three months, 4.2 kg at six months, and 4.7 kg at 12 months.

The study authors noted variation in weight change was large, with about 16% of quitters losing weight and 13% gaining more than 10 kg.³¹

A more recent systematic review found that people who quit smoking gained an average of 4.1kg over five years compared with 1.5kg for continuing smoking.³² Another study found that successful quitters gained an average of 8.97kg where participants were followed-up for 8 years.³³

It is vital to note that although significant weight gain can lead to other serious health problems, the health effects of the modest weight gain many quitters experience is vastly outweighed by the health benefits from stopping smoking.^{34 35 36}

Several risk factors are associated with an increased risk of weight gain after quitting smoking. Being young, of lower socioeconomic status and a heavy smoker are significant predictors of greater weight gain.^{37 38} Obese smokers tend to gain the most weight after quitting smoking.³⁴ Peri and postmenopausal women are also more likely to gain weight after quitting.³⁹

Although the reasons for post-cessation weight gain are not fully understood, some have attributed it to the fact that smoking increases the body’s metabolic rate (the rate at which calories are burned up) by about 10%.^{40 41}The effect of nicotine on metabolic rate may also explain why smokers tend to weigh less than non-smokers.⁴² Another theory is that smoking alters the body-weight set point (the weight towards which a person tends to return despite attempts to gain or lose weight). It has been suggested that nicotine may artificially lower a person’s body weight set point so that the weight gained on stopping reflects a return to the body’s natural weight set point.⁴³ Nicotine also increases central nervous system levels of norepinephrine, dopamine and/or serotonin, which has been shown to suppress appetite, increase energy expenditure, and alter feeding patterns - all of which can result in weight loss.^{42 44}

Although smoking can facilitate weight loss, many smokers are still overweight or obese. The combination of excess weight and smoking has been shown to accelerate the body’s ageing process. One study showed that being both overweight and a smoker can age a person by ten years or more.^{45 46}

It is important to emphasise that the benefits of quitting smoking far outweigh the post-cessation weight gain, even in people who are focused on weight management.⁴⁷

Smoking and body shape

Smoking can affect body shape by changing fat distribution in a way that is associated with diseases.^{48 49} Smokers store body fat in an abnormal distribution because smoking can interfere with the endocrine system (the glands in your body which produce hormones).⁵⁰

In smokers, more fat is stored around the waist and upper torso and less around the hips. This means smokers are more likely to have a higher waist-to-hip ratio (WHR) than non-smokers.^{51 52 53} High levels of WHR have been associated with an increased risk of several diseases, including type 2 diabetes, hypertension, cardiovascular disease, heart disease, gallbladder problems and breast cancer.^{54 55 56 57} Studies have established that the waist to hip ratio increases with the number of cigarettes smoked per day.^{58 59}

Smoking and oral health

Smoking and chewing tobacco products have several well documented detrimental effects on the oral cavity. These include aesthetic changes such as stained teeth and the need for dentures. As well as much more serious complications, including an increased risk of periodontitis (inflammation of the gums) leading to tooth loss, bone loss and impaired wound healing, reduced taste sensation and halitosis (“bad breath”).^{60 61}

A 2018 systematic review also found that smoking increases the risk of periodontitis by 85%.⁶²

Smoking can also impact tooth implants. Smoking increases the risk of failure of tooth implants and post-operative complications.⁶³ The more a person smokes, the more likely the implant is to fail.⁶⁴ One study found that “approximately one in every three implant failures occurred in smokers, and one in five patients with early failures smoked over 10 cigarettes per day, while only 12.3% of patients without failures were smokers.”⁶⁵

Other common non-malignant oral conditions in smokers include the darkening of gum pigmentation (“smoker’s melanosis”); leukoplakia of the tongue (“smoker’s tongue”), characterized by white spots or patches on the tongue or vulva; and a grey-white palate with red papules (bumps) a symptom of inflamed salivary glands (“smoker’s palate”/nicotine stomatitis).^{66 64}

See also: ASH research report Tobacco and Oral Health

Smoking and skin cancer

Skin cancer is one of the most common types of cancer worldwide.⁶⁷ While the evidence on the association between smoking and skin cancer is still developing, several studies have established that smoking is an independent risk factor for developing cutaneous squamous cell carcinoma (SCC).^{68 69} SCC is the second most common type of skin cancer caused by the uncontrolled proliferation of abnormal squamous cells in the epidermis (the outer layer of the skin).⁷⁴ According to a 2012 meta-analysis, smokers had a 52% elevated risk of developing SCC.⁷³

Smokers also have a higher risk of developing wart-related cancers, including cancer of the vulva, anus and penis, as well as genital warts caused by the human papillomavirus (HPV).^{70 71 72} This could be related to the immunosuppressive effects of nicotine which inhibits both the innate and adaptive immune responses.⁷³

A 2019 study conducted in the north of England suggests that smoking may blight the immune system’s response against melanoma, which may reduce survival. The study researchers found that smokers were 40% less likely to survive melanoma than patients who had not smoked within a decade of being diagnosed with the disease.⁷⁴ This risk is reduced when you quit smoking. Stopping smoking should be strongly recommended for people diagnosed with cancer.

Smoking and SLEEP

Smoking can disrupt sleep patterns, which can also have negative effects on the skin. According to a study carried out by CHEST, there is a direct link between smoking and sleep apnea (when a person’s breathing is interrupted during sleep).⁷⁵ The researchers found that cigarette smokers are four times more likely to report feeling unrested after a night’s sleep than nonsmokers. The researchers also found that smokers spent more time in light sleep and less time in deep sleep than nonsmokers. ⁸⁶ This can result in sleep deprivation and sleep fragmentation.⁷⁶

Sleep deprivation can affect the physical look of the eyes, mouth, and skin.^{77 78} For instance, with sleep deprivation, blood flow to the skin is reduced, and according to a study based on 25 participants, faces appeared paler after not sleeping.⁸⁹ Facial cues from sleep deprivation have also been connected to various social consequences, affecting communication and social interaction.^{88 89}

Smoking cessation and appearance

One international study found that 13.3% of men and 21% of women acknowledged that the effect of smoking on their appearance was one of the factors that motivated them to quit.⁷⁹ In a UK study, youth and young adults aged 16-24 also took their appearance into consideration in making the decision to quit smoking.

The effect of this factor varied by gender, with young women more worried about their skin.⁸⁰ Another study from the UK measured the reactions of women aged 18-34 to facial age progression using software which could produce artificial aging in digital images. Respondents were shocked at the possible future appearance of their skin, if they continued to smoke. The study concluded that using age-appearance morphing techniques to personalise the experience for female smokers significantly increased their motivation to quit smoking.⁸¹

While smoking is terrible for your skin, stopping can help it look better. Quitting improves blood flow, allowing the skin to obtain the oxygen and nutrients it demands, resulting in a more youthful appearance.⁸² Finger and nail stains may also fade away, teeth may appear whiter, and your body will start to heal itself. ^{83 75} These factors can be highlighted to promote smoking cessation.

Other effects

Researchers have also found a link between smoking and the following:

• More prone to acne and delay the healing of blemishes. Women have been found to have more frequent and severe acne, which worsens the more they smoke.⁸⁴ Smoking is also considered a trigger for Hidradenitis suppurativa (HS), more commonly known as acne inversa, a chronic inflammatory skin disease that can be disfiguring.^{85 86}
• Accelerated hair loss and greying.⁸⁷
• Smoking can damage eye blood vessels creating a bloodshot appearance in the eyes while causing irritation.⁸⁸
• Prolonged smoking causes noticeable discolouration of the fingers and fingernails on the hand used to hold cigarettes.⁸⁹
• In extreme cases, cancer of the lip, tongue, gums, can cause severe disfiguration.

Cessation advice

Preliminary studies show that smoking cessation interventions related to appearance may have a positive impact on quitting.^{90 91} Although NICE guidance⁹² does not specifically mention using the negative effects on a smoker’s appearance as motivation to quit, the U.S. Clinical Practice Guideline states:

“The clinician should ask the patient to identify potential benefits of stopping tobacco use. The clinician may suggest and highlight those that seem most relevant to the patient. Examples of rewards follow: [Your] home, car, clothing, breath will smell better. [You will have] improved appearance, including reduced wrinkling/ageing of skin and whiter teeth.”

The Guidelines also provides suggestions for what to say to smokers about the likelihood of post-cessation weight gain, including which pharmacological supports have been shown to delay weight gain (bupropion, nicotine gum and nicotine lozenges).³⁵