Research Article Open Access
The Effect of Smoking on Facial Aging Among Females in Saudi Arabia
Basem T Jamal1*, Alaa Bokhari2, Bushra Aljahdali2, Baraa Alsayed3, Hanan Filemban2, Razan Baabdullah4, Mahmoud Fakiha5
1Consultant Oral & Maxillofacial Surgery/Head & Neck Surgical Oncology, King AbdulAziz University, Saudi Arabia
2Demonstrator, Faculty of Dentistry, King AbdulAziz University, Saudi Arabia
3General Practitioner, Almashfa Hospital, Saudi Arabia
4Demonstrator Oral & Maxillofacial Surgery Department, King AbdulAziz, Saudi Arabia
5Assistant Professor and Consultant Plastic Surgeon, Department of Surgery, Saudi Arabia
*Corresponding author: Basem T Jamal, Consultant Oral & Maxillofacial Surgery/Head & Neck Surgical Oncology, Department of Oral & Maxillofacial Surgery, King AbdulAziz University, PO Box 80209 Jeddah 21589, Saudi Arabia. Tel: +966-555591789; E-mail: @
Received: Received: December 12, 2016; Accepted: January 03, 2017; Published: February 24, 2017
Citation: Jamal BT, Bokhari A, Aljahdali B, Alsayed B, Filemban H, et al.. (2017) The Effect of Smoking on Facial Aging Among Females in Saudi Arabia. Clin Res Dermatol Open Access 4(2): 1-4.
Abstract
Background: Cigarettes smoking has been shown by several studies to be one of the significant causes of facial aging and wrinkling. Smoking also worsen the scores for upper eyelid skin redundancy, lower lid bags, malar bags, nasolabial folds, upper and lower lip wrinkles. The prevalence rate of smoking in Saudi Arabia ranges from 2.4-52.3% in the past two decades. Up to date, there is no study in Saudi Arabia regarding smoking and facial aging and so the aim of this study is to investigate the relationship between smoking and facial aging among females in Saudi Arabia.

Methods: Analytical cross-sectional comparative study consisting of 107 female participants aged 30-60 years old was performed. A questionnaire was used to obtain a comprehensive medical and lifestyle histories. Also, clinical examination of the perioral and peri-orbital regions in relaxed and smiling positions was also charted using the Fitzpatrick scale.

Results: 52.3% of the individuals surveyed were either smokers or past smokers with a mean smoking duration of 12.6 years. While there was no significant difference between the smoking status and its relation to the grade of peri-oral and peri-orbital wrinkles, it was noted that the length of smoking in years was correlated with advanced skin aging scores with higher peri-oral and peri-orbital wrinkles.

Conclusion: The sample size is not sufficient to establish the comparison between smokers and nonsmokers in relation to facial aging, the length of smoking in years showed a statistical significant difference in correlation to peri-oral and peri-orbital wrinkles.

Keywords: Aging; Females; Smoking; Wrinkles
Background
Smoking is one of the most dangerous habits for health and human life. It causes unfavorable skin changes and intensifies the course of many skin diseases. Additionally, it quickens the natural process of skin aging. The resultant skin damage is irreversible, and further damage can be avoided by cessation of smoking [1]. As well, smoking has well known serious complications like carcinogenic effect and lead to the development of cardiovascular and chronic obstructive pulmonary disease [2]. Moreover, it results in a disturbed microcirculation and consequent delayed wound healing [3].

Some individuals appear older than their actual age. The main cause of this phenomenon however, is still unclear. Several studies show that smoking cigarettes is one of the significant causes of facial aging and wrinkling [4, 5, 6]. The overall literature indicates that those who smoke have a higher risk of developing premature facial wrinkling as compared to those who do not smoke [7]. Smoking also worsen the scores for upper eyelid skin redundancy, lower lid bags, malar bags, nasolabial folds, upper lip wrinkles, lower lip vermillion wrinkles [8].

The prevalence rate of smoking in Saudi Arabia ranges from 2.4-52.3% in the past two decades [9]. Up to date, there is no study in Saudi Arabia regarding smoking and facial aging. Accordingly, this study aimed at investigating the relationship between smoking and facial aging among females in Saudi Arabia. This could also serve as a motivation for people to quit smoking, especially females.
Objectives
The main purpose of the study was to investigate the relationship between smoking and aging process among women and to increase the awareness of the public toward the various harmful and unpleasant effects of smoking and motivate participants to quit.
Methods
Analytical cross-sectional comparative study consisting of 107 female participants aged 30-60 years old. Among those patients, half of them were either smokers, or past smokers, and the rest were nonsmokers. Samples were collected from coffee shops, restaurants where smoking is permitted, smoking cessation clinics, dental clinics, relatives and colleagues interested in joining the study.

A questionnaire was used to obtain a comprehensive medical and lifestyle histories. Also, clinical examination of the peri-oral and peri-orbital regions in relaxed and smiling positions was also charted using the Fitzpatrick scale [Table 1] and classification of nasolabial folds and marionette grooves [10] [Table2].

Additionally, an educational pamphlet was distributed to increase the awareness of the public toward the effect of smoking on skin aging and motivate participants to quit.
Results
A total of 107 women with a mean age of 43.3 years old were surveyed and examined. Many of them were housewives (43.0%). Among the participants, 56 participants (52.3%) were either smokers or past smokers. Overall, smokers smoked for a mean of 12.6 years. Smoking pattern showed that 24% of the smokers use cigarette and 21.5% use shisha.

In respect of sun exposure per week, 57 participants (53.3%) reported sun exposure of less than one hour, 27 participants (25.2%) reported sun exposure between one to two hours, and only 23 participants (21.5%) reported sun exposure of four hours and more weekly. However the relation of sun exposure to the grades of peri-oral and peri-orbital wrinkles was not statistically significant, (P =0.201 and 0426 respectively). Only 15% of the participants reported the use of sun block or sunscreen creams regularly and 13.2% others reported sun tanning. However, the use of sun block or sunscreen creams in relation to peri-oral and per-orbital wrinkles in this study showed no significant difference. Moreover, 13.2% of the participants experienced significant weight loss (10-15 kg) excluding pregnancy.
Table 1: Fitzpatrick scale

Skin Type

Typical Feature

Reaction to Sun Exposure

I

White

Always burns, never tans

II

White

Usually burns, tans with difficulty

III

White

Sometimes mild burn, gradually tans

IV

Moderate Brown

Rarely burns, tans with ease

V

Dark Brown

Very rarely burns, tans very

easily

VI

Black

Never burns, tans very easily

Table 2: Classification of Nasolabial Folds and Marionette Grooves

Grade

Typical Feature

I

Visible folds of animation

II

Visible folds at rest

III

Visible folds at rest and deepening of folds on animation

IV

Deep folds at rest and deeper on animation

V

Overhanging folds

Only 19 women suffered from skin disease and 19 others suffered from medication or food allergy. With regard to personal or family history of cancers, 34 participants showed a positive response. The relationship between these findings and peri-oral and peri-orbital wrinkles are illustrated in table 3
None of the participants exhibited type I Fitzpatrick’s classification and the majority of them (30.5%) had type IV Fitzpatrick’s classification. The distribution of peri-oral and periorbital wrinkles is shown in table 4. Women in postmenopausal state had significantly higher grades of peri-oral and peri-orbital wrinkles as illustrated in table 3.
While there was no significant difference between the smoking status and its relation to the grade of peri-oral and periorbital wrinkles [Table 5], it was noted that the length of smoking in years was correlated with advanced skin aging scores with higher peri-oral and peri-orbital wrinkles (P =0.002 and 0.043 respectively). [Table 6]
This study showed a high association between marital status and peri-oral wrinkles (P =0.001), with high grades reported among married women. [Table 7].
Discussion
Although the prevalence rate of smoking among females at different ages is reported to be significantly lower in females than males in Saudi Arabia [9], this study indicates a high prevalence rate (52.3%) among females in Saudi Arabia.

Lei Y et al [11] in 2001 studied the effect of tobacco smoke and ultraviolet exposure on wrinkle formation at the molecular level. In their in-vitro study they assessed the alteration of matrix metalloproteinase-1 (MMP-1) mRNA expression in human fibroblasts. The results indicated that tobacco smoke and ultraviolet exposure cause wrinkle formation. Both factors cause aging in human skin through additive induction of MMP-1 expression.

Another study by Jin Ho et al [12] showed that smoking, sun exposure and female sex are independent risk factors for wrinkling. Chien et al [13] study in 2016 reported the same findings. It also revealed severe perioral wrinkling in smokers as opposed to nonsmokers with statistical significant difference in women but not men. Age appears to play a significant role since males older than 45 years exhibit similar degree of perioral wrinkling regardless of their smoking status.
In our study however, neither sun exposure nor smoking showed significant difference its relation to the grades of perioral and peri-orbital wrinkles.

Also, in 2007 D.Doshi et al [4] describe that identical twins with an approximately 52.5 pack-year smoking history showed more severe skin aging than did the nonsmoking twin. Moreover, Emster V et al [5] (1995) and Patricia M. O’Hare et`al [6] (1999) revealed that smoking increases the risk of facial wrinkles two to threefold. Koh J et al [14] (2002) also found that current smokers had a higher wrinkles grade than nonsmokers and past smokers.
Table 3: The relationship between different findings and peri-oral and peri-orbital wrinkles

Variable

Grading of peri-oral wrinkles

Grading of peri-orbital wrinkles

 

 

 

 

Grade I, II, III N=53

Grade IV, V N=54

 

p-value

Grade I, II, III N=37

Grade IV, V N=70

p-value

Do you suffer from any kind of skin disease?

9 (17.0%)

10 (18.5%)

0.835

4 (10.8%)

15 (21.4%)

0.172

Do you have a history of medication or food allergy?

8 (15.1%)

11 (20.4%)

0.475

6 (16.2%)

13 (18.6%)

0.762

Is there a personal or family history of cancers?

13 (24.5%)

21 (38.9%)

0.111

10 (27.0%)

24 (34.3%)

0.443

Do you have any of your family members (household) who are currently smoking?

33 (62.3%)

25 (46.3%)

0.097

22 (59.5%)

36 (51.4%)

0.428

Have you reached menopause?

10 (18.9%)

25 (46.3%)

0.002*

5 (13.5%)

30 (42.9%)

0.002*

(*) Statistical significant difference
Table 4: Distribution of peri-oral and peri-orbital wrinkles

Grading

Class

Count (Percentage)

Grading of peri-oral wrinkles

I

6 (5.6)

II

8 (7.5)

III

39 (36.4)

IV

47 (43.9)

V

7 (6.5)

Total

107 (100)

Grading of peri-orbital wrinkles

I

3 (2.8)

II

20 (18.7)

III

14 (13.1)

IV

58 (54.2)

V

12 (11.2)

Total

107 (100)

Table 5: Smoking status and its relation to the grade of perioral and peri-orbital wrinkles

Grading

Smoking status

Smoker/Past Smoker Count =56 (Percentage)

Non-Smoker Count =51 (Percentage)

p-values

 

 

 

Grading of peri-oral wrinkles

Grade 1,2,3

26 (49.1%)

27 (50.9%)

0.501

Grade 4,5

30 (55.6%)

24 (44.4%)

Grading of peri-orbital wrinkles

Grade 1,2,3

22 (59.5%)

15 (40.5%)

0.283

Grade 4,5

34 (48.6%)

36 (51.4%)

On the contrary, A.Elzen et al [15] conducted a study showed that the smokers group underwent blepharoplasty surgery 3.7 years earlier than the ex-smokers group, and 3.5 years earlier than the never-smokers group. Their study showed no significant difference between the ex-smokers group and the never-smokers group.

This study shows that there is no statistical significant difference between smokers and non-smokers in regards to the grade of peri oral and peri-orbital wrinkles. It carries no statistical significance because a three times as big a sample size is needed to establish that. However, the length of smoking in years showed a statistical significant difference in correlation to peri-oral (P =0.002) and peri-orbital (P =0.043) wrinkles.

Females possess a higher risk of developing wrinkles compared to men. Menopause as suggested in this study and other studies [16, 17] support this phenomenon. Youn CS [16] and colleagues found that hormone replacement therapy significantly reduce the incidence of facial wrinkling in women at their postmenopausal stage.

As Erin Wolff et al [17] reported, black menopausal women have significantly fewer wrinkles compared to white menopausal women. They proposed that wrinkling is attributed to chronologic age and skin color more than estrogen deprivation.
Conclusion
The data suggests that the duration of smoking is correlated with an increased risk of skin aging on both the peri-oral and peri-orbital regions. It also showed increased peri-oral and peri-orbital wrinkles among married women. Additionally, menopause is significantly associated with facial wrinkling.
Acknowledgements
Ethics approval and consent to participate
The study design was approved by King Abdulaziz University Faculty of Dentistry institutional review board. All patients were provided with written and informed consent.
Availability of data and materials
Tables on patients’ characteristics included in the study.
Authors’ contributions
BJ, AB, BA-1 and MF participated in planning the study and analyzing the data. AB, BA-1, BA-2, HF collected, analyzed and interpreted the results. AB, BA-1, HF and RB wrote the manuscript. All authors read and approved the final manuscript.
Table 6: Length of smoking in years and its relation to peri-oral and peri-orbital wrinkles

Length of smoking in years

Grade I, II, III

Grade IV, V

p-value

peri-oral wrinkles

9.00 ± 7.6 years

16.18 ± 8.1 years

0.002*

peri-orbital wrinkles

9.86 ± 8.2 years

17.72 ± 8.4 years

0.043*

Table 7: Association between marital status and peri-oral and periorbital wrinkles

Grading

Marital Status

Married Count=83 (Percentage)

Single/Widow/

p-value

Divorced Count=24 (Percentage)

 

Grading of peri-oral wrinkles

Grade I, II, III

48 (90.6%)

5 (9.4%)

0.001*

Grade IV, V

35 (64.8%)

19 (35.2%)

Grading of peri-orbital wrinkles

Grade I, II, III

30 (81.1%)

 

7 (18.9%)

0.353

Grade IV, V

53 (75.7%)

17 (24.3%)

References
  1. Urbańska M, Nowak G, Florek E. [Cigarette smoking and its influence on skin aging]. Przegl Lek. 2012;69(10):1111–1114.
  2. Hunninghake DB. Cardiovascular Disease in Chronic Obstructive Pulmonary Disease. Proc Am Thorac Soc. 2005;2(1):44–49.
  3. McDaniel JC, Browning KK. Smoking, chronic wound healing, and implications for evidence-based practice. J wound ostomy, Cont Nurs  Off Publ Wound, Ostomy Cont Nurses Soc. 2014;41(5):415-423. doi: 10.1097/WON.0000000000000057.
  4. Doshi DN, Hanneman KK, Cooper KD. Smoking and Skin Aging in Identical Twins. Arch Dermatol. American Medical Association. 2007;143(12):1543-1546. doi:10.1001/archderm.143.12.1543
  5. Ernster VL, Grady D, Miike R, Black D, Selby J, Kerlikowske K. Facial wrinkling in men and women, by smoking status. Am J Public Health. 1995;85(1):78–82.
  6. O’Hare PM, Fleischer AB, D’Agostino RB, Feldman SR, Hinds MA, Rassette SA, et al. Tobacco smoking contributes little to facial wrinkling. J Eur Acad Dermatol Venereol. 1999;12(2):133–139.
  7. Seitz CM, Strack RW, Wyrick DL. Cigarette Smoking and Facial Wrinkles: A Review of the Literature. J Smok Cessat. 2012;7(1):18–24.
  8. Okada HC, Alleyne B, Varghai K, Kinder K, Guyuron B. Facial changes caused by smoking: a comparison between smoking and nonsmoking identical twins. Plast Reconstr Surg. 2013;132(5):1085–1092. doi: 10.1097/PRS.0b013e3182a4c20a.
  9. Bassiony MM. Smoking in Saudi Arabia. Saudi Med J. 2009;30(7):876–881.
  10. Nahai F. The art of aesthetic surgery – principles and techniques. Ann R Coll Surg Engl. 2011; 89(5):558. doi:10.1308/003588407X202173d
  11. 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):178–183.
  12. Chung JH, Lee SH, Youn CS, Park BJ, Kim KH, Park KC, et al. Cutaneous photodamage in Koreans: influence of sex, sun exposure, smoking, and skin color. Arch Dermatol. 2001;137(8):1043–1051.
  13. Chien AL, Qi J, Cheng N, Do TT, Mesfin M, Egbers R, et al. Perioral wrinkles are associated with female gender, aging, and smoking: Development of a gender-specific photonumeric scale. J Am Acad Dermatol. 2016;74(5):924–930. DOI:10.1016/j.jaad.2015.11.042
  14. 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):21–27.
  15. Deliaert AEK, van den Elzen MEP, van den Kerckhove E, Fieuws S, van der Hulst RRWJ. Smoking in relation to age in aesthetic facial surgery. Aesthetic Plast Surg. 2012;36(4):853–856. doi: 10.1007/s00266-012-9913-2
  16. Youn CS, Kwon OS, Eun HC, Chung JH, Hwang EJ, Park BJ, et al. Effect of Pregnancy and Menopause on Facial Wrinkling in Women. Acta Derm Venereol. 2003;83(6):419–424.
  17. Wolff E, Pal L, Altun T, Madankumar R, Freeman R, Amin H, et al. Skin wrinkles and rigidity in early postmenopausal women vary by race/ethnicity: baseline characteristics of the skin ancillary study of the KEEPS trial. Fertil Steril. 2011;95(2):658-623.doi: 10.1016/j.fertnstert.2010.09.025
 
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