AlowBMIconsistentwithextremethinnessisariskfactorforreducedbonemineral density:thinwomenhaveaverymuchlowerbonemineraldensitythanwomenwhoare
morecorpulent [477]
,andthisadversesituationisfurthercompoundedbycigarettesmok- ing
[469,478,479] .Arecentlypublishedstudyhasconirmedthepotentiatingeffectof
thinnessandsmokingtogether [480]
,butthesefactorscanbecounteractedbyHRT.
1.2
0.8 0.6
0.4 0.2
1.2 1.0
0.8 0.6
0.4 0.2
1.0
Bone Mineral Density [gcm
2
]
Bone Mineral Density [gcm
2
]
Lumbar spine Femoral neck
Lumbar spine Femoral neck
Men
Women NS n = 42
ExS n = 140 S n = 42
NS n = 99 ExS n = 64
S n = 23
Fig. 7.8
Cigarettesmoking andbonemineraldensityin
menandwomen.Mean valuesand95conidence
interval,halved.NS non-smokers;ExS
ex-smokers;Ssmokers [476]
Femoral neck Total body
Spine
0.5 0.0
−
0.5
Decrease in Bone Mineral Density [per cent per year]
−
1.0 0.5
0.0
−
0.5
−
1.0 0.5
0.0
−
0.5
−
1.0
Fig. 7.7
Adjustedmeanchangeinbonemineraldensityinthefemoralneck,wholebodyandspine insmokersn=31;hatchedbarsandnon-smokersn=354;whitebars.Bonemineraldensity
wascorrectedforbodyweight,age,sex,nutritionalstatuscalcium+vitaminDorplaceboand forcalciumintake.Statisticallysigniicantdifferencesbetweensmokersandnon-smokerswere
detectedforthefemoralneckp0.02andwholebodyp0.05 [461]
7.7.3 Hip Fractures
Smoking has been reported to increase the likelihood of osteoporotic hip fractures [467,481]
;whilesomeinvestigatorshaveafirmedthisassociation [482–488]
,others have argued against it
[489, 490] . A dose-dependent effect number of cigarettes
smokedhassofarproveddificulttoverify.Inparticular,theincreasingcigarettecon- sumptionamongyoungerwomenisproblematic
[491] .
Inacohortstudyconductedin116,229femalenursesaged34–59yearsatbaseline, informationonsmokinghabits,postmenopausaloestrogenconsumptionanddiseaseswas
collectedonbiennialquestionnairesoveratotalperiodof12years [478]
.Currentsmokers andex-smokersaccountedrespectivelyfor31and26ofthesurveysample.Atotalof377
incidenthipfractureswererecordedinwomenwithameanageof60years.Therelative risksforhipfracturewere1.3CI:1.0–1.7forallcurrentsmokersand1.6CI:1.1–2.3for
currentsmokersof25ormorecigarettesday.Afteradjustmentformenopausalstatus,the relativerisksinthetwogroupsfellto1.2and1.4,respectively.Theriskinex-smokerswas
nothigherthanthatinnon-smokers,butthebeneitwasnotobserveduntil10yearsafter cessation.Boththeincreasedriskamongcurrentsmokersandthedeclineinriskaftersmok-
ingcessationareinpartaccountedforbythedifferencesinbodyweight [478]
. AccordingtoastudyfromDenmarkin13,393womenand17,379men,theriskofhip
fractureinsmokerscomparedwithnon-smokersisincreased1.36-foldCI:1.12–1.65in womenand1.59-foldCI:1.04–2.43inmen.Thereappearstobenogenderdifferenceis
smoking-relatedrisk.After5yearsofsmokingcessation,thefractureriskwasalreadyfound tobeclearlyreducedinmenbutnotinwomen
[492,493] .Similarresultshavebeenreported
inastudyfromLebanonindicatingthatpostmenopausalwomenwhosmokeareparticularly atrisk
[494] .Differencesinriskfactorpatternshavebeenreportedbetweencervicaland
trochanterichipfractures:comparedwithnever-smokers,currentsmokershaveahigherrisk fortrochantericfracturesOR=1.48;CI:1.12–1.95thanforcervicalfracturesOR=1.22;
CI:0.98–1.52.Inwomen,HRTreducedtheriskfortrochantericfracturesOR=0.55;CI: 0.33–0.92morethanforcervicalfracturesOR=1.00;CI:0.71–1.39
[495] .
Associationsbetweenlowbodyweightandsmokinghavebeenrepeatedlyreported [471,483,496]
,andthiswasalsothecaseintheDanishstudycitedabove [478]
.Since women,inparticular,aretakingupsmokingataneveryoungerage,theproblemofosteo-
poroticfracturesdemandsincreasinglyseriousattention [497]
.
7.8 Skin and Mucosa
Theskinchangesproducedbysmokingaremanyandvaried,rangingfrominlammatory, allergicreactionsthroughtothedevelopmentofmalignantanomalies.Ofparticularimpor-
tanceinthiscontextarethecarcinogenicandmitogenicpropertiesoftobaccosmokeand itscapacityforradicalformation.
Nicotinedisplaysavarietyofreactionswithmucocutaneoustissue,inparticularbecause differentnAChRsubtypesseeSect.4.1inChap.4locatedthereareformedbykeratinocytes
[498–500] ,ibroblasts,endothelialcells
[501] ,melanocytes
[502] andlymphocytes
[503] .
Filaggrin,ahumectantwhichimprovesskintexture,isformedinthiswayinkeratinocytesby Ca
2+
-mediatedsecretion [504]
.Nicotinedisturbstheequilibriumbetweencellproliferation, growtharrestandapoptosis,butthisneednotbeconnectedwithtumourgrowth-promoting
activitycf.theindingsreportedbyHeeschen [505]
. AsuggestedrolefornicotineinthepathogenesisofpalmoplantarpustulosisPPPwas
investigatedbuttheobservedalterationinthenAChRsubtypesa
7
-anda
3
-subtypewas notclearlydemonstratedbecauseex-smokerswereusedintheexvivoexperiments
[506]
anddifferentiationbetweenthecausesnicotineortobaccosmokewasimpossible.The enhancedoccurrenceofPPPinsmokersseemstobeconclusive
[507] .
Theconstituentsoftobaccoandthetoxicsubstancesformedduringtheprocessofcom- bustionseeSect.3.1inChap.3arecapableprimarilyofforminghaemoglobinadducts.
Polynucleararomatichydrocarbonsposeaparticulardangertotheskinandmucosa,in additiontothelungs.Themostnoticeableindingsinsmokersare:
Yellowstainingofthefingers
•
Wrinkling,especiallyonthefacialskinofwomen
•
Precancerouslesionsandsquamouscellcarcinomasofthelipsandbuccalmucosa
•
Delayedwoundhealing
•
[508] Frequentandprematurenecrosisofskingrafts
•
[509–511]
7.8.1 Skin Changes
Aslongagoasthe1850s,duringtheassessmentsforinsurancepurposes,itwasremarked thatsmokers’skinwaspaleyellowandwrinkled
[512] .Aroundthesametime,incontrast
withnon-smokers,similarsymptomswerenotedinsmokersamongBritisharmyoficers whohadservedincolonialIndia
[513] .Skinageingisencouragedbysmokingandexpo-
suretosunlight [514]
.Theskinofcigarettesmokershasbeencharacterisedaspaleand thickened,withagreyishhuebutwithoutanychangeinpigmentation.Insomecases,
evidenceofwrinklingoftheentireskinsurfaceisvisibleinthecheeks.Thisskintypeis encounteredin79offemalesmokersandonly19offemalenon-smokers
[514] .Inthis
context,cigarettesmokingisafactorthatoperatesindependentlyofothernoxiousagents [515,516]
.Heavysmokers50pack-yearsareaffectedmorethanless-intensivesmok- ers.Theincreasedriskforfacialwrinklinghasbeenreportedasdose-dependentpack-
years, but BMI, alcohol consumption and sun exposure total 50,000 h are also important,aswellasageandgender
[515] .
Thedevelopmentofthesechangescanbeattributedtotheeffectsofcombustionproducts oftobaccoontheepidermisanddermisviathebloodsupply.Inthefacialregion,thereduced
moistureofthestratumcorneumisamajorfactor [517]
.Changesinvolvingthelipsmaybe relatedtomechanicalfactorsduetopursingofthelipsandcontactwithcombustionproducts
duringsmoking.Smokershavealsobeenreportedtoexhibitelastosisindependentlyofsun exposure,asdemonstratedbyskinbiopsies
[518] .Boththenumberandthicknessofthe