Health and well-being

"For smokers for whom life is a continuing struggle, cigarettes emerge as one of the few constants, one of the few resources they can control and rely on."

 Arterial disease and cancers are the main cause of death for women across Europe.  Yet smoking is linked to many other conditions which damage health.  Dental, musculo-skeletal, and sensory problems also have significant impact on health costs.  Such information may encourage quitting, or give a new ‘media angle’ for advocates.  But cigarettes also play many roles for women, who may see smoking as important to their everyday well-being.

Physical health

General health
Women generally have worse health than men, though patterns are complex. For example, they suffer more physical symptoms, tiredness and pain.  This difference appears around puberty, reversing the pattern of childhood.  By age 12-16 twice as many European girls as boys report frequent headaches (20-9%), nervousness (11-6%) and dizziness (10-2%) - the ‘psychosomatic’ problems which often indicate stress.

As with mortality, poorer women also suffer poorer health. There are marked differences across Europe, often clearly related to social change. For example, eastern Europeans report very poor health. Smoking may play a part here, together with job loss, food shortages, and pollution.

For women generally, smoking is linked with sickness absence from work, long-term illness and disability and poor reported health. The following sections summarize the impact of smoking on various systems.

Digestive system
Poor dental hygiene leads to gingivitis or gum disease.   But smoking prevents bleeding, the usual warning sign.  Periodontitis may follow, with risk of early tooth loss - smoking is an independent risk factor for this disease. A study of Finnish men suggests that smoking also increases risk of caries, proportional to the amount smoked. Dental teams have a role to play in promoting quit attempts, and checking for pre-cancerous lesions.

Other smoking-related disorders include heartburn, gastritis, and ulcers.  Stomach ulcer may be linked to impaired defense mechanisms among smokers, and duodenal ulcer to greater risk of helicobacter pylori infection.  Smoking also increases risk of colon polyps and Crohn’s disease, but nicotine itself seems to protect against ulcerative colitis.

Urinary system
Nicotine promotes water excretion, so water soluble vitamins including C and B-complex are lost, which may interest health-conscious women.  Urinary incontinence is a common and distressing problem for women, and risk is doubled among women smokers (RR 2.5). Nicotine causes bladder contractions, and cough may also increase risk.

Respiration
Smokers have increased cough and wheeze, and tolerate exercise poorly.  Asthma symptoms are made worse by smoking, or smoky air, and women are more affected than men. Respiratory infections including TB and flu are more frequent, and recovery slower.  A recent study showed four-fold risk of pneumonia among younger adult smokers. Smoking also increases risk of carrying bacteria linked to meningitis (RR 1.6).

Established lung conditions have a huge impact on daily life.  Risk is strongly linked to deprivation, and asthma among women shows a very strong link. Teenage smoking may also impair lung growth, which stops earlier in young women, again reducing lung function.

Circulation
Women smokers are prone to cold hands and feet, including severe symptoms linked to Raynaud’s disease.  Working and social life may be limited by problems such as cardiac angina, leg pain on exercise (intermittent claudication), and vasospastic disease, to which women are also more prone. Women who survive heart attack or stroke may suffer major disability, and perhaps adapt less well than men.

Sexual health  For detail see main section Sexual health
Period pain and abnormal discharge are more common among smokers. There is a greater risk of problems during pregnancy. Infertility, miscarriage or sudden infant death may obviously have huge emotional impact.   Smokers also reach menopause around 1-4 years earlier., and perhaps suffer more symptoms, such as hot flushes

Endocrine system
Women are five times as prone to over-active thyroid as men. Smoking is linked to the most common form, Grave’s disease, an auto-immune condition. Under-active thyroid is also more difficult to treat among women smokers. Insulin resistance is increased by smoking, with risk of diabetes up 50% for women smoking 25+ a day  (RR 1.5).  Diabetes has a major impact both on daily well-being and risk of circulatory damage. 

Movement
Tobacco use is associated with a range of painful and disabling conditions including:

Risk of hip fracture from menopause to age 85 is up by half among women smokers (19-12%). Research on female twins shows that smoking reduces lumbar density by 2% every 10 years, a significant change. Even teenage smokers have lower bone density, which suggests lower peak mass, and increased later risk.  Young women who are inactive and restrict dairy foods may be at most risk.

Skin
Smoking damages collagen and elastin, and reduces circulation, so there is early wrinkling and loss of skin tone. Smokers are also more prone to psoriasis, eczema and allergic skin reactions.

Senses and mental function
Women who smoke 25+ a day have double the risk of macular degeneration, the leading cause of poor vision over age 65 (RR 2.5). Smoking promotes development of cataract, and may increase risk of damage for contact lens users, who are mostly female. 

Smoking-related arterial damage nearly doubles risk of hearing loss for current smokers (RR 1.7), and noise-related deafness is more likely. Sense of smell and taste are also reduced, which could impair daily pleasure and safety, and possibly nutritional status.

There is no clear evidence that nicotine improves mental performance, apart from relief of withdrawal.   However, the evidence on dementia is hard to interpret. This is important, as the condition has huge impact on individuals and societies.  Vascular dementia is more common among smokers, but some research shows lower risk of Alzheimer’s.   For example one prospective study found 30% reduction linked to past or present nicotine use (RR 0.7). This effect may be weaker for women. And a recent study from Belgium and the Netherlands found increased risk of dementia, including Alzheimer’s, for smokers of a certain genetic type (RR 4.6, 2.4 in former smokers).

Coping with illness
Reduced immune function among smokers increases risk of infections and cancer. Wound healing is slower, and surgical complications more frequent. Medical treatment may be affected by poor response to drugs often used by women including tricyclic antidepressants, the analgesic dextro-propoxyphene, and theophylline. And in future more women may live longer with serious smoking-related conditions such as cancer, a challenge to all concerned.

Aging
Smoking creates high levels of ‘free radicals’. These increase the rate of oxidation and cell damage, which may be a key part of aging. Early wrinkling and grey hair suggest early aging among smokers.  For example, one small study found only women smokers had gone grey by age 40 (57%), with more than double the risk by age 50 (73-34%).

Emotional Well-being
Smoking obviously damages physical health, at least long term.  But many women see cigarettes as an important boost to everyday well-being.  Nearly half of British women smokers (44%) say this is their main source of pleasure. More subtly, smoking may seem to have positive social roles, for example in controlling social relations, creating image and identity, and providing predictable support.

Nearly all British teenage smokers (80%) believe that smoking keeps you calm. Among adult women poor psychological health is clearly linked to heavy smoking, with a clearer link than for men. Women generally have more depression and anxiety, with risk around double that for men.

Smoking has been linked to a range of distress including:

In these situations, substance use may act as self-medication.  But unlike alcohol abuse, smoking allows women to continue their roles.  This may be seen as socially useful, reducing motivation for political action.

Research on nicotine shows complex mood effects. For example, nicotine may lift mood - boosting dopamine, and increasing neurotransmitter levels in the same way as MAOI anti-depressants.  Depression is common after quitting, and strongly predicts relapse in younger women, especially those prone to depression.  Yet one study found that older women with symptoms of depression were four times as likely to stop as others. This effect was not seen in older men.

NRT offers major benefit to women smokers who are prone to depression or anxiety. Other anti-depressant therapies, including cognitive-behavioral therapy, may also benefit smokers in general. In particular the anti-depressant buproprion (Zyban) appears to at least double quit rates.

Other reviews suggest that nicotine simply relieves nicotine withdrawal.  One study of young people even indicates that smoking causes depression, but not the reverse. Experimental studies also give a complex picture, as mood effects depend on current mental state and type of external stress. There is a great need for clear and memorable health messages on mood and smoking, which neither deny nor over-simplify the reality.

Effects of quitting

Most non-fatal effects of tobacco use are reversible.  For example, after quitting:
However, there may be short-term physical symptoms, including worse cough, and digestive or sleep disorders.  Short-term mood disturbance is normal.  A range of studies have shown recent quitters as more depressed, angry, irritable, anxious, tense and impulsive.  Women are more likely to relapse in response to these symptoms.  But women who quit for several months benefit from lower stress levels, below those of continuing smokers and emotional well-being improves.

And on emotional health:

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