BRITISHMEDICALJOURNALVOLUME2912128DECEMBER19851761TABLEiSmokersfaceandstateofsmokingNonPastCurrentsmokerssmokerssmokersAverageAverageAverageageageageNoyearsNoyearsNoyearsSmokersfacepresent3 ID: 451044
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BRITISHMEDICALJOURNALVOLUME29121-28DECEMBER1985Smoker'sface:anunderratedclinicalsign?DOUGLASMODELAbstractInaprospectivesurveyofpatientsattendingageneralmedicaloutpatientclinicroughlyhalfthecurrentcigarettesmokerswhohadsmokedfor10yearsormorewereidentified,usingdefinedcriteria,bytheirfacialfeaturesalone.Thesefacialfeatures,designated"smoker'sface,"werepresentinthree(8%)ofthosewhohadsmokedcigarettesfor10yearsormoreinthepastandinnoneofthenon-smokers.Theassociationofsmoker'sfacewithcurrentsmokingthathadcontinuedfor10yearsormorewassignificant(p)andremainedafterthepatient'sage,socialclass,exposuretosunlight,recentchangeofweight,andesti-matedlifetimeconsumptionofcigaretteswerecontrolledfor.Smoker'sfacemaybeahelpfulindicatorinantismokingcam-'paigns.IntroductionArelationbetweensmokingandthecomplexionwasfirstsuggestedasearlyas1856.'AlthoughDaniellpointedoutthatarelationbetweencigarettesmokingandwrinklingoftheface"canbereadilyconfirmedbyinterested,eventhoughuntrained,observers,"?sucharelationisnotgenerallyacknowledgedasaphysicalsignandisnotmentionedinanyofthelargestandardtextbooksofmedicine,'-6textbooksofphysicalsigns,orpublicationsaboutmorphologyandsmoking,Ismokingandhealth,9-"'orsmokingandaging.Indeedtodatetherehavebeenonlythreestudiesexploringapossiblerelationbetweencigarettesmokingandwrinklingorotherchangesinthecomplexionoftheface.In1965IppenandIppenreportedsucharelationinGermanwomen."SubsequentlyinamuchlargerstudyfromCaliforniaDaniellreportedasimilarrelationinbothmenandwomen.LaterAllenetalchallengedDaniell'sfindings,"but,asWeisspointedout,whenproperlyinterpretedAllenetal'sdataactuallysupportDaniell'sclaim.'4Havingindependentlyformedtheimpressionthatinsomepeoplecigarettesmokingchangesthefacialfeatures,Icarriedoutaprospectivesurveytotestthehypothesisthatinmiddleagemanycigarettesmokerscanbedifferentiatedfromnon-smokersbytheirfacialfeatures.StudypopulationandmethodsThesurveyincludedallnewpatientsaged35-69attendingageneralmedicaloutpatientclinicattwohospitals.Youngerandolderpeoplewereexcludedasapreliminarysurveyshowedthatsomeyearsarerequiredforthecharacteristicsunderconsiderationtodevelop,whileinthoseagedover70thechangesbeingstudiedtendtoblurwiththoseduetoaging.BeforeIconsideredtheclinicalproblemforwhichtheyhadbeenreferred,asthepatientssatinthewaitingareaoftheclinictheyweretoldthatasurveywasbeingconducted,wereaskedtocooperate,andwerethenaskedbyamedicalstudentabouttheirage,dietaryandsmokinghabits,alcoholintake,occupation,andanyrecentchangeinweight.Thentheywereshownintothesurveyroom.Sothatinformationshouldbeobtainedonlyfromtheirfacesandnotfromanyodouroftobaccoorstainingofthefingersfromnicotine,subjectswereassessedindaylightatafixeddistanceof15mwithonlytheirheadsandnecksvisible.Icategorisedthefeaturesofthepatient'sface,andthedecisionwasnotedonthesurveysheetwithoutanyknowledgeoftheinformationgatheredbythestudentotherthanthepatient'sage.Onthebasisoftheiroccupationpatientsweredividedintonon-manualandmanualsocialclassesaccordingtotheRegistrarGeneral'sclassificationofoccupations1980.Subsequently,apostalsurveywascarriedouttocollectinformationaboutexposuretosunlight.Theinformationgatheredinthiswaywascategorisedwithoutknowledgeoftheresultsofthemainpartofthesurvey.Considerableexposuretothesunwasdefinedaslivinginasunnyclimatefor10ormoreyears,livingforthreeormoremonthsinasunnyclimateonatleast10occasions,orgardeningorpursuingsomeotheroutdoorpastimesuchasfishingforatleasteighthoursaweekforthreemonthsormoreayearoveratleast10years.DEFINITIONSOFSTATEOFSMOKINGAnon-smokerwasonewhosmokedfewerthan10cigarettesorlessthan14gtobaccoaweekorhadsmokedforlessthan10years,orboth.Acurrentsmokerwasonewhowithinthepastyearhadsmoked10ormorecigarettesor14gormoretobaccoaweekandhadsmokedfor10yearsormore.Apastsmokerwasonewhohadnotsmokedwithinthepastyearbuthadsmoked10ormorecigarettesor14gormoretobaccoaweekfor10yearsormorebeforethat.EFFECTSOFSMOKINGONTHEFACEPatientsweredividedintotwogroups;thosewithsmoker'sfaceandthosewithoutsmoker'sface.Smoker'sfacewasdefinedasoneormoreofthefollowing:(a)linesorwrinklesontheface,typicallyradiatingatrightanglesfromtheupperandlowerlipsorcornersoftheeyes,deeplinesonthecheeks,ornumerousshallowlinesonthecheeksandlowerjaw.(b)Asubtlegauntnessofthefacialfeatureswithprominenceoftheunderlyingbonycontours.Fullydevelopedthischangegivesthefacean"atherosclerotic"look;lesserchangesshowasslightsinkingofthecheeks.Insomecasesthesechangesareassociatedwithaleathery,worn,orruggedappearance.(c)Anatrophic,slightlypigmentedgreyappearanceoftheskin.(d)Aplethoric,slightlyorange,purple,andredcomplexiondifferentfromthepurplybluecolourofcyanosisorthebloatedappearanceassociatedwiththepseudo-Cushing'schangesofalcoholism.Thedifferenceinthenumberofpatientswithsmoker'sfacebetweenthecurrentsmokinggroupandthenon-smokinggroupwasanalysedbythex2test.Toexaminethepossibilitythatsmoker'sfacewasrelatedtosmokingviaanintermediatefactorIalsoanalysedtheresultsbycontrollingforthefollowing:patient'sage,socialclass,exposuretosunlight,recentchangeinweight,andestimatedlifetimeconsumptionofcigarettes.ResultsIsurveyed122patients.WiththeexceptionofoneAsianman,allwerewhite.Sixwereexcludedaseitherpipeorcigarsmokers.Theanalysisthereforeconcernedtheremaining116patients,ofwhom41werecurrentcigarettesmokers,37pastsmokers,and38non-smokers.Noneofthepatientswasbeingtreatedforanydermatologicalconditionoftheface.TableIshowsthatsmoker'sfacewaspresentin19(46%)currentsmokers,threepastsmokers,andnoneofthenon-smokers.Theassociationofsmoker'sfacewithcurrentcigarettesmokingwashighlysignificant(X2=23,po1).Mostpatientswithsmoker'sfaceweremen;17ofthe28menandonlytwoofthe13womenwhocurrentlysmokedcigarettes.Amongthementheassociationofsmoker'sfacewithcurrentsmokingwashighlysignificant(x2=18,p)Theaverageagesofthecurrentsmokerswithandwithoutsmoker'sfaceweresimilar-thatis,538and520years,respectively.Severalpatientswithsmoker'sfacewerefairlyyoung:ofthe15currentsmokersagedlessthan50years,fivehadsmoker'sface.Thethreepastsmokerswithsmoker'sfacehadstoppedsmokingtwo,five,andeightyearspreviously.Informationaboutexposuretothesunwasavailablefor108subjects.TableIIshowsthatneithersocialclassnorexposuretothesunaccountedfortherelationbetweensmokinghabitsandsmoker'sface.Norwassmoker'sDepartmentofMedicine,DistrictGeneralHospital,EastbourneBN212UDDOUGLASMODEL,MRCP,consultantphysician1760 BRITISHMEDICALJOURNALVOLUME29121-28DECEMBER19851761TABLEi-Smoker'sfaceandstateofsmokingNon-PastCurrentsmokerssmokerssmokersAverageAverageAverageageageageNo(years)No(years)No(years)Smoker'sfacepresent3*60-01953-8Smoker'sfaceabsent3854-83461-12252-0Total383741*Twowomen,oneman.TABLEiI-Exposuretothesun,socialclass,andsmoker'sfaceincurrentcigarettesmokersandnon-smokersNo(%)ofsmokersNo(%)ofnon-smokerswithsmoker'sfacewithoutsmoker'sfaceNon-manualclass7(47)27(100)Manualclass12(46)11(100)Exposedtosun12(52)20(100)*Notexposedtosun7(39)16�1005**Informationnotavailableontwopatientsinthesegroups.facerelatedtoarecentchangeinweightortothenumberofcigarettessmokedinthepatient'slifetime,roughlyestimatedasthenumberofcigarettescurrentlysmokedadaytimesthenumberofyearsofsmoking.Thusamongthe19currentsmokerswithsmoker'sface13hadsteadyweightandtwowereheavierandfourlighterthanayearbefore.Similarly,althoughtheestimatedlifetimeconsumptionofcigarettesamongthesmokerswithsmoker'sface(mean669(SD376)cigaretteyears)wasslightlygreaterthanthatamongthosewithoutsmoker'sface(mean542(363)cigaretteyears),thedifferencewasnotsignificant.ThediagnosesamongthepatientswerevariedasmightbeexpectedinaSmokers'faces:answersNon-smokerSmokerSmoker67yearoldwoman52vearoldman;46yearoldman;301oztobacco:cigarettes/davfor38weekfor34yearsvearsABCNon-smokerNon-smokerSmokerDavidSimpson,65yearoldwomanWilliamHolden,filmdirectorofActionactoronSmokingandHealthDEFSmokerSmokerNon-smoker62yearoldwoman;20WynstanHugh54yearoldwomancigarettes/dayfor40Auden,poetyearsGHIgeneralmedicaloutpatientclinic.Noassociationwasevidentbetweensmoker'sfaceanddiseaseseitherrelated(eightcases)orunrelated(14cases)tosmoking.DiscussionThissurveyconfirmsthefindingsofIppenandIppen'2andDaniell2thatcigarettesmokingcausesreadilyrecognisablewrink-lingandotherchangestothefacesofmanypeople.Daniell'slargestudy,however,wasmainlyconcernedwithgradingthedegreeoffacialwrinklingforthewholeofhisstudypopulationandrelatingthevariousgradestothenumberofcigarettessmokedaday.Bycontrastthisstudywasconcernedwithidentifyingonlythesubgroupofpeoplewithinapopulationwhofulfilthedefinedcriteriaofaclinicalsignallowingthemtobepickedoutascigarettesmokers.Perhapsthereasonsthatthesechangeshavenotbeenmoregenerallyassociatedwithsmokingisthatsmoker'sfaceisfairlycommonandhasbeenacceptedaspartofthenormalappearanceoftheface.Onepossiblecriticismofthisworkisthatassessingfacesinthiswayisnecessarilysubjective.Similarsubjectivelimitations,how-ever,areacceptedintheassessmentofphysicalsignssuchashypothyroidfacies,depressionasanexpressionoftheface,cyanosis,anaemia,andclubbingofthefingernails.Moreover,justasDaniellfoundthatchildrencanlearntorecognisesmoker'sface,Ifoundthatnursesandmedicalstudentsquicklylearntorecognisethesign,whichconfirmsthatitreallyexists.Theresultsreportedherewereobtainedinpatientsattendingageneralmedicaloutpatientclinicinthe-southeastofEngland.Twoimportantqualificationsresultfromthis.Thefirstisthatsuchagroupofpeopleishighlyselected,andthattheprevalenceofsmoker'sfacegenerallymaybedifferentfromthatreportedhere.Thus,althoughsmoker'sfacewasfoundinsubjectsfromallsocialclasses,thenumberswithineachgroupweretoosmalltoestimateitsprevalenceinsmokersfromeachclass.Similarly,becauseonlyonepersoninthesurveywasnotwhiteitwasnotpossibletocommentontheobservationofAllenetalthatregardlessofwhetherornottheysmokewrinklingdoesnotoccurinblackAmericans.'"Thesecondqualificationisthatthissurveywasconductedinacool,temperateclimatewherethepowerofthesunisfairlyweak.Inotherpartsoftheworldwhererace,exposuretothesun,andnutritionaredifferent,thecriteriaforsmoker'sfacemayberatherdifferentasitisgenerallyagreedthatsunlightdamagestheskinofwhitepeople.'ThusDaniell,reportingfromsunnyCalifornia,foundthatsmokingandexposuretothesuneachseparatelycausedwrinklingofthefaceandthattogethertheyhadaconsiderablygreatereffect.2Twopossibleexplanationsarisefortheobservationthatsofewpastsmokershadsmoker'sface:eithertheyhadhadsmoker'sfaceandithaddisappearedwhentheystoppedsmokingortheyweresmokerswhohadneverhadsmoker'sface.Alongitudinalsurveyofpeoplewhostopsmokingwouldberequiredtodecidethispoint.Likewise,afurtherstudywouldbenecessarytoinvestigatemyimpressionthatobesitytendstoobscuresmoker'sface,presumablybystretchingandfillingoutlinesonthefaceandalsofillingoutthecheeks.Conceivablyitwasbecauseofweightgainthatsofewpastsmokershadsmoker'sface.Inthissurveyonlyfourpeopleadmittedtohaving25ormorealcoholicdrinksaweek,andonlyoneofthesewasacurrentsmokerwithsmoker'sface.Hisfacewaslinedratherthanplethoric.Itthereforeseemsunlikelythatsmoker'sfacewasconfusedwiththeplethoraofalcoholism.Howdoessmokingbringabouttheobservedchanges?Insomewayssmoker'sfaceresemblesanagingprocess,butontheotherhand,thesimilarityintheaverageagesofthecurrentsmokerswithandwithoutsmoker'sfaceandthefactthatsomanyofthepeoplewithsmoker'sfacewerefairlyyoungindicatethatsmoker'sfaceisnotsimplyasymptomofage.Thechangesinthecolourandqualityoftheskinsuggestatoxicprocess.RecentlyKlempetalandReusetalshowedthatsmokingreducesthecirculationtotheskininman'6andnudemice'7respectively.Perhapsbiochemicalandhisto-logicalinvestigationswouldelucidateotherchanges.Likewisethecontributionofanygeneticfactorwouldneedfurtherinvestigation. 1762BRITISHMEDICALJOURNALVOLUME29121-28DECEMBER1985Althoughthedevelopmentofnoticeablelinesonthefaceisusuallyassociatedwithsmoking,thisisnotalwaysso.Althoughnosuchpersonswereencounteredduringthissurvey,non-smokersareoccasionallyencounteredwithlinedfacessuggestiveofsmoker'sface.Thesepeopletendtobewomenandalthoughtheirfacesarelined,theircomplexionsareusuallysufficientlycleartosuggestthatinfacttheyareeithernon-smokersorpastsmokers.Apartfrombeingclinicallyimportantinthedocumentationofapatientthefactthatsmokingcanaffectthefacesoprofoundlyisimportantbecauseitissoreadilyappreciatedbypatientsthem-selves.Inmyexperiencemanypeoplenoticetheravagesofsmokingforthefirsttimewhenitispointedouttothemthattheycanbeidentifiedassmokersbytheirfacesalone.Properlyexplainedandperhapssupportedbypostersbearingphotographicexamples,theconceptofsmoker'sfacemightbehelpfulinantismokingcampaigns.IthankMrRichardWilkinson,UniversityofSussex,forstatisticaladviceandhelpwiththemanuscript,MrsMKinnearforsecretarialhelp,andmedicalstudentsMr0RSaguil,MrRTasharofi,andMrFHamatiforhelpwithcollectionofthedata.ReferencesSollvS.Clinicallecturesonparalvsis.Lancet1856;ii:641-3.2DaniellHW.Smoker'swrinkles:astudvintheepidemiologyof"crow'sfeet."AnnInternMed1971-;75:873-80.3CecilRL.Textbookofmedicine.16thed.Philadelphia:WBSaunders,1982.4HartFD,ed.French'sltndexofdifferentialdiagnzosis.IIthed.Bristol:JohnWrightandSons,1979.5IsselbacherKJ,ed.Harmson'spnnciplesof-internalmeditine.10thed.NewYork:McGraw-HillBookCompany,1983.6WeatherallDJ,LedinghamJGG,WarrellDA,eds.Oxfordtextbooksfjmedictne.Oxford:OxfordUniversityPress,1983.7OgilvieC.Chamberlain'srvmptomsandsignsinclinicalmedtcine.Bristol:JohnWrightandSons,1980.8SeltzerCC.Morphologicalconstitutionandsmoking.ArchEnvironlHealth.1968;17:143-7.9SurgeonGeneral.Smokingandhealth:areportsfthesurgeongeneral.Washington:USDepartmcntofHealth,EducationandWelfare,1979.10RoyalCollegeofPhysicians.Smokingorhealth.London:Pitman,1983.IIBosseR,RoseCL.Smokingandageing.Lexington:LexingtonBooks,1984.12IppenM,IppenH.Approachestoaprophylaxisofskinageing.7ournaloftheSocietvofCosmeticChemists1%5;16:305-8.13AllenHB,JohnsonBL,DiamondSM.Smoker'swrinkles?3'AMA1973;225:1067-9.14WeissW.Smoker'swrinkles.J4MA1973;226:788.15KligmanAM.Earlydestructiveeffectofsunlightonhumanskin.JAMA1969;210:2377-80.16KlempP,StabergB,ThomsenK.Skincirculationinregularsmokers.UgeskrLeger1982;144:1604-6.17ReusWF,RobsonMC,ZacharyL,HeggersJP.Acuteeffectsoftobaccosmokingonbloodflowinthecutaneousmicro-circulation.BrJPlastSurg1984;37:213-5.(Ac-eptedlOjudv1985)DISHatMertonPriory:evidencefora"new"occupationaldisease?TONYWALDRONDisseminatedidiopathicskeletalhyperostosis(DISH)isadiseaseofconsiderableantiquity';itrarelydeclaresitsprese'ncetotheclinicianbeforethepatientisaged40butthereafterbecomesincreasinglyprevalentsothataftertheageof70about10%ofmenand7%ofwomencanbefoundwiththecondition.2Ipresentheresomeevidencetosuggestthatintimespastthediseasewasparticularlycommonamongthosefollowingareligiouslifeandquestionwhetheritmighthavebeenrelatedinparttothatoccupation.TheclinicalmaterialthatformsthebasisofthestudycomesfromMertonPrioryinSurrey.ThiswasoneoftheearliestoftheAugustinianhouses,foundedin1140;itsharedinthecommonfateofthemonasteriesduringthereignofHenryVIIIandwasdissolvedanddemolishedin1540.Thesitewasusedmuchlaterforindustrialpurposes:acalicobleachingtrenchwasdugacrossitinthelatterpartoftheeighteenthcenturyandLiberty'susedpartofthesitefordyingmaterialinthenineteenth.In1868arailwaylinewasbuiltacrossthechapterhouse.Itwasremovedin1975,andthesitewasexcavatedbetween1976and1978;mostoftheareaisnowoccupiedbyindustrialunits.DiscoveriesatMertonPrioryDuringtheexcavationsskeletonswererecoveredfromwithinthechapterhouseandfromthecanon'scemeterytotheeastofthechapterhouse.Therewasatotalof35moreorlesscompleteburials,butsomeofthegravescontainedsmallnumbersofintrusivebones(alegacyofthemanydisturbancesthatthesitehadsuffered),andinonecasetherewereclearlytwoburialswithinonegrave.Whereverpossibletheintrusiveboneswerematchedtotheappropriateskeleton,afterwhichitbecameapparentthatthebonesfromatLondonSchoolofHygieneandTropicalMedicine,LondonWC1E7HTTONYWALDRON,MB,MRCP,seniorlecturerinoccupationalmedicineleastsevenbodieswerepresentinadditiontothe35burials.Therewasevidence,therefore,foratleast42peoplemostofwhomshouldhavebeenpriors,althoughthiswascertainlynotthecasefortheonefemaleskeletonpresent.Shewaspresumablyabenefactressofthepriorywhohadwishedtobeburiedwithinitsconfines.Amongtheburialsthreewerefoundwithchangesconsistentwithspinalhyperostosis(fig1).EachoftheseskeletonsalsoshowedextraspinallesionsofthetypenotedbyResnicketaloftentoaccompanythelesionsinthespine.4Therewereeightotherburialsinwhichextraspinalhyperostoseswerepresent.InthreeofthesetheFigIFig2FIG1-LateralviewoffusedthoracicvertebraefromMertonPriory.Hyperos-losesareseenonrighthandside.FIG2-AnteriorviewoffusedthoracicvertebraefromMertonPriorv.Bodiesofvertebraeareextensivelyfused;therearenoexostoses.