3.21 Health effects for younger smokers

Last updated: April 2015
Suggested citation: Letcher, T, Greenhalgh, EM & Winstanley, MH. 3.21 Health effects for younger smokers. In Scollo, MM and Winstanley, MH [editors]. Tobacco in Australia: Facts and issues. Melbourne: Cancer Council Victoria; 2015. Available from http://www.tobaccoinaustralia.org.au/3-21-health-effects-for-younger-smokers


Most of the risk of dying prematurely due to smoking is reversed if people quit smoking before the age of 30.1 However smoking during childhood and adolescence also causes a range of immediate health problems, as well as laying the foundation for the development of serious disease in adulthood.2

3.21.1 Early signs of addiction

There is contention around how best to characterise nicotine dependence in young people, with increasing recognition that it may be inappropriate to extend adult criteria to adolescent smokers. Recent research has also highlighted qualitative differences between adolescents and adults in their experiences of withdrawal; craving tends to be the predominant symptom that is experienced by young people during abstinence, while withdrawal symptoms are minimal.2 Nonetheless,  evidence shows that nicotine addiction can be developed rapidly by young people, with adolescent smokers reporting some symptoms of dependence at even low levels of cigarette consumption.3 The majority of people who begin to use tobacco products regularly have great trouble breaking this addiction.3 Factors influencing smoking behaviour in young people are discussed in Chapter 5. Research in Victoria tracking the smoking career of a large cohort of teenagers over a 10-year period has found a greater likelihood of substance abuse (especially cannabis dependence) and psychiatric illness in continuing smokers.4

3.21.2 Respiratory infections and exacerbation of asthma

Active smoking is associated with an increased risk for developing asthma and for exacerbating existing asthma in adolescents.5 Smoking also causes wheezing severe enough to be diagnosed as asthma in children and adolescents.2 Surveys among adolescent smokers (12–14 year olds) have found active smoking to be associated with asthma/wheezing and rhinitis,6,7 particularly in girls,7 and with asthma-related wheezing symptoms in 15–16 year old adolescents.8

Active smoking causes respiratory symptoms including shortness of breath, coughing, phlegm production and wheezing in children and adolescents.19 Even occasional smoking (on at least 5 days in the prior 30 days) has been found to be associated with shortness of breath/fatigue following regular activity in 18–24 year old college students,9 while regular smokers among this group were more likely than non-smokers to report having any cough or sore throat in the past 30 days.9 The prevalence of self-reported bronchitis symptoms (chronic cough and sputum production) among a cohort of 18–21 year old Finnish males was significantly higher among daily smokers than occasional smokers, and symptoms were significantly associated with smoking history.10

3.21.3 General health of young smokers

Young smokers are more likely to report suffering an overall diminished level of health compared with non-smokers.11 Recurrent headache has been associated with current smoking (daily and occasional) in Norwegian students aged 13–18 years,12 while among US students (grades 6 to 10), adolescent daily and experimental smokers were more likely than never smokers to report recurrent subjective health complaints such as headache and backache.13 Among a cohort of young US Navy recruits (average age 19.7 years at baseline), cigarette smoking was a prospective predictor of hospitalisation: data for more than 5000 young healthy female recruits from entry into the Navy for up to 7–8 years of service indicated that daily smokers had higher rates of hospitalisation for any reason and for musculoskeletal conditions.14 Daily smokers were also hospitalised for a significantly greater mean number of days compared with never smokers and other smokers (including experimental, occasional and former smokers), following adjustment for differences in time in service and socio-demographic variables.14

Evidence suggests other health effects among young people associated with current smoking; these include significantly reduced taste sensitivity and atrophic papillary structures compared with non-smokers (all male participants, mean age 24.9 years),15 as well as an association between an increase in some sleep disorders and current smoking in adolescents.16 For example, a study among about 29 000 Chinese adolescents aged 12–18 years found current smoking to be associated with increased snoring, difficulty breathing during sleep and difficulty maintaining sleep compared with never smokers.16

3.21.4 Fitness and lung function in young smokers

Young smokers tend to be less physically fit than their non-smoking peers, fitness declining with increasing levels of tobacco consumption.11 The cumulative effects of smoking from a young age on physical performance in midlife was assessed in a large British cohort study with data on smoking history from age 20 (median age at smoking initiation 16 years).17 Researchers found that at age 53, ever-smokers had significantly poorer overall physical performance, balance and chair rising than never smokers, with performance decreasing significantly for every 10 pack-years smoked.17

A study among a cohort of 18–21 year old Finnish males found levels of aerobic fitness to be significantly lower in regular smokers compared with non-smokers (after controlling for physical activity, education and body mass index) and fitness was associated with smoking history.10 A small study among a group of healthy young smokers (mean age 21.4 years) found that smoking was associated with resting and exercise tachycardia, demonstrating significant and acute negative effects on cardiac autonomic function due to smoking both at rest and during exercise. Results suggested that pre-exercise smoking of a single cigarette impaired physiological response to both peak and sub-maximal exercise; this may greatly increase vulnerability to myocardial electrical instability and therefore predispose to higher risk of cardiovascular events.18

3.21.5 Early signs of lung disease

Lung development is also altered by early tobacco use. Active smoking causes impaired lung growth during childhood and adolescence, and the early onset of lung function decline during late adolescence and early adulthood.19 Young smokers’ lungs stop growing earlier, they attain lower maximal lung function, they have a briefer plateau phase, and their lung function declines earlier. This reduced lung growth can increase the risk of chronic obstructive pulmonary disease later in life. Early quitting may therefore be particularly beneficial, to potentially avoid these effects on growing lungs.2

3.21.6 Early signs of cardiovascular disease

Cigarette smoking during adolescence and young adulthood begins the damaging processes that lead to cardiovascular disease.2 Damage to the circulatory system becomes evident in young smokers, and may become clinically significant in early adulthood.11 There is robust evidence demonstrating that smoking during adolescence and young adulthood increases the development of atherosclerosis. By early middle age, the more rapid progression of atherosclerosis and the rapid decline of lung function mentioned above lead to higher rates of coronary heart disease, stroke, and COPD. These diseases play a major role in the premature mortality of middle-aged and elderly smokers.2 While premenopausal women are typically relatively protected from heart disease compared with men and develop coronary heart disease 10 years later, smoking increases cardiovascular risk in young women and removes the protective effect of the premenopausal state; this is possibly caused by smoking disrupting the normal ovarian pattern of sympathetic nervous system activity.20

A study assessing the influence of smoking on blood biochemistry in male Taiwanese university students (mean age 19.4 years) found young smokers had significantly increased risk of several conditions associated with cardiovascular and haematological disorders, including hypertriglyceridaemia, neutrophilia and hyperchromia, compared with non-smokers.21 There is also evidence suggesting that even occasional smoking on a regular basis (<1 pack per week for at least 1 year) is associated with both acute and chronic impairment of arterial function (related to the development of atherosclerosis and future cardiovascular complications) in otherwise healthy young people (20–26 year olds).22 Similarly, a study on the effect of chronic smoking on arterial stiffness among young smokers (mean age 24.3 years) compared with non-smokers (mean age 20.2 years) found significantly higher arterial stiffness among smokers, suggesting that the negative effect of cigarette smoking on the vascular system may be apparent even in young smokers who have been smoking for fewer than 10 years.23 Arterial stiffness is an important factor in the development of a range of pathophysiological processes including atherosclerosis, left ventricular hypertrophy and aneurysm.23

Tobacco use among young men, particularly cigarette smoking, is strongly associated with thromboangiitis obliterans (Buerger's disease), a recurrent inflammatory, non-atherosclerotic vasoocclusive disease.24 Caused by vasculitis (inflammation of the blood vessels), Buerger's disease mostly affects males aged 20–40 (average age of symptom onset about 35 years) with a current or recent history of heavy smoking or chewing tobacco.25 Typically it involves progressive inflammation and thrombosis (clotting) of blood vessels of the hands and feet, and the development of ulcers and gangrene of extremities as a result of vascular ischaemia.26 Commonly necessitating amputation, major amputations (of limbs rather than fingers/toes) are almost twice as likely in patients who continue to smoke. Buerger's disease has also been documented to involve scrotal and penile necrosis resulting in partial penectomy and scrotal debridement.24 The only apparent therapeutic measure to slow or prevent disease progression is smoking cessation.27

Smoking has been identified as one of the major risk factors for hospital admission for acute coronary syndrome and more severe acute myocardial infarction (AMI) among Middle Eastern28 and Swedish29 populations, particularly among younger patients (≤40 years old,28; 25–<65 years old,29). A prospective study to evaluate the impact of smoking habits on long-term outcome in individuals who sustained AMI at the age of ≤35 years found that the most common risk factor at initial presentation was smoking.30 During follow-up (for up to 10 years) most patients (55.6%) reported continuing to smoke. One-third (32.6%) presented cardiac events during the follow-up period, including readmission for acute coronary syndrome, cardiac death or coronary revascularisation because of clinical deterioration. Continuation of smoking was the most significant predictor of cardiac events during follow-up.30

Smoking has also been found to be a determinant of isolated systolic hypertension among younger US adults (18–39 year olds); this is of concern because even small increases in systolic blood pressure in early adulthood increase risk of further cardiovascular disease (CVD) morbidity in later life.31 Studies of hypertension in young adults have found associations with structural changes in the heart including increases in left ventricular wall thickness, left ventricular mass and higher prevalence of left ventricular hypertrophy.31

Particular populations of young smokers may be at greater risk of experiencing tobacco-related adverse health effects, such as youth with chronic conditions because their health is already compromised.32 For example, people with diabetes mellitus are at increased risk of developing health problems such as CVD: a large US study among young people (10–22 years old) with diabetes mellitus found that current and past smokers were significantly more likely than non-smokers with the same condition to display cardiometabolic risk factors such as high triglyceride levels and to be physically inactive.32

Evidence suggests there is a strong dose–response relationship between cigarette smoking and ischemic stroke risk in younger women.33,34 For example, a population-based case–control study of risk factors in more than 1000 US women aged 15–49 years found that the OR for ischemic stroke risk comparing current smokers to never smokers was 2.6 (p<0.0001), after multivariable adjustment (including for age, race, education, hypertension, diabetes, body mass index, coronary heart disease, oral contraceptive use and elevated total cholesterol); the adjusted OR increased with increasing number of cigarettes smoked per day.33 No difference in stroke risk was observed between former smokers (those who had smoked more than 100 cigarettes in their lifetime, but had not smoked in the 30 days before their stroke) and never smokers.33 A prospective cohort study among more than 45 000 Swedish women aged 30–50 years (mean age 40 years) at time of enrolment found that, after an average of 11 years of follow-up, current smoking significantly increased the risk of stroke, particularly for ischemic stroke. There was a dose–response effect of current smoking on all strokes, with those smoking ≥10 cigarettes/day having a three-fold excess risk compared with never smokers. Similar risk patterns were observed using cumulative pack-years as an indicator of smoking exposure. Former smokers had a 60% increased risk for all strokes, which was of borderline statistical significance.34 The use of the oral contraceptive pill is a risk factor for stroke, and research among teenage girls (15–17 year olds) who have suffered stroke suggests its use has a negative synergistic effect with smoking, risk increasing with the number of cigarettes smoked.35

3.21.7 Dental health problems in young people

Smoking is also a major risk factor for poor periodontal health and oral cavity diseases36; about half of the periodontitis seen in those aged under 30 is thought to be linked to smoking.37 Daily smoking and infrequent tooth brushing (less than twice a day) among 14–18 year old Finnish adolescents have been found to be strongly associated.38 There is also evidence to suggest that among young males (20–25 years old), even moderate smoking of 10 cigarettes per day induces variations of salivary lipid pattern.36 The regulation of salivary lipid levels is important in the maintenance of oral cavity health: elevated lipid levels are associated with an increase of caries incidence, plaque development, calculus formation and periodontal disease.36

3.21.8 Muscular skeletal problems in young people

While considerable evidence associates tobacco use with low bone mass and increased fracture risk in older people,39,40 research has emerged more recently linking smoking at a young age with unfavourable bone geometry and density, reduction in peak bone mass and increased fracture prevalence.41,42 A cross-sectional population-based study among 677 healthy male Belgian siblings at the age of peak bone mass (aged 25–45 years, mean age 33.4–35.7 years) found that those who took up smoking at an early age (16 years old or younger) had lower areal bone mineral density (aBMD), lower cortical bone area at the tibia and lower trabecular and cortical bone density at the radius compared with current and never smokers.41 There were significant negative associations between number of pack-years smoked and lumbar spine, hip and total body aBMD, as well as total body bone mineral content. In addition, self-reported fractures were significantly more prevalent in early and current smokers, after adjustment for age, weight, education and alcohol use, and exclusion of childhood fractures.41 It has been suggested this may be caused by smoking disrupting the acquisition of peak bone mass during puberty, possibly due to an interaction with sex steroid action.41

Similarly, in a large population-based study of more than 1000 young Swedish men (mean age 18.9 years), significantly lower aBMD of the total body, lumbar spine, femoral neck, and trochanter was found among current smokers (at least one cigarette per day) compared with non-smokers.42 The magnitude of observed differences was considerable, including a mean difference of 3.3% in the spine and 5% in the trochanter after adjusting for age, height, weight, calcium intake and physical activity. Volumetric BMD (vBMD) and bone size were also measured: smokers had lower cortical thickness than non-smokers of both the radius and tibia. The authors suggest that the effects of smoking on bone mass may occur quite rapidly, because the mean duration of smoking in this study was 4.1 years.42

3.21.9 Other health problems, younger smokers

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15. Pavlos P, Vasilios N, Antonia A, Dimitrios K, Georgios K and Georgios A. Evaluation of young smokers and non-smokers with electrogustometry and contact endoscopy. BMC Ear, Nose and Throat Disorders 2009;9(9):1-7. Available from: http://www.biomedcentral.com/content/pdf/1472-6815-9-9.pdf

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