JMIR J Med Internet Res Journal of Medical Internet Research 1438-8871 JMIR Publications Toronto, Canada v19i9e326 28935619 10.2196/jmir.8743 Viewpoint Viewpoint A Dermatologist's Ammunition in the War Against Smoking: A Photoaging App Eysenbach Gunther Burford Oksana Langley Tessa Brinker Titus Josef MD 1
Department of Dermatology and National Center for Tumor Diseases (NCT) University of Heidelberg Im Neuenheimer Feld 440/460 Heidelberg, Germany 49 151 7508 4347 titus.brinker@gmail.com
2 3 http://orcid.org/0000-0002-3620-5919 Enk Alexander MD 1 http://orcid.org/0000-0002-7358-185X Gatzka Martina MD 4 http://orcid.org/0000-0001-6520-9794 Nakamura Yasuhiro MD 5 http://orcid.org/0000-0002-3664-5818 Sondermann Wiebke MD 2 3 6 http://orcid.org/0000-0002-3684-3523 Omlor Albert Joachim MD 7 http://orcid.org/0000-0002-0030-9468 Petri Maximilian Philip MD 2 3 6 http://orcid.org/0000-0001-8257-9316 Karoglan Ante MD 8 http://orcid.org/0000-0002-6100-5927 Seeger Werner MD, PhD 9 http://orcid.org/0000-0003-1946-0894 Klode Joachim MD, PhD 2 3 6 http://orcid.org/0000-0001-9239-7014 von Kalle Christof MD 10 11 12 http://orcid.org/0000-0001-9221-3297 Schadendorf Dirk MD, PhD 2 3 6 http://orcid.org/0000-0003-3524-7858 1 Department of Dermatology and National Center for Tumor Diseases (NCT) University Hospital Heidelberg University of Heidelberg Heidelberg Germany 2 Department of Dermatology, Venereology and Allergology University-Hospital Essen University of Duisburg-Essen Essen Germany 3 German Cancer Consortium Heidelberg Germany 4 Department of Dermatology and Allergic Diseases University of Ulm Ulm Germany 5 Department of Skin Oncology/Dermatology Saitama Medical University International Medical Center Saitama Japan 6 West German Cancer Center University of Duisburg-Essen Essen Germany 7 Department of Experimental Pneumology and Allergology Saarland University Faculty of Medicine Homburg Germany 8 Department of Dermatology University Hospital Magdeburg University of Magdeburg Magdeburg Germany 9 Department of Internal Medicine Universities of Giessen and Marburg Lung Center; Member of the German Center for Lung Research Justus-Liebig-University of Giessen Gießen Germany 10 National Center for Tumor Diseases (NCT) University of Heidelberg Heidelberg Germany 11 Heidelberg Center for Personalized Oncology (DKFZ-HIPO) Heidelberg Germany 12 German Cancer Research Center (DKFZ) and German Cancer Consortium (DKTK) Division of Translational Oncology University of Heidelberg Heidelberg Germany Corresponding Author: Titus Josef Brinker titus.brinker@gmail.com 092017 21 09 2017 19 9 e326 14 8 2017 30 8 2017 30 8 2017 30 8 2017 ©Titus Josef Brinker, Alexander Enk, Martina Gatzka, Yasuhiro Nakamura, Wiebke Sondermann, Albert Joachim Omlor, Maximilian Philip Petri, Ante Karoglan, Werner Seeger, Joachim Klode, Christof von Kalle, Dirk Schadendorf. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 21.09.2017. 2017

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This viewpoint reviews the perspectives for dermatology as a specialty to go beyond the substantial impact of smoking on skin disease and leverage the impact of skin changes on a person's self-concept and behavior in the design of effective interventions for smoking prevention and cessation.

 dermatology smoking apps photoaging face skin tobacco tobacco cessation tobacco prevention

Most smokers start smoking during their early adolescence, often with the idea that smoking is glamorous; the problems related to impaired wound healing, erectile dysfunction, and oral cancers are too far in the future to fathom. In contrast, for the majority of teenagers, attractiveness is the most important predictor of their own self-esteem [1].

Interventions focusing on the negative dermatologic changes due to smoking have been effective in altering behavior, both in adolescence [2-4] and young adulthood [5,6]. Skin damage due to smoking that is culturally associated with a decrease in attractiveness (ie, wrinkles, early hair loss, declined capillary perfusion, pale or grayish skin [7-9]) predominantly affects the self-concept of young people with low education [1], who are at significantly greater risk for tobacco addiction [10-12] and benefit the most from abstinence [13]. After reviewing the evidence regarding facial changes due to smoking on PubMed, we designed Figure 1 in order to extrapolate the typical appearance of a smoker’s face as frequently seen and noted by dermatologists.

Normal aging versus effects of smoking a pack a day for 15 years.

First steps have been taken to disseminate this dermatologic knowledge on irreversible aesthetic damage to the target groups and measure its effectiveness in randomized trials (ie, via the free photoaging app Smokerface, in which a selfie is altered to predict future appearance) in Germany [3,4,14,15] and Brazil [16] with a total of more than 150,000 downloads. In addition, photoaging desktop-based interventions in France [6], Switzerland [2], and Australia [5] showed promising results that justify definitive randomized trials. The relevance of skin-based appearance for individual behavior was also confirmed in the setting of skin cancer prevention [4,17-21].

Dermatology as an interdisciplinary specialty needs to go beyond the substantial impact of smoking on skin disease [22,23] and leverage the impact of skin changes on a person’s self-concept [1] and behavior [5] in the design of effective interventions for the largest cause of preventable death and disease in the western world [24]. Future dermatologic research should focus on developing, evaluating, and optimizing new ways to implement the specialty’s superior ammunition in the war against smoking.

Baudson T Weber K Freund PA More than only skin deep: appearance self-concept predicts most of secondary school students' self-esteem Front Psychol 2016 7 1568 10.3389/fpsyg.2016.01568 27803681 PMC5067372 Weiss C Hanebuth D Coda P Dratva J Heintz M Stutz EZ Aging images as a motivational trigger for smoking cessation in young women Int J Environ Res Public Health 2010 12 7 9 3499 3512 10.3390/ijerph7093499 20948939 ijerph7093499 PMC2954560 Brinker T Owczarek A Seeger W Groneberg D Brieske C Jansen P Klode J Stoffels I Schadendorf D Izar B Fries FN Hofmann FJ A medical student-delivered smoking prevention program, education against tobacco, for secondary schools in Germany: randomized controlled trial J Med Internet Res 2017 06 06 19 6 e199 10.2196/jmir.7906 28588007 v19i6e199 PMC5478798 Brinker TJ Seeger W Buslaff F Photoaging mobile apps in school-based tobacco prevention: the mirroring approach J Med Internet Res 2016 06 28 18 6 e183 10.2196/jmir.6016 27352819 v18i6e183 PMC4942683 Burford O Jiwa M Carter O Parsons R Hendrie D Internet-based photoaging within Australian pharmacies to promote smoking cessation: randomized controlled trial J Med Internet Res 2013 03 26 15 3 e64 10.2196/jmir.2337 23531984 v15i3e64 PMC3636310 Burford O Kindarji S Parsons R Falcoff H Using visual demonstrations in young adults to promote smoking cessation: preliminary findings from a French pilot study Res Social Adm Pharm 2017 05 04 1 10.1016/j.sapharm.2017.04.050 28495124 S1551-7411(17)30427-8 Okada H 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 11 132 5 1085 1092 10.1097/PRS.0b013e3182a4c20a 23924651 Dupati A Helfrich YR Effect of cigarette smoking on skin aging Expert Rev Dermatol 2009 4 4 371 378 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 08 17 4 178 183 11499540 Cutler DM Lleras-Muney A Understanding differences in health behaviors by education J Health Econ 2010 01 29 1 1 28 10.1016/j.jhealeco.2009.10.003 19963292 S0167-6296(09)00114-3 PMC2824018 Hoebel J Kuntz B Kroll L Finger J Zeiher J Lange C Lampert T Trends in absolute and relative educational inequalities in adult smoking since the early 2000s: the case of Germany Nicotine Tob Res 2017 04 18 1 10.1093/ntr/ntx087 28431153 3738714 Kuntz B Lampert T Smoking and passive smoke exposure among adolescents in Germany: prevalence, trends over time, and differences between social groups Dtsch Arztebl Int 2016 113 3 23 30 Doll R Peto R Boreham J Sutherland I Mortality in relation to smoking: 50 years' observations on male British doctors BMJ 2004 328 7455 50 Brinker TJ Holzapfel J Baudson TG Sies K Jakob L Baumert HM Heckl M Cirac A Suhre JL Mathes V Fries FN Spielmann H Rigotti N Seeger W Herth F Groneberg DA Raupach T Gall H Bauer C Marek P Batra A Harrison CH Taha L Owczarek A Hofmann FJ Thomas R Mons U Kreuter M Photoaging smartphone app promoting poster campaign to reduce smoking prevalence in secondary schools: the Smokerface Randomized Trial: design and baseline characteristics BMJ Open 2016 11 07 6 11 e014288 10.1136/bmjopen-2016-014288 27821601 bmjopen-2016-014288 PMC5128772 Brinker T Seeger W Photoaging mobile apps: a novel opportunity for smoking cessation? J Med Internet Res 2015 17 7 e186 Xavier L Bernardes-Souza B Lisboa O Seeger W Groneberg D Tran T Fries F A medical student-delivered smoking prevention program, Education Against Tobacco, for secondary schools in Brazil: study protocol for a randomized trial JMIR Research Protocols 2017 2017 6 1 e16 Brinker TJ Schadendorf D Klode J Cosgarea I Rösch A Jansen P Stoffels I Izar B Photoaging mobile apps as a novel opportunity for melanoma prevention: pilot study JMIR Mhealth Uhealth 2017 07 26 5 7 e101 10.2196/mhealth.8231 28747297 v5i7e101 PMC5550737 Olson AL Gaffney CA Starr P Dietrich AJ The impact of an appearance-based educational intervention on adolescent intention to use sunscreen Health Educ Res 2008 10 23 5 763 769 10.1093/her/cym005 18039727 cym005 PMC2733802 Owen A Grogan S Clark-Carter D Effects of an appearance-focussed versus a health-focussed intervention on men's attitudes towards UV exposure Int J Men Health 2016 15 1 34 Tuong W Armstrong AW Effect of appearance-based education compared with health-based education on sunscreen use and knowledge: a randomized controlled trial J Am Acad Dermatol 2014 70 4 665 669 24508292 Brinker T Brieske Christian Martin Schaefer Christoph Matthias Buslaff Fabian Gatzka Martina Petri Maximilian Philip Sondermann Wiebke Schadendorf Dirk Stoffels Ingo Klode Joachim Photoaging Mobile Apps in School-Based Melanoma Prevention: Pilot Study J Med Internet Res 2017 09 08 19 9 e319 10.2196/jmir.8661 28887295 v19i9e319 Ortiz A Grando SA Smoking and the skin Int J Dermatol 2012 03 51 3 250 262 10.1111/j.1365-4632.2011.05205.x 22348557 Dusingize J Olsen C Pandeya N Subramaniam P Thompson B Neale R Green A Whiteman D Cigarette smoking and the risks of basal cell carcinoma and squamous cell carcinoma J Invest Dermatol 2017 08 137 8 1700 1708 10.1016/j.jid.2017.03.027 28414022 S0022-202X(17)31412-4 GBD 2015 Tobacco Collaborators Smoking prevalence and attributable disease burden in 195 countries and territories, 1990-2015: a systematic analysis from the Global Burden of Disease Study 2015 Lancet 2017 05 13 389 10082 1885 1906 10.1016/S0140-6736(17)30819-X 28390697 S0140-6736(17)30819-X PMC5439023