Smoking, vaping and waterpipe: why people continue and what they really do to the body

Everyone knows the risks — why do people still smoke?

People rarely smoke because they believe it is healthy. Use persists because the reward is immediate — nicotine, a break, social connection or distraction — while cancer, COPD and cardiovascular disease may feel distant. Tobacco and nicotine products are also designed and marketed in ways that promote appeal and repeated use (World Health Organization, 2025, 2026).

Knowledge alone does not remove dependence, an automated routine or a smoking social environment. In the Dutch Youth Monitor, monthly smokers most often mentioned nicotine, taste, social reasons and mental-health reasons for continuing (Trimbos Institute, 2025).

Nicotine and the feeling of relaxation

Repeated nicotine use can produce craving, irritability, restlessness and concentration problems between doses. The next cigarette temporarily reduces these withdrawal symptoms, which can be experienced as stress relief (World Health Organization, 2026; Taylor et al., 2021).

A Cochrane review found that quitting did not worsen mental health on average and was associated with improvements in anxiety, depression, stress, positive mood and psychological quality of life (Taylor et al., 2021).

A cigarette may change the feeling for a moment, but it does not change the cause of workload, grief, uncertainty or exhaustion.

Is it the cigarette, or the moment?

Smoking becomes linked to coffee, driving, finishing a meal, work breaks and conversations. Repetition turns these contexts into triggers, while social context and habit formation reinforce the pharmacological effect of nicotine (Trimbos Institute, 2025; World Health Organization, 2026).

The positive part of a smoking break may be stopping work, going outside and talking. These functions can be retained without smoking: walk outside, move for five minutes or speak to colleagues without a cigarette.

Why do young people start and continue?

Curiosity, flavours, social influence, parties and peers all play a role. Pressure may be subtle: when a product is offered and everyone else uses it, use can begin to feel normal (Trimbos Institute, 2025).

Young people may underestimate dependence. In the Youth Monitor, fewer exclusive vapers felt addicted than exclusive smokers, despite nicotine in vapes being able to produce dependence (Trimbos Institute, 2025).

Vaping: less harmful does not mean safe

A vape heats liquid rather than burning tobacco. RIVM considers e-cigarettes probably less unhealthy than conventional cigarettes, but still unhealthy. The potential advantage mainly applies when an adult smoker switches completely; dual use preserves exposure to tobacco smoke (RIVM, 2026).

Vapour may contain nicotine and irritating or harmful substances. Flavours and design increase appeal, particularly among young people. A non-smoker gains no health benefit from starting (RIVM, 2026; World Health Organization, 2025).

Shisha and waterpipe

Passing smoke through water does not make it safe. Waterpipe smoke can contain nicotine, carbon monoxide, metals, particulate matter and carcinogenic compounds, and long sessions can produce a large inhaled smoke volume (World Health Organization, 2015).

Exposure varies by product, charcoal, duration and inhalation behaviour, so one session should not be equated with a fixed number of cigarettes. The robust conclusion is that waterpipe is not a harmless social alternative (World Health Organization, 2015).

What does tobacco smoke do to the body?

Tobacco harms nearly every organ and increases the risk of cancer, cardiovascular disease, stroke, lung disease, reduced fertility, infections and premature death. Second-hand smoke is harmful and there is no safe exposure level (World Health Organization, 2026).

The damage is not caused by nicotine alone. Combustion creates a complex mixture of toxic and carcinogenic compounds; nicotine primarily drives dependence, while combustion products account for much of the disease burden (World Health Organization, 2026).

Circulation, oxygen and fitness

Nicotine can raise heart rate and blood pressure and constrict vessels. Carbon monoxide binds to haemoglobin, reducing oxygen-carrying capacity, while chronic smoking may impair muscular mitochondrial function (Degens et al., 2024; Xu et al., 2021).

Smoking is associated with lower exercise capacity and lower local muscle fatigue resistance. The degree varies with exposure, health and training level (Degens et al., 2024).

Muscle, resistance training and recovery

Chronic smoking is associated with lower muscle mass, lower strength and a higher risk of sarcopenia. Proposed pathways include impaired anabolic processes, inflammation, lower glucose uptake and poorer oxidative capacity (Lin et al., 2024).

This does not mean a smoker cannot build muscle, but smoking may create a less favourable environment for training quality, muscle maintenance and recovery (Degens et al., 2024; Lin et al., 2024).

You can still become stronger while smoking, but you are maintaining processes that can work against oxygen use, muscle function and recovery.

Bones, tendons and joints

Smoking is associated with more fracture non-union and deep infection after fracture treatment; at least four weeks of preoperative cessation was associated with fewer postoperative wound infections (Xu et al., 2021).

Evidence differs between conditions. Smoking is an established risk factor for rheumatoid arthritis, particularly with greater lifetime exposure, while the relationship with ordinary osteoarthritis is less clear (Di Giuseppe et al., 2014).

Nerve pain and nerve damage

Nerve symptoms have many causes, so “smoking causes nerve pain” is too broad. In people with diabetes, smoking is associated with a higher risk of diabetic peripheral neuropathy, although causality and effect size remain under study (Bader et al., 2025).

New numbness, tingling, burning pain or weakness warrants medical assessment and should not automatically be attributed only to smoking.

Hormones and fertility

The popular claim that smoking automatically lowers testosterone in every man is incorrect. A meta-analysis found higher average measured total testosterone in male smokers, which does not make smoking hormonally healthy (Zhao et al., 2016).

Smoking remains harmful to fertility, vascular and sexual health, so its effects cannot be reduced to one hormone value (World Health Organization, 2026; Zhao et al., 2016).

The immune system is dysregulated

Smoking can both intensify damaging inflammatory responses and weaken protective responses. Components of innate and adaptive immunity are affected (Qiu et al., 2017).

For a trainee, this may indirectly contribute to illness, missed sessions and poorer continuity, although sleep, diet, stress and disease also matter (Qiu et al., 2017; World Health Organization, 2026).

Smoking during fat loss

Nicotine may temporarily suppress appetite and quitting may be followed by some weight gain. A lower scale weight does not automatically mean better body composition or health; smoking is associated with poorer muscle outcomes and physical capacity (Degens et al., 2024; Lin et al., 2024).

A sound cut aims to reduce fat while preserving muscle, training quality and health. Smoking is therefore not a responsible weight-loss method.

Can you train the damage away?

Exercise remains valuable for people who smoke, but it does not neutralise tobacco smoke or erase damage to lungs, vessels, DNA or tissue healing (World Health Organization, 2026).

The strongest combination is to keep moving while working to remove the exposure.

Quitting is not only about character

Nicotine dependence includes withdrawal, routines and social triggers. Behavioural support improves long-term cessation rates, and effective options may include nicotine replacement, varenicline, cytisine and bupropion, depending on availability and medical suitability (Hartmann-Boyce et al., 2021; Livingstone-Banks et al., 2024).

A previous unsuccessful attempt does not mean quitting is impossible. Discuss appropriate support with a general practitioner or trained cessation professional.

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