Version May 2024
INTRODUCTION — Elevated blood pressure and tobacco smoking are, respectively, the first and second leading causes of preventable mortality worldwide [1]. Hence, from both a population perspective and a patient perspective, the joint occurrence of tobacco smoking and elevated blood pressure has enormous health consequences.
Tobacco smoking, electronic cigarette (e-cigarette) use, and hookah (water pipe, narghile, shisha) use may raise blood pressure and accelerate atherothrombotic processes though a variety of potential mechanisms, including deleterious effects on endothelial function, inflammation, lipids, and thrombosis [2-4]. The effects of tobacco products on blood pressure and hypertension are discussed in this topic. Hypertension control and smoking cessation to prevent cardiovascular disease and the approach to smoking cessation are discussed elsewhere. (See "Overview of primary prevention of cardiovascular disease" and "Overview of smoking cessation management in adults".)
TRENDS IN SMOKING — Worldwide, the absolute number of cigarette smokers has increased because of population growth, despite a decrease in the age-adjusted prevalence of smoking [5]. In the United States, the estimated number of cigarette smokers has decreased as a result of tobacco-control efforts, from 45.1 million in 2005 to 30.8 million in 2020 [6-8]. However, while cigarette smoking has decreased, the use of electronic cigarettes (e-cigarettes) has increased substantially in the United States, along with concerns about their potential health risks [9]. Hookah smoking is also common, especially in some Middle Eastern, Southeast Asian, and Western European countries, and to a lesser extent in the United States and Canada [10]. (See "Patterns of tobacco use".)
CIGARETTE SMOKING AND BLOOD PRESSURE — The effects of cigarette smoking on blood pressure are complex, with evidence that smoking increases blood pressure acutely and increases the risk of renovascular, malignant, and masked hypertension. (See 'Acute effects of cigarette smoking' below.)
However, the chronic effects of smoking on blood pressure and the development of hypertension are uncertain. (See 'Chronic effects of cigarette smoking' below.)
Passive (or secondhand) tobacco smoke exposure also appears to raise blood pressure [11]. In one study, nonsmoking individuals who lived in communities that implemented smoke-free policies in bars, restaurants, and workplaces had lower systolic blood pressures than those living in communities without these policies [12].
Acute effects of cigarette smoking — The acute effects of tobacco smoking are related to sympathetic nervous system overactivity, which leads to an increase in blood pressure, heart rate, myocardial contractility, and myocardial oxygen consumption [2,13].
The rise in blood pressure with each cigarette is transient, and this transient increase may be most prominent with the first cigarette of the day, even in those who smoke cigarettes habitually. As an example, in one study of normotensive individuals who smoke, the average elevation in systolic pressure after the first cigarette of the day was approximately 20 mmHg (figure 1) [14]. Blood pressure began to fall 10 to 15 minutes after smoking ceased, and no pressor effect was detected after 30 minutes. However, if smoking continued (eg, one cigarette every 15 minutes for an hour), blood pressure remained elevated [14].
In addition, the acute effects of smoking on blood pressure may be exacerbated by coffee drinking, which is associated with an increase in epinephrine levels [15]. In an observational study of approximately 900 hypertensive individuals, those who both smoked tobacco and consumed coffee had a mean daytime ambulatory blood pressure that was 6 mmHg higher than those who neither smoked nor drank coffee [15]. Daytime blood pressures of those who either smoked or drank coffee were intermediate.
Chronic effects of cigarette smoking — There are inconsistent data that cigarette smoking raises blood pressure chronically or increases the incidence of hypertension.
In many, but not all studies, individuals who smoke cigarettes habitually had lower blood pressure than nonsmokers [16-18]. This finding might be related to the following:
●Those who smoke cigarettes generally have a lower body weight compared with those who do not smoke [19]; this may mitigate the blood pressure-elevating effects of cigarette smoking. Indirect support for this hypothesis comes from findings that individuals who have quit smoking have higher body weight and higher blood pressure compared with those who have never smoked [20].
●Cotinine, the major metabolite of nicotine, has a vasodilator effect that might also contribute to lower blood pressure in those who smoke [21].
However, cigarette smoking increases the risk of masked hypertension (normal blood pressure in the office but elevated blood pressure outside of the office environment) [22], which should be treated in the same manner as sustained hypertension. Thus, studies relying upon office measurements that reported lower blood pressure among smokers may have reached different conclusions if ambulatory monitoring was employed. (See "White coat and masked hypertension", section on 'Treatment of masked and masked uncontrolled hypertension' and "Out-of-office blood pressure measurement: Ambulatory and self-measured blood pressure monitoring", section on 'Identification of white coat and masked hypertension'.)
Despite uncertain chronic effects on blood pressure, cigarette smoking has effects on other conditions related to blood pressure:
●Cigarette smoking increases arterial stiffness, which may persist for a decade after smoking cessation [23]. (See "Overview of possible risk factors for cardiovascular disease", section on 'Arterial stiffness'.)
●Cigarette smoking increases the risk of renovascular hypertension [24]. (See "Establishing the diagnosis of renovascular hypertension".)
●Cigarette smoking is associated with severe hypertensive retinopathy (often called "malignant hypertension") [25]; whether or not this relation is the result of renovascular hypertension is unknown. (See "Moderate to severe hypertensive retinopathy and hypertensive encephalopathy in adults".)
Although smoking may not increase the risk of new-onset hypertension, it markedly increases the risk of atherosclerotic cardiovascular events [26] and end-stage kidney disease in patients with hypertension [27,28]. The mechanism underlying the adverse effect on kidney function is unclear but may be related to smoking-induced, transient increases in systemic blood pressure that are then transmitted to the glomerulus, resulting in glomerular hypertension.
Cessation of smoking rapidly lowers the risk of coronary heart disease, and this benefit is independent of the duration of smoking. It is unclear whether cessation of smoking has a similar benefit in helping preserve kidney function. The cardiovascular effects of smoking and smoking cessation are reviewed in detail elsewhere. (See "Cardiovascular risk of smoking and benefits of smoking cessation".)
E-CIGARETTES AND BLOOD PRESSURE — There has been a marked increase in use of electronic cigarettes (e-cigarettes), but data on their long-term health effects are sparse; this is reviewed elsewhere (see "Vaping and e-cigarettes", section on 'Adverse health effects'). However, cardiopulmonary physiology studies in humans and animals suggest that many health effects of e-cigarettes may be similar to those of cigarette smoking [29].
Acute effects of e-cigarettes — Acute effects of nicotine containing e-cigarettes on blood pressure are inconsistent [9,30-32], although studies vary in the e-cigarette products used (which differ in the rate and amount of nicotine delivery). A 2018 report from the National Academy of Medicine that summarized findings from a variety of studies concluded that e-cigarettes are associated with a mild, short-term increase in diastolic pressure and a mild, short-term increase or no effect on systolic blood pressure [9].
The acute changes in blood pressure with e-cigarette use are attributable to the nicotine rather than other aerosol components [32].
Chronic effects of e-cigarettes — High-quality data on the chronic blood pressure effects of e-cigarettes are limited [33,34] and may be difficult to interpret since many e-cigarette users currently or previously smoked cigarettes [35,36]. In a retrospective, case-control study of 89 cigarette smokers with hypertension, switching from combustible tobacco cigarettes to e-cigarettes was associated with a reduction in systolic and diastolic blood pressure at 12 months (-10 mmHg and -6 mmHg, respectively) [33].
HOOKAH (WATER PIPE) SMOKING AND BLOOD PRESSURE — Regions with the highest rates of hookah smoking include Europe, the Middle East, and Southeast Asia, and rates of use are rising [10]. In the United States, hookah smoking is particularly common among youth; in 2021, an estimated 1.2 percent of high school students reported smoking tobacco through a water pipe within the prior month [37,38] . (See "Patterns of tobacco use", section on 'Waterpipes or hookahs'.)
Hookah tobacco smoke contains harmful or potentially harmful substances that are also found in cigarette smoke, including nicotine, carbon monoxide, nitrosamine, polycyclic aromatic hydrocarbons, and particulate matter [3].
High-quality data on the effect of hookah smoking on blood pressure are lacking. However, indirect and direct evidence suggest that hookah smoking has blood pressure and other cardiovascular effects similar to cigarette smoking. In several studies, hookah smoking for 15 to 30 minutes acutely increased systolic pressure (by 3 to 16 mmHg) [39,40] and diastolic pressure (by 2 to 14 mmHg) [39-41]. In observational studies, hookah smoking was associated with increased systolic pressure [42] and an increased prevalence of hypertension [43].
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Hypertension in adults".)
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
●Beyond the Basics topic (see "Patient education: Quitting smoking (Beyond the Basics)")
SUMMARY
●Acute effects of cigarette smoking on blood pressure – The acute effects of cigarette smoking are related to sympathetic nervous system overactivity, which leads to an increase in blood pressure, heart rate, myocardial contractility, and myocardial oxygen consumption. The rise in blood pressure with each cigarette is transient, even among those who smoke regularly (figure 1); this transient blood pressure increase resolves after 30 minutes. (See 'Acute effects of cigarette smoking' above.)
●Chronic effects of cigarette smoking on blood pressure – There are inconsistent data that tobacco smoking raises blood pressure chronically or increases the incidence of hypertension. Those who smoke habitually often have lower blood pressure than nonsmokers, which might be related to a generally lower body weight compared with nonsmokers and the vasodilatory effects of cotinine, the major metabolite of nicotine. However, cigarette smoking increases the risk of masked hypertension (normal blood pressure in the office but elevated blood pressure outside of the office environment), renovascular hypertension, severe hypertensive retinopathy, and arterial stiffness. (See 'Chronic effects of cigarette smoking' above.)
●Effects of e-cigarettes on blood pressure – Acute e-cigarette use appears to be associated with a mild, short-term increase in diastolic blood pressure and a mild, short-term increase or no effect on systolic blood pressure. Data are limited on the chronic blood pressure effects of e-cigarettes. (See 'E-cigarettes and blood pressure' above.)
●Effects of hookah (water pipe) smoking on blood pressure – Indirect and direct evidence suggest that smoking by hookah has blood pressure and other cardiovascular effects that are similar to traditional cigarette smoking. (See 'Hookah (water pipe) smoking and blood pressure' above.)
ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Norman M Kaplan, MD, who contributed to an earlier version of this topic review.
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