Smoking has been shown to lead to acute increases in blood pressure (BP) within minutes of the first inhalation, but BP returns to pre-smoking levels about an hour after cessation of smoking.1 Systolic blood pressure has been reported to increase 10 – 25 mm Hg and diastolic 6 – 12 mm Hg depending on the nicotine content of the cigarette. Nicotine has been shown to cause the release of norepinephrine through a cascade of events in the sympathetic nervous system.2 The increase in BP is attributed to the effects of nicotine on the sympathetic nervous system, which increases total peripheral resistance and cardiac output.1
However, the long-term effects of smoking are not as clear. Evidence from multiple studies on chronic smokers compared to non-smokers reveal much smaller and variable effects of smoking on BP.3-8 The differences in BP of smokers compared to non-smokers seem to be influenced more by body mass index and alcohol intake than by smoking.8 When examined more closely, the chronic effects of smoking are better demonstrated by the high prevalence of renovascular hypertension (renal artery stenosis [RAS]) and malignant hypertension (systolic BP ≥ 180 mm Hg or diastolic BP ≥ 110 mm Hg) in smokers due to the development of atherosclerosis.9-14 In a study of patients with RAS (n=63) and a control group of age (±3 years) and sex matched hypertensive patients, there were significantly more smokers among patients with RAS (53/63, 84%) than in the control group (29/63, 46%) (p<0.001).12 Another study compared smoking habits in 48 consecutive cases of malignant hypertension to 92 consecutive patients without malignant hypertension at a blood pressure clinic.10 Patients with malignant hypertension were more likely to be smokers than those without malignant hypertension (69% vs 37%, p<0.001).
There are a few proposed mechanisms by which cigarette smoking induces atherogenesis.15 One mechanism involves the increased adhesion and aggregation of platelets due to reduced availability of platelet-derived nitric oxide and decreased platelet sensitivity to nitric oxide.16 Another is the alteration on thrombotic factors such as increased levels of fibrinogen and tissue factor that increase atherosclerosis.17-20
- Omvik P. How smoking affects blood pressure. Blood Press. 1996;5(2):71-77.
- Haass M, Kübler W. Nicotine and sympathetic neurotransmission. Cardiovasc Drugs Ther. 1997;10(6):657-665.
- Mikkelsen KL, Wiinberg N, Høegholm A, et al. Smoking related to 24-h ambulatory blood pressure and heart rate. A study in 352 normotensive Danish subjects. Am J Hypertens. 1997;10(5):483-491.
- Verberk WJ, Kessels AG, de Leeuw PW. Prevalence, causes, and consequences of masked hypertension: a meta-analysis. Am J Hypertens. 2008;21(9):969-975.
- Stewart MJ, Jyothinagaram S, McGinley IM, Padfield PL. Cardiovascular effects of cigarette smoking: ambulatory blood pressure and BP variability. J Hum Hypertens. 1994;8(1):19-22.
- Verdecchia P, Schillaci G, Borgioni C, et al. Cigarette smoking, ambulatory blood pressure and cardiac hypertrophy in essential hypertension. J Hypertens. 1995;13(10):1209-1215.
- Mann SJ, James GD, Wang RS, Pickering TG. Elevation of ambulatory systolic blood pressure in hypertensive smokers. A case-control study. JAMA. 1991;265(17):2226-2228.
- Primatesta P, Falaschetti E, Gupta S, Marmot MG, Poulter NR. Association between smoking and blood pressure. Evidence From the Health Survey for England. 2001;37(2):187-193.
- Black HR, Cooper KA. Cigarette smoking and atherosclerotic renal artery stenosis. J Clin Hypertens. 1986;2(4):322-330.
- Bloxham CA, Beevers DG, Walker JM. Malignant hypertension and cigarette smoking. Br Med J. 1979;1(6163):581-583.
- Janke AT, McNaughton CD, Brody AM, Welch RD, Levy PD. Trends in the incidence of hypertensive emergencies in US emergency departments from 2006 to 2013. Journal of the American Heart Association. 2016;5(12).
- Mackay A, Brown JJ, Cumming AM, Isles C, Lever AF, Robertson JI. Smoking and renal artery stenosis. Br Med J. 1979;2(6193):770-770.
- Plus M. Renovascular hypertension. https://medlineplus.gov/ency/article/000204.htm. Accessed 12 December, 2017.
- Tuomilehto J, Elo J, Nissinen A. Smoking among patients with malignant hypertension. Br Med J (Clin Res Ed). 1982;284(6322):1086-1086.
- Ambrose JA, Barua RS. The pathophysiology of cigarette smoking and cardiovascular disease: an update. J Am Coll Cardiol. 2004;43(10):1731-1737.
- Ichiki K, Ikeda H, Haramaki N, Ueno T, Imaizumi T. Long-term smoking impairs platelet-derived nitric oxide release. Circulation. 1996;94(12):3109-3114.
- Sambola A, Fuster V, Badimon JJ. Role of coronary risk factors in blood thrombogenicity and acute coronary syndromes. Revista Española de Cardiología (English Edition). 2003;56(10):1001-1009.
- Barua RS, Ambrose JA, Saha DC, Eales-Reynolds LJ. Smoking is associated with altered endothelial-derived fibrinolytic and antithrombotic factors: an in vitro demonstration. Circulation. 2002;106(8):905-908.
- Smith FB, Lee AJ, Fowkes FG, Price JF, Rumley A, Lowe GD. Hemostatic factors as predictors of ischemic heart disease and stroke in the Edinburgh Artery Study. Arterioscler Thromb Vasc Biol. 1997;17(11):3321-3325.
- Kannel WB, D'Agostino RB, Belanger AJ. Fibrinogen, cigarette smoking, and risk of cardiovascular disease: insights from the Framingham Study. Am Heart J. 1987;113(4):1006-1010.