Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate®

Smoking and hypertension

Norman M Kaplan, MD
Section Editors
George L Bakris, MD
James K Stoller, MD, MS
Deputy Editor
John P Forman, MD, MSc


Tobacco use is the most common cause of avoidable cardiovascular mortality worldwide [1]. There are now 1.3 billion cigarette smokers, 82 percent in developing countries, and if current practices continue, there will be an estimated one billion tobacco-related deaths during the 21st century. The immediate noxious effects of smoking are related to sympathetic nervous overactivity, which increases myocardial oxygen consumption through a rise in blood pressure, heart rate, and myocardial contractility [2].

Chronically, cigarette smoking induces arterial stiffness which may persist for a decade after smoking cessation [3]. The incidence of hypertension is increased among those who smoke 15 or more cigarettes per day [4], and the coexistence of hypertension and smoking decreases left ventricular function in asymptomatic people [5].

With each cigarette, the blood pressure rises transiently and the pressor effect may be missed if the blood pressure is measured 30 minutes after the last smoke. The transient rise in blood pressure may be most prominent with the first cigarette of the day even in habitual smokers. In one study of normotensive smokers, there was an average elevation in systolic pressure of 20 mmHg after the first cigarette (figure 1) [6]. Furthermore, ambulatory blood pressure monitoring suggests an interactive effect between smoking and coffee drinking in patients with mild primary hypertension (formerly called "essential" hypertension), resulting in a mean elevation in daytime systolic pressure of approximately 6 mmHg [7].

However, habitual smokers generally have lower blood pressures than nonsmokers as observed in most [8,9], but not all [10], studies. The mild reduction in blood pressure in smokers is related to decreased body weight [11]. Support for this observation is the higher body weight and increased blood pressure among former smokers versus that observed among never-smokers [12]. A vasodilator effect of cotinine, the major metabolite of nicotine, also may contribute to the lower blood pressure [13].

Despite these observations, smoking should be avoided in any hypertensive patient because it can markedly increase the risk of secondary cardiovascular complications and enhance the progression of renal insufficiency [14,15]. An example of the latter effect was observed in one prospective study (with a mean follow-up of 35 months) that examined the factors associated with alterations in renal function among 53 hypertensive patients in whom the serum creatinine concentration rose from 1.5 to 1.9 mg/dL (133 to 168 µmol/L) despite a significant reduction in the target mean blood pressure (127 to 97 mmHg) [14]. Smoking was the most significant independent factor underlying progressive renal disease (serum creatinine 1.5 and 2.1 mg/dL [133 and 186 µmol/L] at the beginning and end of the study for smokers, respectively, versus 1.25 and 1.32 mg/dL [110 and 117 µmol/L] for nonsmokers, respectively). The mechanism underlying this adverse effect is unclear but may be related to the transient increase in systemic blood pressure with smoking being transmitted to the glomerulus, resulting in glomerular hypertension.


Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Dec 2016. | This topic last updated: Wed Dec 02 00:00:00 GMT+00:00 2015.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
  1. Teo KK, Ounpuu S, Hawken S, et al. Tobacco use and risk of myocardial infarction in 52 countries in the INTERHEART study: a case-control study. Lancet 2006; 368:647.
  2. Najem B, Houssière A, Pathak A, et al. Acute cardiovascular and sympathetic effects of nicotine replacement therapy. Hypertension 2006; 47:1162.
  3. Jatoi NA, Jerrard-Dunne P, Feely J, Mahmud A. Impact of smoking and smoking cessation on arterial stiffness and aortic wave reflection in hypertension. Hypertension 2007; 49:981.
  4. Bowman TS, Gaziano JM, Buring JE, Sesso HD. A prospective study of cigarette smoking and risk of incident hypertension in women. J Am Coll Cardiol 2007; 50:2085.
  5. Rosen BD, Saad MF, Shea S, et al. Hypertension and smoking are associated with reduced regional left ventricular function in asymptomatic: individuals the Multi-Ethnic Study of Atherosclerosis. J Am Coll Cardiol 2006; 47:1150.
  6. Groppelli A, Giorgi DM, Omboni S, et al. Persistent blood pressure increase induced by heavy smoking. J Hypertens 1992; 10:495.
  7. Narkiewicz K, Maraglino G, Biasion T, et al. Interactive effect of cigarettes and coffee on daytime systolic blood pressure in patients with mild essential hypertension. HARVEST Study Group (Italy). Hypertension Ambulatory Recording VEnetia STudy. J Hypertens 1995; 13:965.
  8. 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; 10:483.
  9. Green MS, Jucha E, Luz Y. Blood pressure in smokers and nonsmokers: epidemiologic findings. Am Heart J 1986; 111:932.
  10. Primatesta P, Falaschetti E, Gupta S, et al. Association between smoking and blood pressure: evidence from the health survey for England. Hypertension 2001; 37:187.
  11. Perkins KA, Epstein LH, Marks BL, et al. The effect of nicotine on energy expenditure during light physical activity. N Engl J Med 1989; 320:898.
  12. Poulter NR. Independent effects of smoking on risk of hypertension: small, if present. J Hypertens 2002; 20:171.
  13. Benowitz NL, Sharp DS. Inverse relation between serum cotinine concentration and blood pressure in cigarette smokers. Circulation 1989; 80:1309.
  14. Regalado M, Yang S, Wesson DE. Cigarette smoking is associated with augmented progression of renal insufficiency in severe essential hypertension. Am J Kidney Dis 2000; 35:687.
  15. Orth SR. Smoking and the kidney. J Am Soc Nephrol 2002; 13:1663.