Why does smoking raise my blood pressure?

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 after cessation of smoking. A 1992 study (n=40) found that after stratifying by both baseline BP and baseline smoking status, both systolic BP (SBP) and diastolic BP (DBP) increased after smoking a cigarette, reaching a peak at 2.5 minutes (p<0.001).¹ For both normotensive and hypertensive smokers and nonsmokers, both SBP and DBP increased by 20-30 mmHg after one cigarette and 10 mmHg after subsequent cigarettes. A 1978 study (n=8) found that acute increases in BP returned to pre-smoking levels 15 minutes after cessation of smoking a high nicotine content cigarette and five minutes after smoking a low nicotine content cigarette.²

Nicotine stimulates the sympathetic nervous system, leading to the release of norepinephrine and epinephrine.^1,3 These catecholamines cause vasoconstriction, preventing the normal vasodilation response to hypoxia, thus increasing BP.

A 2006 randomized controlled trial (n=16) found that after the administration of a 4-mg nicotine tablet, SBP, DBP, heart rate, and muscle sympathetic nerve activity (MSNA) all increased.⁴ Compared to placebo, SBP increased from 118 to 123 mmHg (p<0.05), and DBP increased from 63 to 69 mmHg (p<0.01). Heart rate increased from 64 to 71 peats per minute (p<0.05), and MSNA increased from 28 to 31 bursts per minute (p<0.05). During simulated hypoxia, nicotine increased SBP from 121 to 126 mmHg (p<0.05), DBP from 67 to 69 mmHg (non-significant), heart rate from 80 to 88 beats per minute (p<0.01), and MSNA from 25 to 32 bursts per minute (p<0.05). These results suggest that nicotine raises blood pressure by increasing sympathetic nerve activity during the period of reduced oxygen availability.

A 1999 randomized trial (n=39) asked habitual smokers to cease smoking for one week and resume usual smoking habits for one week.⁵ SBP and DBP were significantly lower during the nonsmoking period (SBP decreased by 3.5 mmHg, p<0.01; DBP decreased by 1.9 mmHg, p<0.05). Levels of plasma norepinephrine lowered from 1.54 to 1.28 nmol/L and epinephrine lowered from 179 to 147 pmol/L, indicating that sympathetic nerve activity was reduced.

Hypertension

The long-term effects of smoking on BP and the potential development of hypertension are not clear. Evidence from multiple studies on chronic smokers compared to non-smokers revealed small and variable effects of smoking on long-term BP.^6-11 A 2015 meta-analysis of 23 population-based studies (n=141,317) found that smoking was associated with lower SBP and DBP compared to never smokers, with SBP 2.40 mmHg lower and DBP 1.93 mmHg lower.¹² Smokers had lower risk of hypertension even when adjusting for body mass index (BMI) (OR 0.84, 95% Confidence Interval [CI] [0.73-0.94]). ​Number of cigarettes smoked daily was linked to a slight increase in BP of 0.08/0.05 mmHg per cigarette per day (p<0.05), but Mendelian randomization analyses did not support a causal relationship.

A 2001 study (n=33,860) which collected survey data from 1994-1996 also found that smoking had little effect on the long-term BP changes.¹³ After adjusting for age, BMI, alcohol intake, and social class, men older than 45 smoking 20+ cigarettes per day had a mean of 2.8 mmHg higher SBP than non-smokers (p<0.01), but there was no significant increases in DBP, for men aged 16-44, or for women. In fact, women aged 16-44 who smoked 1-9 cigarettes per day had significantly lower DBP (67.8 mmHg) than non-smokers (69.2 mmHg, p<0.001).

Heart Disease

Although smoking is not associated with the development of hypertension, tobacco use is a leading cause of heart disease in the United States.¹⁴ American College of Cardiology and American Heart Association (ACC/AHA) guidelines advise that cigarette smoking is a strong independent risk factor for atherosclerotic cardiovascular disease (ASCVD) and strongly recommend against tobacco use. According to a report by the United States Surgeon General, the average smoking-attributable mortality due to cardiovascular and metabolic diseases was 95,600 among those 35 years and older, accounting for 28.9% of all smoking-attributable mortality.¹⁵

References

1. De Cesaris R, Ranieri G, Filitti V, Vincenzo Bonfantino M, Andriani A. Cardiovascular Effects of Cigarette Smoking. Cardiology. 2008;81(4-5):233-237. doi:10.1159/000175809
2. Tachmes L, Fernandez RJ, Sackner MA. Hemodynamic effects of smoking cigarettes of high and low nicotine content. Chest. Sep 1978;74(3):243-6. doi:10.1378/chest.74.3.243
3. Omvik P. How smoking affects blood pressure. Blood Pressure. 1996/01/01 1996;5(2):71-77. doi:10.3109/08037059609062111
4. Najem B, Houssière A, Pathak A, et al. Acute Cardiovascular and Sympathetic Effects of Nicotine Replacement Therapy. Hypertension. 2006;47(6):1162-1167. doi:doi:10.1161/01.HYP.0000219284.47970.34
5. Minami J, Ishimitsu T, Matsuoka H. Effects of Smoking Cessation on Blood Pressure and Heart Rate Variability in Habitual Smokers. Hypertension. 1999;33(1):586-590. doi:doi:10.1161/01.HYP.33.1.586
6. Lee D-H, Ha M-H, Kim J-R, Jacobs DR. Effects of Smoking Cessation on Changes in Blood Pressure and Incidence of Hypertension. Hypertension. 2001;37(2):194-198. doi:doi:10.1161/01.HYP.37.2.194
7. 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. doi:10.1001/jama.1991.03460170080037
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. American Journal of Hypertension. 1997;10(5):483-491. doi:10.1016/s0895-7061(96)00487-6
9. Stewart MJ, Jyothinagaram S, McGinley IM, Padfield PL. Cardiovascular effects of cigarette smoking: ambulatory blood pressure and BP variability. J Hum Hypertens. 1994/01// 1994;8(1):19-22.
10. Verberk WJ, Kessels AGH, de Leeuw PW. Prevalence, Causes, and Consequences of Masked Hypertension: A Meta-analysis. American Journal of Hypertension. 2008;21(9):969-975. doi:10.1038/ajh.2008.221
11. Verdecchia P, SchillacI G, Borgioni C, et al. Cigarette smoking, ambulatory blood pressure and cardiac hypertrophy in essential hypertension. Journal of Hypertension. 1995;13(10):1209-1216.
12. Linneberg A, Jacobsen RK, Skaaby T, et al. Effect of Smoking on Blood Pressure and Resting Heart Rate. Circulation: Cardiovascular Genetics. 2015;8(6):832-841. doi:doi:10.1161/CIRCGENETICS.115.001225
13. Primatesta P, Falaschetti E, Gupta S, Marmot MG, Poulter NR. Association Between Smoking and Blood Pressure. Hypertension. 2001;37(2):187-193. doi:doi:10.1161/01.HYP.37.2.187
14. Arnett DK, Blumenthal RS, Albert MA, et al. 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease: Executive Summary. Journal of the American College of Cardiology. 2019;74(10):1376-1414. doi:doi:10.1016/j.jacc.2019.03.009
15. Office of the Surgeon G, Office on S, Health. Reports of the Surgeon General. The Health Consequences of Smoking: A Report of the Surgeon General. Centers for Disease Control and Prevention (US); 2004.