The Effect of Cigarette Smoking on Blood Pressure and Hypertension

Abstract

Cigarette smoking and hypertension are significant cardiovascular risk factors. The effect of cigarettes on blood pressure and the development of hypertension are unclear. Studies on the subject report contradictory results. The purpose of this study was to investigate the effect of cigarette smoking on blood pressure and hypertension. Our study population consisted of 712 patients with a mean age of 51.2±15.1 years, 44% of them were male and 56% of them were female. Thirty-six percent of patients were smokers, 9% of them were ever smoked and stopped smoking or ex-smoker and 55% of them were nonsmoker. Systolic and diastolic blood pressures were lowest in the smokers, higher among ex-smokers compared to smokers and highest in the non-smokers (P<0.001). The mean systolic and diastolic blood pressures were 119/74 mmHg in the smokers, 134/81 mmHg in the ex-smokers and 150/88 mmHg in the non-smokers. Prevalence of hypertension did not change by smoking status. A significant variation was determined, at 15% in smokers, 33% in ex-smokers and 55% in non-smokers (P<0.001). In conclusion, blood pressures and prevalence of hypertension were significantly low in smokers in this study. Despite the limitless harm it has, cigarette smoking exhibits a lowering effect in blood pressure, although the mechanism involved is unclear.

Full text

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Original article
Advances in Bioscience & Clinical Medicine
The Effect of Cigarette Smoking on Blood Pressure and
Hypertension
Aziz Gumus1, Servet Kayhan1*, Halit Cinarka1, Unal Sahin1
1.Department of Pulmonary Medicine, Recep Tayyip Erdogan University, Rize, Turkey
1. Introduction
Cigarette smoking and hypertension are the
two most important long-term risk factors for
atherosclerosis, coronary artery disease, acute
myocardial infarction and sudden death (1,2).
Cigarette smoking alone causes the deaths of
5.4 million people per year across the world (3).
Although studies have investigated the effect of
cigarette smoking on blood pressure and the
development of hypertension, the mechanism
involved is still unclear (4). The acute effect of
cigarette smoking is a temporary increase in
Corresponding author:
Servet Kayhan,
Department of Pulmonary Medicine, Recep Tayyip Erdogan University, Rize, Turkey
Tel/Fax: +904642170364 E-mail: kayhanservet@gmail.com
Received: 14-05-2013, Accepted: 28-05-2013, Published: 07-06-2013
doi:10.7575/aiac.abcmed.v.1n.1p.6 URL: http://dx.doi.org/10.7575/aiac.abcmed.v.1n.1p.6
Abstract
Cigarette smoking and hypertension are significant cardiovascular risk factors. The effect of
cigarettes on blood pressure and the development of hypertension are unclear. Studies on the
subject report contradictory results. The purpose of this study was to investigate the effect of
cigarette smoking on blood pressure and hypertension. Our study population consisted of 712
patients with a mean age of 51.2±15.1 years, 44% of them were male and 56% of them were
female. Thirty-six percent of patients were smokers, 9% of them were ever smoked and stopped
smoking or ex-smoker and 55% of them were nonsmoker. Systolic and diastolic blood pressures
were lowest in the smokers, higher among ex-smokers compared to smokers and highest in the
non-smokers (P<0.001). The mean systolic and diastolic blood pressures were 119/74 mmHg in
the smokers, 134/81 mmHg in the ex-smokers and 150/88 mmHg in the non-smokers.
Prevalence of hypertension did not change by smoking status. A significant variation was
determined, at 15% in smokers, 33% in ex-smokers and 55% in non-smokers (P<0.001). In
conclusion, blood pressures and prevalence of hypertension were significantly low in smokers in
this study. Despite the limitless harm it has, cigarette smoking exhibits a lowering effect in blood
pressure, although the mechanism involved is unclear.
Keywords: Blood pressure; cigarettes; hypertension

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Advances in Bioscience & Clinical Medicine
heart rate and blood pressure with an increase
in epinephrine and norepinephrine production
due to activation of the sympathetic system (5).
It has been suggested that long-term cigarette
smoking raises blood pressure by causing an
increase in inflammation, endothelial
dysfunction, plaque progression and vascular
damage. Some studies support this view. An
increase in blood pressure and development of
hypertension in cigarette smokers compared to
non-smokers has been reported in some studies
(6,7). Other studies, however, have reported
less development of hypertension in non- or ex-
smokers compared to smokers (8,9). Studies
have also reported that cigarette smoking does
not affect development of hypertension
(10,11). Since the relationship between
cigarette smoking and hypertension is unclear,
current guidelines do not recommend quitting
smoking in the treatment and prevention of
hypertension (12-13). The relationship between
cigarette smoking and hypertension during
pregnancy period is similarly unclear. While
some studies have emphasized that cigarette
smoking increases pregnancy-induced
hypertension (14), others have reported that
cigarette use reduces the development of
hypertension (15).
The purpose of this study was to investigate the
effect of cigarette smoking on blood pressure
and the development of hypertension and to
contribute to this still controversial issue.
2. Methods
2.1 Patients
In a cross-sectional study, 712 consecutive
patients applied to outpatient clinic of chest
disease of Educational and Research Hospital of
Recep Tayyip Erdoğan University, Rize, Turkey,
between 01 February and 30 April, 2013, were
enrolled. Patients’ age, height, weight, body
mass index (BMI) and blood pressure were
measured. Cigarette smoking status was
determined. Drugs used were recorded for
those patients with a diagnosis of hypertension.
Pregnant patients, patients aged under 20 or
over 80 years, patients with previous coronary
artery, peripheral vascular, cerebrovascular
disease, active infection, cancer, heart failure,
atrial fibrillation, moderate or severe heart
valve disease, malnutrition and renal or hepatic
failure were excluded. The study was carried
out in accordance with the principles in the
Declaration of Helsinki and was approved by
the local Ethics Committee.
2.2 Blood pressure
Systolic and diastolic blood pressures (BP) were
measured twice at 5 min intervals from the left
arm after at least 15 min of rest. BP values were
obtained by the traditional auscultatory
method using a sphygmomanometer (Erka,
Germany) in an office. The means of the two
measurements were recorded as mean systolic
and diastolic blood pressure. Mean blood
pressure (MAP) was calculated using the
following formula: MAP = diastolic blood
pressure + 1/3 (systolic blood pressure -
diastolic blood pressure).
2.3 Blood measurements
Blood samples were drawn by venipuncture to
measure routine blood chemistry parameters
after fasting for at least 8 h. Biochemical
parameters including glucose, blood urea
nitrogen, creatinine, hepatic function tests and
lipid profile were determined using standard
methods. BMI was determined using the
following formula: BMI = weight (kg) / height2

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(m).
2.4 Definitions
Smokers were defined as subjects who had
smoked at least 100 cigarettes in their life
period and who were still smoking. Ex-smokers
were those who had smoked at least 100
cigarettes in their life period and stopped the
smoking for at least 1 year. Non-smokers had
smoked fewer than 100 cigarettes in their life
period or who had never smoked at all.
Diagnosis of hypertension was based on systolic
blood pressure ≥140mmHg and/or diastolic
blood pressure ≥90mmHg. Hypertension was
defined as longstanding in patients with
previous diagnosis of hypertension on
antihypertensive therapy. New hypertension
was defined in those without any previous
diagnosis of hypertension who were diagnosed
with hypertension during the study period.
2.5 Statistical analysis
The SPSS statistical software (SPSS for windows,
version 16; SPSS Inc., Chicago, IL, USA) was used
for all statistical calculations. Continuous
variables were defined as mean ± standard
deviation (SD) and categorical variables were
defined as percentages. Independent-Samples T
test and analysis of variance (ANOVA) were
used for parametric variables at comparison of
means and Chi square test in the comparison of
levels. Univariate analysis and analysis of
covariance were used in order to eliminate the
effect of age and BMI in order to determine
whether cigarette smoking status is an
independent predictor factor affecting the
blood pressure. P<0.05 was regarded as
statistically significant.
3. Results
In the present study, 712 patients were
included. The mean age was 51.2±15.1 years
(range 20-80); 310 (44%) participants were
male and 402 (56%) were female. In terms of
smoking status, 254 (36%) patients were still
smoking, 65 (9%) were ex-smokers and 393
(55%) had never smoked. Smoking level in the
smoking group was 28±17 pack-years, and
32±15 pack-years in the ex-smokers group. The
amount smoked was higher among the ex-
smokers, although the difference was not
statistically significant (P=0.15). The mean time
since quitting among ex-smokers was 7.9±7.5
years (range 1-30 years). The characteristics of
the three groups established on the basis of
smoking status are shown in Table 1. Males
were in the majority in the smoker and ex-
smoker groups, while women predominated
significantly in the group that had never
smoked (P<0.001). Age was lower among the
smokers compared to the ex-smoker and non-
smoker groups, at 47.1±12.7, 56.1±13.6 and
53.4±16.9 years, respectively (P<0.001). Ex-
smokers and non-smokers were comparable in
terms of age (P=0.384). Systolic, diastolic and
mean blood pressures in the smoking group
were significantly lower compared to the ex-
and non-smoker groups (P<0.001). In addition,
blood pressure levels were significantly lower in
the ex-smokers compared to those who had
never smoked (P<0.001). The differences
between the groups’ blood pressures are
shown in Figure 1. Non-smoking group BMI
(30.0±6.0 kg/m2) was higher than those in the
smoking (26.4±4.7 kg/m2) and ex-smoker
(27.2±4.4 kg/m2) groups (P<0.001). The
smoking and ex-smoker groups were similar in
terms of BMI (P=0.57). Covariate and univariate
analyses were preformed due to the presence
of variations between the groups in terms of

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age and BMI and the effect of these factors was
thus eliminated. The analysis revealed that
cigarette-smoking status affected blood
pressure as an independent factor. The
differences in systolic, diastolic and mean blood
pressures between the smokers and the ex-
smokers at analysis of covariance were P=0.007,
P=0.03 and P=0.01, respectively. Between the
smoker and non-smoker groups these were
P<0.001 for all three parameters.
Characteristics
Smokers
Ex-smokers
Non-smokers
P value
Patient number
254
65
393
-
Age
47.1±12.7
56.1±13.6
53.4±16.9
<0.001*
Sex (M/F)
163/91
53/12
94/299
<0.001**
Systolic BP (mmHg)
119±23
134±26
150±29
<0.001*
Mean BP (mmHg)
89±17
99±16
109±19
<0.001*
Diastolic BP (mmHg)
74±14
81±13
88±15
<0.001*
BMI (kg/m²)
26.4±4.7
27.2±4.4
30.0±6.0
<0.001*
Longstanding HT-Male (yes/no)
13/149
8/45
27/66
<0.001**
Longstanding HT-Female (yes/no)
10/82
1/11
103/196
<0.001**
Total longstanding HT (yes/no)
23/231
9/56
130/263
<0.001**
New HT-Male (yes/no)
9/154
9/44
20/74
0.001**
New HT-Female (yes/no)
8/83
2/10
68/231
0.01**
Total new HT (yes/no)
17/237
11/54
88/305
<0.001**
All HT (yes/no)
40/214
20/45
218/175
<0.001**
Table 1: Comparison of characteristics of groups established on the basis of smoking status
M, male; F, female; BP, blood pressure; BMI, body mass index; HT, hypertension. *ANOVA
performed; **Chi-square test performed
The level of patients previously diagnosed with
hypertension and receiving antihypertensive
therapy was 9% in the smokers, 14% among ex-
smokers and 33% in those who had never
smoked. When the groups were compared
using the chi-square test, hypertension levels
were lower among smokers compared to ex-
and non-smokers (P<0.001). In addition,
hypertension levels were lower among ex-
smokers compared to non-smokers (P<0.001).
Levels among patients with no previous
diagnosis of hypertension and who were
diagnosed at examination at the clinic were 6%
among smokers, 17% in ex-smokers and 22%
among non-smokers. The lowest level was
among smokers and the highest among non-
smokers, a significant difference being observed
with the chi-square test (P<0.001). The
Figure 1: Comparison of blood pressures in three studied groups

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prevalence of hypertension on the basis of
cigarette smoking status is shown in Table 1 and
Figure 2. In terms of all cases, longstanding and
new, the prevalence of hypertension was 16%
among smokers, 31% among ex-smokers and
55% among non-smokers. Hypertension was
determined in 278 (39%) of the total 712
Figure 2: Hypertension levels in groups established on the basis of smoking status
patients enrolled. Men and women exhibited
similar characteristics in terms of previously
and newly diagnosed hypertension levels.
Diastolic, mean and systolic blood pressures in
the smoking group were 74, 89 and 119 mmHg,
respectively. Diastolic, mean and systolic blood
pressures in the ex-smoker group were 81, 99
and 134 mmHg, respectively. Diastolic, mean
and systolic blood pressures in the non-smoker
group were 88, 109 and 150 mmHg,
respectively.
New hypertension was detected in 17 (6%) of
the 254 smokers, longstanding hypertension in
23 (9%) and no hypertension in 214 (85%). New
hypertension was present in 11 (17%) of the ex-
smokers, longstanding hypertension in 11 (17%)
and no hypertension (76%) in 45. New
hypertension was present in 88 (22%) of the
393 non-smokers, longstanding hypertension in
130 (33%) and no HT in 175 (45%). New
hypertension was present in 116 (16%) of all
712 cases, longstanding hypertension in 162
(23%) and no hypertension in 434 (61%).
4. Discussion
0
20
40
60
80
100
120
140
160
Diastolic BP Mean PB Systolic BP
mmHg
Smokers
Ex-smokers
Non-smokers
0%
20%
40%
60%
80%
100%
New HT
Longstanding HT
Normotensive

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Although many studies have been performed,
the effect of cigarette smoking on blood
pressure and development of hypertension is
still unclear (4). Mutually incompatible results
have been obtained from wide-ranging,
prospective studies (6-10). Chronic cigarette
smoking was shown to lead to endothelial
dysfunction in a study by Li et al. (16), to
atherosclerotic plaque formation in a study by
Sharrett et al. (17), and to arterial rigidity in a
study by Kim et al. (18). It has been suggested
that chronic cigarette smoking increases blood
pressure and the incidence of hypertension
through these mechanisms. In a study involving
12,417 in which only males participated, Halimi
et al. showed that smoking increased the risk of
systolic hypertension in cases aged 60 and over
that continued to smoke (6). They also
identified an increased prevalence of
hypertension attributed to weight gain in ex-
smokers compared to non-smokers. The fact
that it involved only males was a major weak
point of that study (6). In a study by Bowman et
al., 28,236 women were monitored for a mean
9.8 years, and the incidence of hypertension
rose, particularly in subjects smoking more than
15 cigarettes per day. The limitation of this
important study was that it was performed with
women only and therefore its results would not
reflect the entire society (7). Yin et al. reported
high systolic and diastolic blood pressure and
prevalence of hypertension in smokers
compared to non-smokers in a study of 1780
patients (19). There are also a limited number
of studies reporting that cigarette smoking has
no effect on blood pressure. Primatesta et al.
observed no difference in systolic and diastolic
blood pressures between smokers, ex-smokers
and non-smokers (20).
In this study, systolic and diastolic blood
pressures were lower and the prevalence of
hypertension significantly less in smokers
compared to ex- and non-smokers. The levels
were significantly lower in both patients with a
previous diagnosis of hypertension and those
diagnosed during the study. Similar results were
obtained when men and women were analyzed
separately. Blood pressures were lower and the
prevalence of hypertension significantly lower
among ex- compared to non-smokers. Lee et
al. monitored 8170 individuals for 4 years in a
prospective study and reported a rise in both
blood pressure and incidence of hypertension
in ex-smokers compared to subjects who still
smoked (8). The results of that important study
were similar to ours. John et al. reported a
higher incidence of hypertension in obese
patients among ex-smokers compared to
smokers (21). However, no difference was
determined among subjects of normal weight.
The results of that study to a great extent
confirm those of our own.
In a recent study of 679 individuals in Ethiopia,
Awoke et al. reported a prevalence of
hypertension of 28.8% in non-smokers, 25% in
ex-smokers and 15.8% in smokers (22). These
data are compatible with our study findings.
Prevalence of hypertension in our study was
55% in non-smokers, 33% in ex-smokers and
15% in smokers. The prevalence of
hypertension in non-smokers was significantly
high. We mainly attribute this to our study
population being more obese. The mean age in
the study by Awoke et al. was 51.5 and mean
BMI was 23.35, compared to a mean age of
51.2 and mean BMI of 28.5 in our study (22). In
a recent study involving 10,738 participants
providing significant data for Turkey,

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Süleymanlar et al. reported a prevalence of
hypertension of 32.7% (23). The mean age in
their study was 40.5±16.3, with 55.7% of the
population being female (23). Prevalence of
hypertension in our study was 39%, while 56%
of participants were women. Our population
resembled that of Süleymanlar et al. from that
perspective (23). However, the age of our
participants was higher, at 51.2±15.1. We
attribute the higher prevalence of hypertension
in our study to significantly more advanced age.
The effect of cigarette smoking on hypertension
in pregnancy has also been investigated. Yang
et al. performed a retrospective study of nearly
3 million women with single pregnancies and
reported that cigarette smoking significantly
reduced pregnancy-induced hypertension (15).
In another recent study, Rauchfuss et al.
reported that cigarette smoking had no effect
on the development of pregnancy-induced
hypertension (14).
The main limitation of this study is the sample
size and selection of the participants from a
single outpatient clinic rather than a general
population. We used specific patient inclusion
criteria to avoid potential confounders.
In conclusion, despite many studies performed,
the effect of cigarette smoking on blood
pressure and the development of hypertension
is uncertain. Our study showed that cigarettes
reduce the prevalence of hypertension and
lower blood pressure. However, the mechanism
underlying this is unclear. The effect of
cigarettes on preventing weight gain may be a
significant factor. Further research is needed on
the subject.
Conflicts of interest
The authors declare that they have no conflict
of interest.
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