How does smoking cause hypertension?

From the Guidelines

Smoking is a major risk factor for hypertension, causing an acute increase in blood pressure and heart rate, and persisting for more than 15 minutes after smoking one cigarette, as a consequence of stimulation of the sympathetic nervous system at the central level and at the nerve endings. When considering the impact of smoking on hypertension, it is essential to understand the mechanisms by which smoking affects blood pressure. According to the 2013 ESH/ESC guidelines for the management of arterial hypertension 1, smoking causes an acute increase in blood pressure and heart rate, which can persist for more than 15 minutes after smoking one cigarette. This is due to the stimulation of the sympathetic nervous system at the central level and at the nerve endings. Some key points to consider when evaluating the relationship between smoking and hypertension include:

• The ill-health effects of passive smoking, which can also contribute to increased blood pressure and cardiovascular risk 1
• The fact that smoking is a powerful cardiovascular risk factor, and quitting smoking is probably the single most effective lifestyle measure for the prevention of cardiovascular diseases, including stroke, myocardial infarction, and peripheral vascular disease 1
• The importance of establishing tobacco use status at each patient visit and counseling hypertensive smokers regarding giving up smoking, as programs to stop smoking are successful in only 20-30% of motivated patients 1
• The potential benefits of smoking cessation medications, such as nicotine replacement therapy, bupropion, or varenicline, in helping patients to quit smoking and reduce their cardiovascular risk 1.

From the Research

Mechanisms of Smoking-Induced Hypertension

• Smoking can transiently modify the regulation of blood pressure (BP) by a swift effect on the autonomic nervous system, as noted in 2.
• The rise in blood pressure is due to an increase in cardiac output and total peripheral vascular resistance, specifically associated with nicotine, as stated in 3.
• Chronic sympathetic activation induced by tobacco smoking also has some involvement in lipid metabolism and insulin resistance, both implicated in atheromatous disease, according to 2.

Effects of Smoking on Blood Pressure

• Blood pressure and heart rate increase during smoking, with the blood pressure rise appearing immediately and occurring before any increase in circulating catecholamines, as observed in 3.
• In hypertensive patients, the blood pressure lowering effect of beta-blockers may be partly abolished by tobacco smoking, whereas alpha-receptor blockers seem to maintain the antihypertensive efficacy in smokers, as reported in 3.
• Smoking can contribute to the development of atheromatous renal artery stenosis, which is an aggravating cause of hypertension, as mentioned in 2.

Relationship Between Smoking and Cardiovascular Health

• The main risk factor for atherosclerotic cardiovascular disease is smoking, with nicotine and carbon monoxide being two dangerous substances found in cigarette smoke, as stated in 4.
• Smoking is well known to cause oxidative stress, endanger the lining of the arteries, and accelerate the accumulation of fatty plaque in the blood vessels, increasing the risk of sudden thrombotic events, inflammatory alterations, and low-density lipoprotein oxidation, according to 4.
• Chronic cigarette smoking has been shown to affect the macrophages' ability to remove cholesterol, while abstinence from smoking enhances the function of high-density lipoproteins and cholesterol efflux, lowering the risk of plaque buildup, as noted in 4.