Smoking and hypertension significantly increase cardiovascular risks. A meta-analysis found that smoking increased the risk of subarachnoid hemorrhage by 2.4 times while hypertension increased it by 2 times. Another study found smoking increased the risk of fatal heart failure by 30% and each 10 mmHg increase in blood pressure raised the risk by 13%. A Japanese study showed those under 60 with both smoking and hypertension had the highest risks, with over 3 times greater CVD mortality. Efforts to discourage smoking and control hypertension, especially in youth, could substantially reduce cardiovascular disease burden.

1. CV Outcomes Of
Smoking And Hypertension
Nemencio A. Nicodemus Jr., MD, FPCP, FPSEDM
Professor, UP College of Medicine
Vice-President, Philippine Society of Endocrinology, Diabetes & Metabolism

2. Learning Objectives
• To discuss the potential mechanisms for
smoking-mediated cardiovascular
dysfunction
• To discuss the burden of disease
attributable to and prevalence of smoking
and hypertension
• To discuss the cardiovascular outcomes of
smoking and hypertension

4. Cigarette Smoke Is Divided Into
Two Phases
Tar Or Particulate Phase
• Material that is trapped
when the smoke stream is
passed through the
cambridge glass-fiber filter
that retains 99.9% of all
particulate material with a
size >0.1 m
• Contains >1017 free
radicals/g
• Radicals associated are
long-lived (hours to months)
Gas Phase
• Material that passes
through the filter
• Contains >1015 free
radicals/puff
• Radicals have a shorter
life span (seconds)
Pryor WA, Stone K. Ann NY Acad Sci 1993; 686:12–28.

5. Mainstream Smoke
• Cigarette smoke that
is drawn through the
tobacco into an active
smoker’s mouth
• Comprises 8% of tar
and 92% of gaseous
components
Pryor WA, Stone K. Ann NY Acad Sci 1993; 686:12–28.

6. Sidestream Smoke
• Smoke emitted from the burning ends
of a cigarette
• Contains a relatively higher
concentration of the toxic gaseous
component than mainstream cigarette
smoke
Glantz SA, Parmley WW. CirculaDon 1991;83:1–12.

7. Environmental Tobacco Smoke
• Results from the combination of
sidestream smoke (85%) and a small
fraction of exhaled mainstream smoke
(15%) from smokers
Taylor AE, Johnson DC, Kazemi H. CirculaDon 1992;86:699–702.

8. The Ugly Truth!
• Both active and passive
(environmental) cigarette
smoke exposure
predispose to
cardiovascular events
Amrose, JA and Barua RS. JACC Vol. 43, No. 10, 2004:1731–7

9. Potential Mechanisms For Cigarette Smoking-mediated
Cardiovascular Dysfunction
Amrose, JA and Barua RS. JACC Vol. 43, No. 10, 2004:1731–7

10. Potential Mechanisms For Cigarette Smoking-mediated
Cardiovascular Dysfunction
Amrose, JA and Barua RS. JACC Vol. 43, No. 10, 2004:1731–7

11. Main Determinants Of The Acute
Vascular Damage From Smoking
Active smoking Passive smoking
Increased platelet
aggregation
Impaired endothelium-
dependent vasodilatation
Increased platelet
adhesiveness
Reduced nitric oxide
production
Changes in platelet form Increased systolic blood
pressure
Thrombus formation Increased heart rate
Increased
carboxyhemoglobin
Increased
carboxyhemoglobin
Leone A. J Cardiol Curr Res 2015, 2(2): 00057

12. Common Classes Of Antihypertensive
Drugs And Their Response To Smoking
Drug Response to smoking
Beta-blockers Highly reduced (+++)
ACE-Inhibitors Highly reduced (+++)
Calcium Antagonists Reduced (++/−)
Diuretics Highly reduced (+++)
Angiotensin receptor
blockers
not yet known (−−/+ ?)
Leone A. Cardiology Research and PracDce. Volume 2011, doi:10.4061/2011/264894

13. Burden Of Disease Attributable To 20
Leading Risk Factors In Both Sexes, 2010
Lim SS, et al, Lancet. 2012 Dec 15; 380(9859): 2224–2260

14. Burden Of Disease Attributable To 20
Leading Risk Factors In Men, 2010
Lim SS, et al, Lancet. 2012 Dec 15; 380(9859): 2224–2260

15. Burden Of Disease Attributable To 20
Leading Risk Factors In Women, 2010
Lim SS, et al, Lancet. 2012 Dec 15; 380(9859): 2224–2260

21. CV Risks With Smoking &
Hypertension

22. Feigin V, et al. on behalf of the Asia Pacific Cohort Studies CollaboraDon Stroke. 2005;36:1360-1365.

23. Design
• Included Individual
participant data from 26
prospective cohort
studies (total number of
participants 306,620)
that reported incident
cases of SAH (fatal
and/or nonfatal)
• Median follow-up period
of 8.2 years
Feigin V, et al. on behalf of the Asia Pacific Cohort Studies CollaboraDon Stroke. 2005;36:1360-1365.

24. Hypertension And Smoking Significantly
Increase The Risk Of SAH
Feigin V, et al. on behalf of the Asia Pacific Cohort Studies CollaboraDon Stroke. 2005;36:1360-1365.

25. Findings From This Meta-analysis
• Current smoking (HR, 2.4; 95% CI, 1.8 to 3.4) and
SBP >140 mm Hg (HR, 2.0; 95% CI, 1.5 to 2.7)
were significant and independent risk factors for
SAH
• Attributable risks of SAH associated with current
smoking and elevated SBP (≥140 mm Hg) were
29% and 19%, respectively
• The strength of the associations of the common
cardiovascular risk factors with the risk of SAH did
not differ much between Asian and Australasian
regions
Feigin V, et al. on behalf of the Asia Pacific Cohort Studies CollaboraDon Stroke. 2005;36:1360-1365.

27. Design
• Individual level data from 543,694 (85% Asian;
36% female) participants from 32 cohorts in the
Asia Pacific Cohort Studies Collaboration were
included
• Adjusted hazard ratios for mortality from HF were
estimated separately for Asians and non-Asians
for a quintet of cardiovascular risk factors:
– systolic blood pressure, diabetes, body mass index,
cigarette smoking and total cholesterol
• 3,793,229 person-years of follow-up
Huxley et al. BMC Cardiovascular Disorders 2014, 14:61

28. A 10 mm-Hg Increment In Systolic BP
Increased The Risk Of Fatal HF By 13%
Huxley et al. BMC Cardiovascular Disorders 2014, 14:61
Hazard ratios for fatal heart failure associated with a 10 mm-Hg
Increment in systolic blood pressure

29. Cigarette Smoking Increased The
Risk Of Fatal Heart Failure By 30%
Huxley et al. BMC Cardiovascular Disorders 2014, 14:61
Hazard ratios for fatal heart failure associated with cigarette smoking
(ever versus never)

30. Findings From This Meta-analysis
• Most traditional
cardiovascular risk
factors including
elevated blood
pressure, obesity and
cigarette smoking
appear to operate
similarly to increase the
risk of death from HF in
Asians and non-Asians
populations alike
Huxley et al. BMC Cardiovascular Disorders 2014, 14:61

31. Hypertens Res 2007; 30: 1169–1175

32. Design
• 8,912 Japanese men and women without a
history of stroke and heart disease
• Categorized into 4 groups:
– Individuals who neither smoked nor had
hypertension (HT)
– Current smokers
– With HT
– Current smokers with HT
• Follow-up of 19 years
• Assessing risk of CVD and all-cause mortality
Hozawa A, et al. Hypertens Res 2007; 30: 1169–1175

33. HR for CVD and All-cause Mortality According
to BP or Smoking Status, age < 60 years
Normotensive Hypertensive
Non-
smoker
Current Non-smoker Current
Men
HR for CVD
mortality
1 1.58
(0.63 – 3.97)
1.96
(0.73 – 5.22)
3.86
(1.62 – 9.19)
HR for all-
cause
mortality
1 1.4
(0.98 – 2.01)
1.21
(0.79 – 1.84)
1.69
(1.17 – 2.42)
Women
HR for CVD
mortality
1 2.58
(0.75 – 8.93)
2.19
(1.13 – 4.22)
5.88
(2.07 – 16.72)
HR for all-
cause
mortality
1 1.63
(0.90 – 2.94)
1.07
(0.79 – 1.47)
1.77
(0.91 – 3.46)
Adapted from Hozawa A, et al. Hypertens Res 2007; 30: 1169–1175

34. HR for CVD and All-cause Mortality According
to BP or Smoking Status, age ≥ 60 years
Normotensive Hypertensive
Non-
smoker
Current Non-smoker Current
Men
HR for CVD
mortality
1 1.02
(0.56 – 1.87)
1.27
(0.74 – 2.17)
1.72
(1.02 – 2.89)
HR for all-
cause
mortality
1 1.24
(0.87 – 1.76)
1.32
(0.95 – 1.82)
1.47
(1.07 – 2.02)
Women
HR for CVD
mortality
1 0.46
(0.14 – 1.48)
1.23
(0.88 – 1.71)
2.01
(1.25 – 3.23)
HR for all-
cause
mortality
1 1.23
(0.75 – 2.01)
1.28
(1.03 – 1.59)
1.61
(1.15 – 2.26)
Adapted from Hozawa A, et al. Hypertens Res 2007; 30: 1169–1175

35. Implications of this Study
• Aggressive attempts to
discourage smoking and
to curb HT could yield
large health benefits ,
particularly for those
aged <60 years.
Hozawa A, et al. Hypertens Res 2007; 30: 1169–1175

36. Implications of this Study
• Efforts to warn about the adverse
consequence of HT and smoking during
adolescence and youth could yield the
greatest health benefits, since positive
behaviors adopted early are more easily
continued into middle adulthood and later
life
Hozawa A, et al. Hypertens Res 2007; 30: 1169–1175

37. CV Outcomes Of Smoking And Hypertension:
Summary
• Smoking and hypertension both induce vascular
damage that could lead to the initiation and
progression of atherothrombotic diseases
• Smoking and hypertension increase the risk of
SAH and mortality from HF, CVD and all causes
• Younger patients with HT and smoking are at
higher risk for mortality and will benefit more with
interventions, especially in our country where a
significant number with risk these risk factors are
young