SMOKING AND BLOOD PRESSURE

J. Fiala, M.D., Ph.D.1), V. Soska, M.D., Ph.D.2), D. Hruba, prof., Ph.D.1), K. Nebeska, mgr. 1)

1)
Department of Preventive Medicine, Faculty of Medicine, Masaryk University,
Komenskeho n. 2, 662 43 Brno, Czech Republic
Chief: Prof. Z. Derflerova Brazdova, M.D., DrSc.

2)
Department of Clinical Biochemistry, University hospital „St. Anna“ in Brno,

Pekarska 53, 656 91 Brno, Czech Republic

Chief: V. Soska, M.D., Ph.D.

The manuscript has not been published previously and it is not under consideration for

publication elsewhere. The publication is approved by all authors and by the responsible

authorities of the institutions. If the manuscript will be accepted, it will not be published

elsewhere in the same form, in English or in any other language.

Corresponding author:

Prof. Drahoslava Hruba, M.D., Ph.D.

hruba@med.muni.cz
Department of Preventive Medicine, Faculty of Medicine, Masaryk University,
Tomesova 12,
600 00 Brno
Czech Republic

Tel. 420 54 949 4068

Fax. 420 54 949 1390
Abstract

Objectives: Hypertension is an important cardiovascular risk factor. Several non- preventable

and preventable determinants, including smoking, in the multifactorial ethiology have been

described. The relationship between smoking and the development of hypertension is unclear,

the results of studies are inconsistent. This paper presents the results obtained from the cohort

of young healthy women involved into the study investigating the influence of hormonal

contraceptive treatment on important markers of cardiovascular health.

Methods: The main condition for voluntary participation in the study was an absence of any

chronic disease. From the series of four examinations, each collected data concerning

nutritional habits and alcohol consumption, smoking, physical activity, family and personal

health history by special questionnaire. Objective parameters measured basic anthropometry

(weight, height, body mass index BMI, waist circumference), and blood pressure.

Biochemical data obtained from blood and urinary sampling are not involved in this paper.

Blood pressure was measured twice during the every session, sitting, within a 10-15 minutes

interval. The differences between smoking and non-smoking participants were evaluated by

paired T-test and Pearson’s test by SPSS ver. 15 statistical software.

Results: In the first examination before the beginning of the contraceptive treatment, from a

total of 66 participants, 44 (66.7%) were non-smokers and 22 (33.3%) reported daily smoking

less than 10 cigarettes. There were no differences in age, body mass index (BMI) and waist

circumferences, nor in sportindex between smokers and non-smokers. Smokers reported

significantly higher consumption of alcoholic beverages: on average almost three times more

drinks per week than non-smokers. In both measurements the average values of blood

pressure were lower in the group of smokers compared to non-smokers; but the differences

were significant only for the diastolic blood pressure. No significant correlations were found

between blood pressure and alcohol consumption, BMI, waist circumferences.

2
Conclusions: Our results did not confirm the hypothesis that smoking´s beneficial influence

on blood pressure is mediated mainly via reduction abdominal obesity, as we found no

associations between blood pressure, BMI, and waist circumference.

Key words: smoking; young healthy women; blood pressure

3
Introduction

Hypertension is an important cardiovascular risk factor; it is associated with structural

vascular remodelling, endothelial dysfunction and arterial stiffness (1). The multi-factorial

pathophysiology of hypertension is well known: the main non-preventable determinants are

genetic predisposition (2), changes in renin-angiotensin system, age and gender (3). On the

other hand, individual behaviour includes other risk factors, which are preventable, such as

physical inactivity, obesity, alcohol abuse, smoking (4) and oral contraceptives / hormone

replacement therapy (5).

The mechanisms of the short-term increase in blood pressure occurring immediately after

smoking even one single cigarette are well understand: as the impact of nicotine on

sympathetic nervous system activation and the release of suprarenal hormones (6), and an

immediate increase of arterial stiffness (7). On the other hand, the relationship between

smoking and the development of hypertension is unclear. Results of studies describing

associations between habitual smoking and blood pressure and/or newly developed

hypertension are inconsistent and vary from modest positive effects (8, 9, 10, 11), through no

observed effect (12, 13), to protective effects.

According to our knowledge, the first study describing slightly lower blood pressure in

smokers was conducted in Finland in the middle of the last century (14). Later on, numerous

studies found similar but not fully consistent results (recently 15, 16, and 17). Habitually

smoking men had significantly negative correlation on the development of hypertension, but

the same effect was not seen among women (18). In the Women’s Health Study following up

more than 28 000 women for almost 10 years, the adjusted risk 1.12 (95% CI 1.03-1.21) was

seen only for heavy smokers (smoking more than 15 cigarettes daily), but not for those who

smoked up to 15 cigarettes per day (11). The similar results – lower blood pressure among

lightly smoking women (up to 10 cigarettes per day) than of both heavier smokers and non-

4
smokers was also evident from the Health Survey for England. The differences were most

expressed among those who did not drink alcohol (19).

This paper presents the results obtained from the cohort of young healthy women involved

into the study investigating the influence of hormonal contraceptive treatment on important

markers of cardiovascular health, including changes in blood pressure. The main condition for

the voluntary participation in the study was an absence of any chronic disease, with special

concern for hypertension, diabetes mellitus, obesity, elevated levels of serum lipids and no

hormonal treatment before the first laboratory measurement. The design of the semi-

longitudinal prospective study included an introductory examination immediately before the

start of using hormonal contraception, and three repeated examinations, each after the three-

month period. As the first observation was performed before the start of any hormonal

contraceptive treatment, or after at least three months abstinence, the results are not

influenced by such therapy and allow the comparing of smoking and non-smoking

participants.

Methods

Recruitment of participants was organized both though cooperation with gynaecologists and

by e-mail and/or given in information leaflets to university students. Participating volunteers

were informed about the aims of the study, about the rules to be kept and asked to sign their

informed consent to the work, which has been approved by ethical committees of both

Medical Faculty and University Hospital. The rules included no alcohol and food

consumption and no smoking overnight, at least eight hours before the examination.

Each examination collected the data concerned on nutritional habits and alcohol consumption,

smoking, physical activity, family and personal health history by special questionnaire.

5
Dietary habits were measured by the food frequency within the last week, self-reported intake

of cereal products, fresh and boiled fruits and vegetables, milk and diary products, meat, fish,

eggs and leguminous products, fat spread and sugar/sweat products. Alcohol intake was

measured by the number of units (one unit = approx. 10g of ethanol) calculated by the

consumption of different kinds in their typical glasses. Also leisure physical activity was self-

reported as time spent by walking, bicycling, swimming, and regular/competitive sport. The

level of physical activity was summarized by so-called „Sportindex“, which was calculated by

multiplying three parameters: 1) weekly frequency of exercise, 2) usual duration of one

exercise, and 3) self-estimated intensity expressed in MET units (Metabolic Equivalent),

estimated by means of auxiliary scale 1-10 (1=rest, 10= maximum intensity). Objective

parameters measured basic anthropometry (weight, height, body mass index BMI, waist

circumference), blood pressure, blood and urinary sampling ( blood lipid parameters, C-

reactive protein, fibrinogen and Factor 8, urinary cotinine and creatinine); these biochemical

data are not involved in this paper. Height was measured without shoes to the nearest 0.5 cm,

and weight was measured without shoes, overcoat and jersey to the nearest 0.1kg. BMI was

calculated as kg/m2. Waist circumference was measured without clothes, midway between the

lower rib margin and the iliac crest. Systolic and diastolic blood pressures were measured

twice using the OMRON type M4; sitting, within a 10 - 15 minute interval. All these

measurements were made by two registered nurses. According to the smoking data, daily

and/or occasional smokers smoked cigarettes only. Women were divided into the groups of

never and/or former smokers and current smokers. Exposure to environmental tobacco smoke

(never, rarely, often) was also stated, but exposure of non-smokers was not mentioned at all,

or only rarely. The differences between smoking and non-smoking participants were

evaluated by paired T-test and Pearson’s test, by SPSS ver. 15 statistic software.

6
Results

From the total of 66 participants, 44 (66.7 %) were non-smokers and 22 (33.3 %) reported

daily smoking from 1 to 10 cigarettes. There were no differences in age, body mass index

(BMI) and waist circumferences between smokers and non-smokers (tab. 1).

Tab. 1

Smoking women compared with non-smokers had a lower level of sportindex expressing their

physical activity, but differences were not significant (tab. 2). Smokers reported significantly

higher consumption of alcoholic beverages: on average almost three times more drinks per

week than non-smokers (tab. 2). These differences were influenced predominantly by the

drinking of beer (0.5 drinks for non-smokers, 3.2 drinks for smokers, p< 0.0001) and spirits

(0.7 drinks for no smokers, 1.8 drinks for smokers, p< 0.05). The average consumption of

wine per week was also higher among smokers, but the differences were not significant (2.8

drinks vs. 1.5 drinks, p > 0.05).

Tab. 2

In both measurements, the average values of blood pressure were lower in the group of

smokers compared to non-smokers. The differences were significant only for the diastolic

blood pressure in both measurements (tab. 3). Except for one single case, no significant

correlation (using the Pearson’s test) were found between blood pressure and alcohol

consumption, BMI, and waist circumferences (tab. 4).

Tab. 3, Tab. 4

Discussion

Hypertension is one of the important risk factors of cardiovascular diseases and it is necessary

to understand the effect of smoking on blood pressure. The controversial results, mentioned in

7
introduction, are supported by the results of studies concerned on the changes after smoking

cessation: most of them have found no effect (20, 21, 22), but the increase in blood pressure

after stopping smoking was also described (23), as well as the beneficial influence on lowered

blood pressure (24).

Numerous possible causes are hypothesized to influence the beneficial impact of smoking on

blood pressure:

- smoking may control the body weight and keep BMI reduced

- the coronary heart disease occurring among smokers may reduce myocardial

contractility

- long-term smoking leads to an increase in nicotinic receptors and consequently the

mechanism of sympathetic reflex may be dysregulated

- cadmium in tobacco smoke might reduce blood pressure (25)

- smokers compared with non-smokers have inhibited psychophysiological stress

responsiveness (8, 20).

On the other hand, the pathways described smoking as an independent risk factor for

developing of hypertension are also investigated.

Arterial stiffness seems to be associated both with atherosclerosis and hypertension. It has

been described that not only chronic smoking can increase arterial stiffness (7), but even a

single cigarette can cause a short-term rise in arterial wall stiffness (26). Negative effects of

smoking on the vascular system were found even for young light smokers (up to 10 cigarettes

a day) (27). While the effects of smoking cessation on blood pressure have been well

documented (24), it is not clear whether similar benefit effects occurs also for arterial

stiffness. It is suspected that the improvement of the arterial stiffness parameters to those of

non-smoking controls needs longer - at least a decade of smoking cessation (28). On the other

8
hand, other studies claimed positive changes in arterial elasticity after a short time of smoking

abstinence: from four weeks (29) to six months (30).

Gradual changes in the vascular structure have an influence on the decreasing of vascular

compliance and the increasing of arterial stiffness occur during the process of normal arterial

ageing. In susceptible persons, a more rapid progression of vascular changes and

atherosclerosis with characteristic lesions and plaque formation might occur and result in

premature manifestation of cardiovascular diseases. It is now suggested, that an important

part of the vascular ageing is based on the telomere length and lower level of enzyme

telomerase activity (31).

In some experimental studies, a direct link between telomerase activity and hypertension was

described (32), and shorter telomere length has been found in persons with hypertension and

atherosclerosis (33). Accelerated telomere shortening has been also described for some of the

risk factors of cardiovascular diseases, especially smoking, obesity (34, 35), and lower

socioeconomic status (36).

Conclusion

Our study has found a significantly lower average blood pressure in smoking women

compared with non-smokers, although they were only light smokers (up to 10 cigarettes per

day) and the measurements were performed during the morning hours, when smokers may

have higher sympathetic reflex activity and their blood pressure is usually greater during

morning hours (37). Our results did not confirm the hypothesis that smoking´s beneficial

influence on the blood pressure is mediated mainly via reduction abdominal obesity, as we

found no associations between blood pressure, BMI, and waist circumference.

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Acknowledgement: The study is supported by the IGA MZ CR (Internal Grant Agency,

Ministry of Health, Czech Republic) No NR8841-4

Statement: The work has been approved by the ethical committees of the Faculty of Medicine

and University Hospital, Masaryk University, Brno. All subjects gave informed consent to the

work. No competing interest is declared.

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Tab 1: Age and anthropometric parameters of no-smoking (NS) and smoking (S) women

Total NS S sig

N 66 44 22

Age (years): mean 22.61 22.84 22.14 ,410

S.D. 3.24 3.04 3.64

95% CI 21.81 21.92 20.52

23.40 23.77 23.75

BMI : mean 21.72 21.69 21.79 ,882

S.D. 2.55 2.49 2.73

95% CI 21.10 20.94 20.58

22.35 22.44 23.00

Waist circumference (cm) : mean 72.81 72.51 73.41 ,644

S.D. 7.40 7.72 6.82

95% CI 71.00 70.19 70.39

74.61 74.83 76.43

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Tab. 2: Physical activity (as „sportindex“) and alcohol consumption (drinks per week, one

drink = 10 g of ethylalcohol) of no-smoking (NS) and smoking (S) women

Total NS S sig

Sport index: mean 1037.5 1106.8 898.9 ,420

S.D. 907.8 995.2 705.3

95% CI 796.7 779.7 559.0

1278.4 1434.0 1238.9

Alcohol (Summ): mean 4.37 2.73 7.73 ,000

S.D. 4.83 2.65 6.41

95% CI 3.19 1.94 4.88

5.55 3.53 10.57

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Tab 3: The values of blood pressure (torrs) of no-smoking (NS) and smoking (S) women

mean SD 95% CI min max sig

Systolic 1 : total 121.25 14.76 117.65 - 124.85 95 163

NS 123.29 13.84 119.13 - 127.45 96 163

S 117.09 16.00 110.00 - 124.18 95 148 ,107

Diastolic 1: total 71.49 8.12 69.51 - 73.47 52 89

NS 72.89 7.27 70.70 - 75.07 53 89

S 68.64 9.14 65.59 - 72.69 52 86 ,043

Systolic 2 : total 114.03 12.23 111.05 - 117.01 89 141

NS 114.58 11.81 111.03 - 118.12 89 136

S 112.91 13.25 107.04 - 118.78 97 141 ,604

Diastolic 2: total 69.27 8.03 67.31 - 71.23 52 91

NS 70.71 7.71 68.39 - 73.03 53 91

S 66.32 8.03 62.76 - 69.88 52 82 ,034

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Tab. 4: The correlations between blood pressure and some other cardiovascular risk factors

(values of the Pearson´s coeficients).

Blood pressure

systolic 1 diastolic 1 systolic 2 diastolic 2

Alcohol intake (summ) -0.112 -0.150 -0.070 -0.140

BMI 0.192 0.128 0.129 0.043

Whist circumference 0.044 0.021 0.068 -0.061

17