Introduction
Cardiovascular disease (CVD) encompasses a broad spectrum of heart and blood vessel disorders, including coronary artery disease (CAD), heart failure, stroke, and arrhythmias. It remains a leading cause of morbidity and mortality worldwide. In the UK alone, CVD is responsible for 26% of all deaths and accounts for 2 of the top 5 causes of death. Over 7 million people live in the UK with cardiovascular disease. Approximately every 3 minutes someone dies in the UK form a cardiovascular disease and approximately every 5 minutes someone is admitted to a hospital in the UK with a stroke.
(https://www.bhf.org.uk/what-we-do/our-research/heart-statistics)
Cardiovascular disease (CVD) risk factors encompass genetics, lifestyle choices, and environmental influences. These factors are categorized into two groups: modifiable and non-modifiable.
Modifiable risk factors include diabetes, smoking, hypertension (high blood pressure), high cholesterol, and a high body mass index (BMI). These can be managed or altered through lifestyle changes and medical interventions.
Non-modifiable risk factors are those beyond an individual’s control, such as age (over 55), male gender, and a family history of CVD.
Among the most critical and preventable risk factors for CVD is tobacco use. Traditional cigarette smoking is well known for its detrimental impact on cardiovascular health, with decades of research linking it to increased risks of heart attacks, strokes, and peripheral vascular diseases. More recently, vaping—using electronic cigarettes (e-cigarettes) to inhale aerosolized nicotine and other chemicals—has emerged as a popular alternative. Proponents claim that vaping is a safer substitute for traditional smoking, but scientific investigations have raised concerns about its effects on cardiovascular health.
This article explores the evidence surrounding smoking and vaping in relation to cardiovascular disease, examining their physiological effects, mechanisms of harm, and potential benefits of smoking cessation.
Smoking and Heart Disease
In the UK, smoking-related diseases cause approximately 100,000 deaths annually. The majority of these fatalities result from one of three conditions: lung cancer, chronic obstructive pulmonary disease (COPD), or coronary heart disease.
(https://www.bhf.org.uk/informationsupport/heart-matters-magazine/news/e-cigarettes)
The relationship between smoking and heart disease is well-documented. Tobacco smoke contains thousands of harmful chemicals, including carbon monoxide, nicotine, tar, and oxidizing agents, all of which contribute to cardiovascular pathology. Smoking’s adverse cardiovascular effects occur through multiple pathways, including endothelial dysfunction, atherosclerosis, increased blood clotting, inflammation, and oxidative stress.
Endothelial Dysfunction and Atherosclerosis
The endothelium, a thin layer of cells lining blood vessels, plays a vital role in vascular homeostasis by regulating blood flow, preventing clot formation, and controlling inflammatory responses. Smoking impairs endothelial function by reducing the bioavailability of nitric oxide, a critical vasodilator. This results in increased vascular stiffness, impaired blood flow, and elevated blood pressure, which collectively contribute to atherosclerosis.
Atherosclerosis is the buildup of fatty deposits (plaques) in arteries, narrowing them and restricting blood flow. Over time, this process can lead to heart attacks, strokes, and peripheral artery disease (PAD). Smoking decreases arterial elasticity, leading to stiffened vessel walls and increased vascular strain.
(https://pubmed.ncbi.nlm.nih.gov/8994413/)
Increased Blood Clotting and Thrombosis Risk
Smoking promotes thrombosis (blood clot formation) by increasing platelet aggregation and altering fibrinogen levels. These changes make the blood more prone to clotting, raising the risk of heart attacks and strokes.
Inflammation and Oxidative Stress
Cigarette smoke is a potent source of oxidative stress, which generates free radicals that damage blood vessels and promote inflammation. Chronic inflammation contributes to plaque instability, increasing the likelihood of atherosclerotic plaques rupturing and triggering cardiovascular events. Cigarette smoking accelerates the oxidation of plasma LDL cholesterol, the “bad” cholesterol, which promotes atherosclerosis and disrupts endothelial function.
(https://pubmed.ncbi.nlm.nih.gov/8759254/)
Impact on insulin resistance/hyperinsulinemia and diabetes
Smoking is linked to increased insulin resistance and hyperinsulinemia, both of which contribute to the development of diabetes and the progression of atherosclerosis. Insulin resistance is often accompanied by disruptions in lipid metabolism, further compounding cardiovascular risk. Additionally, chronic smoking promotes visceral fat accumulation, which exacerbates insulin resistance and metabolic dysfunction.
(https://pubmed.ncbi.nlm.nih.gov/18400700/)
Smokers exhibit greater insulin resistance and higher insulin levels compared to nonsmokers, a condition believed to be a precursor to type 2 diabetes.
(https://pubmed.ncbi.nlm.nih.gov/1349365/)
Smokers with diabetes have higher hemoglobin A1c (HbA1c) levels. HbA1c is a glycated hemoglobin, which indicates long-term control of blood sugar. If elevated it points towards poor glucose control. Smokers also require more insulin, and have higher risk of vascular complications of diabetes such as CVD, problems with eyes and kidneys.
(https://pubmed.ncbi.nlm.nih.gov/22108412/)
Impact on Blood Pressure and Heart Rate
Blood pressure spikes sharply upon smoking but gradually returns to pre-smoking levels within a few hours.
(https://pubmed.ncbi.nlm.nih.gov/688779/)
Age may influence the relationship between smoking and blood pressure. A large cross-sectional study of a nationally representative sample of UK adults found that older male smokers had higher systolic blood pressure, even after adjusting for other factors. However, this effect was not observed in younger smokers.
(https://pubmed.ncbi.nlm.nih.gov/11230269/)
Smoking and high cholesterol
Compared to nonsmokers, smokers exhibit higher levels of low-density lipoprotein (LDL) cholesterol and lower concentrations of high-density lipoprotein (HDL) cholesterol. On average, smokers have 3% higher total cholesterol, 9% higher triglycerides, and 5.7% lower HDL levels, increasing their cardiovascular risk. (https://pmc.ncbi.nlm.nih.gov/articles/PMC1836079/)
Vaping Effects on Cardiovascular Health
E-cigarettes have gained popularity as a perceived safer alternative to traditional smoking. According to a 2019 YouGov survey, more than 3.6 million adults in Great Britain use e-cigarettes – 7.1 per cent of the adult population. Of these users, 54 per cent are ex-smokers, suggesting they are helping people to stop smoking. (https://www.bhf.org.uk/informationsupport/heart-matters-magazine/news/e-cigarettes) Unlike combustible cigarettes, e-cigarettes do not produce tar or carbon monoxide. However, they still deliver nicotine and a variety of other chemicals, some of which may pose cardiovascular risks.
E-cigarettes and vascular endothelial function
According to a meta-analysis published in European Journal of Preventive Cardiology in March 2023, they:
* increase pulse wave velocity
* increase heart rated corrected augmentation index
* have no effect on flow-mediated dilation.
The above was compared to vaping without nicotine and tobacco. It was a study, which included overall 8 trials and 372 individuals. The authors concluded: ‘In summary, evidence from our pooled analyses indicated that acute inhalation of e-cigarettes leads to negative changes in vascular endothelial function. E-cigarettes cannot be used as an alternative to public health strategies for tobacco-control and should not be considered cardiovascular safety products. More future research should be conducted to verify our findings.’ (https://pubmed.ncbi.nlm.nih.gov/36316290/)
A study published in 2022 in a journal Arteriosclerosis, Thrombosis, and Vascular Biology concluded that: Vaping, unlike smoking, alters the blood in a way that increases microvascular endothelial permeability and may uniquely impact the intracellular oxidative state. (https://www.ahajournals.org/doi/10.1161/ATVBAHA.121.317749)
Acute and Chronic Effects of Vaping on Cardiovascular Function
Although e-cigarette use is on the rise, they are not without risks. A 2016 study in Environmental Science & Technology found that e-cigarette vapor contains harmful emissions, including potential carcinogens and irritants—albeit at significantly lower levels than those in traditional cigarettes. (https://www.bhf.org.uk/informationsupport/heart-matters-magazine/news/e-cigarettes)
Nicotine’s Role in Vaping and Cardiovascular Risk
Nicotine is a key component in most e-cigarettes. Nicotine is highly addictive but not a major health risk for individuals without heart conditions. It does not cause acute cardiac events, coronary heart disease, or cancer. However, for those with heart disease, nicotine poses a concern as it elevates heart rate, counteracting the effects of most treatments. (https://www.bhf.org.uk/informationsupport/heart-matters-magazine/news/e-cigarettes) Nicotine exposure through vaping activates the sympathetic nervous system, increasing heart rate. While some vaping products contain lower nicotine levels than cigarettes, heavy e-cigarette use can result in similar nicotine intake and, consequently, similar cardiovascular risks.
E-Cigarettes and Myocardial Infarction Risk
Recent epidemiological studies have linked e-cigarette use to an increased risk of myocardial infarction (heart attack). Data from the National Health Interview Survey found that individuals who used e-cigarettes daily may have an increased risk of myocardial infarction in individuals who have never smoked traditional cigarettes. (https://pmc.ncbi.nlm.nih.gov/articles/PMC10700683/pdf/cureus-0015-00000048402.pdf) This risk was even more pronounced in dual users—those who smoke traditional cigarettes while also vaping, according to a study published in November 2023. (https://tehj.springeropen.com/articles/10.1186/s43044-023-00426-6)
Tobacco Use and Cardiovascular Risk
The overall cardiovascular risks associated with tobacco use is profound. Any form of tobacco consumption contributes to increased oxidative stress, inflammation, endothelial dysfunction, and thrombosis, all of which heighten the risk of CVD.
Dual Use of cigarettes and E-cigarettes
Many smokers turn to vaping as a means of quitting, but a significant portion continue to use both products.
Nicotine and Heart Health
Nicotine is a primary ingredient in both e-cigarettes and cigarettes and is highly addictive. While it is not a major health risk for individuals without preexisting heart conditions and does not directly cause acute cardiac events, coronary heart disease, or cancer, it can be problematic for those with cardiovascular disease. Nicotine increases heart rate and blood pressure, potentially counteracting the benefits of many heart disease treatments and exacerbating cardiovascular strain.
Nicotine Replacement Therapy (NRT) and Cardiovascular Safety
Nicotine replacement therapy (NRT) is a well-established and effective pharmacological aid for smoking cessation. However, anecdotal concerns about potential adverse cardiovascular effects have led to cautious use, particularly among individuals with existing heart disease. Despite these concerns, research indicates that NRT does not increase cardiovascular events compared to continued smoking.
For individuals with cardiovascular disease, persistent smoking significantly heightens the risk of myocardial infarction, stroke, and other serious vascular complications. The benefits of NRT in supporting smoking cessation are well-documented, with evidence strongly supporting its role in improving quit rates. Its effectiveness is further enhanced when combined with behavioral counseling and other cessation strategies. Given its proven safety and efficacy, NRT should be considered a valuable tool in helping high-risk patients quit smoking and reduce their cardiovascular risk. (https://www.mayoclinicproceedings.org/article/S0025-6196(11)63097-8/fulltext)
Smoking Cessation and Heart Disease
The benefits of smoking cessation for cardiovascular health are substantial and well-documented. The risk of CVD declines rapidly after quitting, with significant improvements occurring within weeks to months.
Timeline of Cardiovascular Benefits After Quitting (https://www.cancer.org/cancer/risk-prevention/tobacco/guide-quitting-smoking/benefits-of-quitting-smoking-over-time.html)
- 20 minutes after quitting: Heart rate and blood pressure normalize.
- 12 hours: Carbon monoxide levels in the blood decrease.
- 2–3 weeks: Your risk of myocardial infarction starts to decrease.
- 1 year: Risk of heart disease is reduced by 50%.
- 5 years: Stroke risk falls to that of a non-smoker.
- 15 years: Risk of coronary heart disease returns to that of a non-smoker.
Dr Bart Olechowski: An experienced Consultant Cardiologist based in Hampshire (Winchester, Basingstoke, Andover and Farnham), UK
Dr Bart Olechowski works an NHS and a private consultant cardiologist. He sees patients across Hampshire in three different private clinics – Candover in Basingstoke, Sarum Road Hospital in Winchester and Spire Clare Park Hospital in Farnham. With years of experience Dr Olechowski provides comprehensive consultations, which include primary prevention and life style advice. His patient-centred approach emphasizes prevention, early detection, and personalised treatment plans tailored to each individual’s needs. Dr Bart`s commitment to holistic care underscores the importance of collaboration between medical professionals and patients to achieve optimal heart health and long term satisfactory results.
Summary and Conclusions
Smoking is associated with an increased cardiovascular risk. Vaping may also be associated with a higher risk of heart disease. Although the mechanisms and severity differ between the two unhealthy habits. While traditional smoking is a well-established contributor to heart disease through endothelial dysfunction, atherosclerosis, and thrombosis, vaping also appears to poses significant risks, particularly due to nicotine exposure and endothelial dysfunction.
Smoking cessation is one of the most effective ways to reduce cardiovascular risk. Former smokers experience dramatic improvements in heart health, emphasizing the importance of cessation programs and interventions.
As the body of research on vaping grows, it is crucial for public health policies to address its risks while also providing clear guidance on cessation strategies. The best strategy for heart health remains complete cessation of all tobacco and nicotine products.
