4.8 Cardiovascular disease and secondhand smoke

Last updated: January 2017
Suggested citation: Campbell MA, Ford C, & Winstanley MH. Ch 4. The health effects of secondhand smoke. 4.8 Cardiovascular disease and secondhand smoke. In Scollo, MM and Winstanley, MH [editors]. Tobacco in Australia: Facts and issues. Melbourne: Cancer Council Victoria; 2017. Available from http://www.tobaccoinaustralia.org.au/chapter-4-secondhand/4-8-cardiovascular-disease-and-secondhand-smoke

4.8.1 Coronary heart disease

Exposure to secondhand smoke causes coronary heart disease (also known as ischaemic heart disease) in non-smokers.1-4

Secondhand smoke affects the cardiovascular system in non-smokers by multiple mechanisms.3 Secondhand smoke activates blood platelets, which increases the risk of thrombosis and damages the cellular lining of the arteries, which promotes atherosclerosis.3, 5 Secondhand smoke increases arterial stiffness, and affects the ability of arteries to properly expand and contract in order to regulate blood flow. Exposure to secondhand smoke is associated with changes in lipoprotein profiles, including lower blood levels of high density lipoprotein (HDL), a ‘good’ cholesterol, which plays an important role in preventing the progression of atherosclerosis.5 Other mechanisms mediated by secondhand smoke that contribute to cardiovascular disease include increased oxidative stress and decreased antioxidant defence, reduced nitric oxide availability (which mediates vasodilation), infection and inflammation, decreased energy production in the heart muscle, and a decrease in heart rate variability.3, 5, 6 Most of these responses occur rapidly following exposure.3, 5, 7 Where underlying cardiovascular disease already exists, exposure to secondhand smoke exacerbates the condition. Individuals with underlying diabetes, vascular disease or hypertension are at greater risk of harm from secondhand smoke.

It is estimated that exposure to secondhand smoke increases the risk of an acute coronary heart disease event in non-smokers by about 25–30%.2, 3, 8, 9 In comparison, active smoking increases the risk of coronary heart disease by 50–400% depending on the quantity of cigarettes smoked, age and gender.10 Thus the risk of a cardiovascular event among non-smokers approaches the risk for active smokers despite a lower dose of tobacco smoke.3, 11 British research suggests that taking into account all sources of exposure, secondhand smoke may account for an excess risk of up to 60% for coronary heart disease in heavily exposed non-smokers, a rate similar to that for people who smoke up to 10 cigarettes per day.12

Due to the extreme sensitivity of the cardiovascular system to comparatively low exposures of tobacco smoke (See also Section 4.6), secondhand smoke causes a disproportionately high amount of damage. For non-smokers, even brief exposures to secondhand smoke (ranging from minutes to hours) may have 80–90% of the effect of active smoking on some cardiovascular disease mechanisms, including platelet activation and arterial vasodilation.3, 5, 13 For smokers, studies suggest that secondhand smoke does not induce additional effects for these processes, suggesting that they may become saturated at doses experienced by exposed non-smokers (See Section 4.6: Mechanisms of disease).11, 13

4.8.2 Stroke

Current evidence suggests that secondhand smoke may be an independent risk factor for stroke,14 through encouraging atherosclerosis (through the mechanisms outlined above) in the carotid and otherarteries supplying blood to the brain. Further research is required before this finding can be confirmed.2, 3

4.8.3 Exposure to secondhand smoke in children and cardiovascular disease

Exposure to secondhand smoke in childhood and adolescence has been demonstrated to lead to changes in cardiovascular function. This includes impaired endothelial function, thickening of artery walls resulting in reduced aortic elasticity, inflammation and lower blood levels of HDL.2, 3, 15-18

Two studies found that children exposed to tobacco smoke had increased thickness of the walls of the carotid and aortic arteries, with one study linking it to long-term exposure to secondhand smoke,15 and the other to parental smoking during pregnancy.19

There is limited evidence to suggest that childhood exposure to secondhand smoke has long-term effects on cardiovascular function. Children exposed to parental secondhand smoke have also been shown to have impaired endothelial function as adults including increased arterial wall thickness and lower brachial artery flow mediated dilatation, two risk factors for cardiovascular disease.20, 21


1. Scientific Committee on Tobacco and Health. Report of the Scientific Committee on Tobacco and Health. London: UK Department of Health, 1998. Available from: http://www.archive.official-documents.co.uk/document/doh/tobacco/contents.htm

2. Office of Environmental Health Hazard Assessment and California Air Resources Board. Health effects of exposure to environmental tobacco smoke: Final report, approved at the Panel's June 24, 2005 meeting. Sacramento: California Environmental Protection Agency, 2005. Available from: http://www.oehha.ca.gov/air/environmental_tobacco/2005etsfinal.html

3. US Department of Health and Human Services. The health consequences of involuntary exposure to tobacco smoke: A report of the Surgeon General. Atlanta, Georgia: US Department of Health and Human Services, Centers for Disease Control and Prevention, Coordinating Center for Health Promotion, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2006. Available from: http://www.cdc.gov/tobacco/data_statistics/sgr/sgr_2006/index.htm

4. Lv X, Sun J, Bi Y, Xu M, Lu J, et al. Risk of all-cause mortality and cardiovascular disease associated with secondhand smoke exposure: A systematic review and meta-analysis. International Journal of Cardiology, 2015; 199:106–15. Available from: http://www.ncbi.nlm.nih.gov/pubmed/26188829

5. Barnoya J and Glantz S. Cardiovascular effects of secondhand smoke: Nearly as large as smoking. Circulation, 2005; 111:2684–98. Available from: http://www.ncbi.nlm.nih.gov/pubmed/15911719

6. Adams T, Wan E, Wei Y, Wahab R, Castagna F, et al. Secondhand smoking is associated with vascular inflammation. Chest, 2015. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25742439

7. Raupach T, Schafer K, Konstantinides S, and Andreas S. Secondhand smoke as an acute threat for the cardiovascular system: A change in paradigm. European Heart Journal, 2006; 27:386–92. Available from: http://www.ncbi.nlm.nih.gov/pubmed/16230308

8. Law M and Wald N. Environmental tobacco smoke and ischemic heart disease. Progress in Cardiovascular Diseases, 2003; 46:31–8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/12920699

9. Teo KK, Ounpuu S, Hawken S, Pandey MR, Valentin V, et al. Tobacco use and risk of myocardial infarction in 52 countries in the interheart study: A case-control study. Lancet, 2006; 368(9536):647–58. Available from: http://www.ncbi.nlm.nih.gov/entrez/pubmed/16920470

10. International Agency for Research on Cancer. Reversal of risk after quitting smoking. Handbooks of cancer prevention, tobacco control, 11 Vol. 11.Lyon, France: IARC, 2007. Available from: http://apps.who.int/bookorders/anglais/detart1.jsp?sesslan=1&codlan=1&codcol=76&codcch=22

11. Glantz SA and Parmley WW. Even a little secondhand smoke is dangerous. Journal of the American Medical Association, 2001; 286(4):462–3. Available from: http://www.ncbi.nlm.nih.gov/pubmed/11466127

12. Whincup PH, Gilg JA, Emberson JR, Jarvis MJ, Feyerabend C, et al. Passive smoking and risk of coronary heart disease and stroke: Prospective study with cotinine measurement. British Medical Journal, 2004; 329:200–5. Available from: http://www.bmj.com/cgi/content/full/329/7459/200

13. Smith K and Peel J. Mind the gap. Environmental Health Perspectives, 2010; 18(12). Available from: http://ehp03.niehs.nih.gov/article/info:doi/10.1289/ehp.1002517

14. Malek AM, Cushman M, Lackland DT, Howard G, and McClure LA. Secondhand smoke exposure and stroke: The reasons for geographic and racial differences in stroke (regards) study. American Journal of Preventive Medicine, 2015. Available from: http://www.ncbi.nlm.nih.gov/pubmed/26117341

15. Kallio K, Jokinen E, Saarinen M, Hamalainen M, Volanen I, et al. Arterial intima-media thickness, endothelial function, and apolipoproteins in adolescents frequently exposed to tobacco smoke. Circulation. Cardiovascular Quality and Outcomes, 2010; 3(2):196–203. Available from: http://circoutcomes.ahajournals.org/content/3/2/196

16. Geerts CC, Bots ML, van der Ent CK, Grobbee DE, and Uiterwaal CS. Parental smoking and vascular damange in their 5-year old children. Pediatrics, 2012; 129(1):45–54. Available from: http://pediatrics.aappublications.org/content/129/1/45

17. Metsios G, Flouris A, Angioi M, and Koutedakis Y. Passive smoking and the development of cardiovascular disease in children: A systematic review. Cardiology Research and Practice, 2010; 2011. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2945638/?tool=pubmed

18. Nagel G, Arnold F, Wilhelm M, Link B, Zoellner I, et al. Environmental tobacco smoke and cardiometabolic risk in young children: Results from a survey in south-west Germany. European Heart Journal, 2009; 30(15):1885–93. Available from: http://eurheartj.oxfordjournals.org/content/30/15/1885.long

19. Geerts C, Bots M, Grobbee D, and Uiterwaal C. Parental smoking and vascular damage in young adult offspring: Is early life exposure critical? The atherosclerosis risk in young adults study. Arteriosclerosis, Thrombosis, and Vascular Biology, 2008; 28(12):2296–302. Available from: http://atvb.ahajournals.org/cgi/content/full/28/12/2296

20. Gall S, Huynh QL, Magnussen CG, Juonala M, Viikari JS, et al. Exposure to parental smoking in childhood or adolescence is associated with increased carotid intima-media thickness in young adults: Evidence from the cardiovascular risk in young finns study and the childhood determinants of adult health study. European Heart Journal, 2014; 35(36):2484–91. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24595866

21. Juonala M, Magnussen CG, Venn A, Gall S, Kahonen M, et al. Parental smoking in childhood and brachial artery flow-mediated dilatation in young adults. Arteriosclerosis, Thrombosis, and Vascular Biology, 2012; 32:1024–31. Available from: https://www.ncbi.nlm.nih.gov/pubmed/22345167

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