As detailed in Section 3.1, smoking causes cardiovascular disease, and generally, if a person continues to smoke after developing a cardiovascular disease, then their prognosis is worse than if they had quit. Smoking is also associated with poorer outcomes and increased risk of some complications after heart and vascular surgery, including coronary artery bypass and carotid endarterectomy (Sections 3.15.1.2 and 3.15.1.3).
Statins are a range of medications that improve cardiovascular outcomes by lowering cholesterol. They are used to prevent cardiovascular disease or to lower the risk of mortality from cardiovascular disease for people who have it. Statins reduce cardiovascular disease outcomes and mortality for people who smoke1 and their use is recommended for people who smoke for prevention of cardiovascular disease.2
A study of more than 18,000 patients who were receiving a statin drug for coronary disease found that over a five-year period those who continued to smoke had about a 50% higher chance of a major cardiovascular event (heart attack, stroke, cardiac arrest or death) than patients who quit.3 Another study found that although statins were effective in reducing cardiovascular events (heart attack, angina stroke, etc) for people with coronary artery disease who smoke, they still had a greater risk of cardiovascular events compared to non-smokers.2 However, a meta-analysis from 2017 found that the risk of major cardiovascular events in people using statins was similar for people who smoke and non-smokers.4 More research is necessary to better define the effects of smoking on statin treatment.
Percutaneous coronary intervention (PCI) is a minimally invasive procedure used to treat narrowing of the arteries in the heart. It can reduce the risk of heart attack, or be used to treat a person undergoing a heart attack. Coronary artery bypass graft (CABG) is a surgical procedure that creates a new path for blood to flow around a blocked or narrowed coronary artery by grafting a blood vessel from another part of the body. A 2019 meta-analysis involving over 120,000 patients undergoing either type of percutaneous coronary intervention(i.e. either placement of a stent, a small device to open up an artery) or CABG found that people who smoke and former smokers had a higher risk of all-cause mortality compared to non-smokers.5 However, there was no statistically significant difference in the rate of heart attacks, all cardiovascular events or cardiovascular deaths. A longitudinal study that minimised the misclassification of people who smoke, former smokers and non-smokers, found that former and current smokers were at similar higher risk of major adverse cardiovascular and cerebrovascular events in the year after treatment.6,7 At odds with the 2019 meta-analysis, some studies have found lower rates of mortality for people who smoke who undergo percutaneous coronary intervention to treat acute coronary syndrome. One study has found that younger age, male gender, and lower prevalence of diabetes mellitus in people who smoke may explain why mortality is lower in such studies for people who smoke.8
Smoking is a risk factor for other complications after percutaneous coronary intervention. People who smoke have a higher risk of gastrointestinal bleeding,9 blood clots in the stent10 and restenosis, the re-narrowing of the artery after a stent is inserted.11 There is some evidence that persistent smoking after percutaneous coronary intervention reduces the effects of statin treatment, meaning that plaque in the arteries of PCI patients who smoke is not stabilised by statins.12
Variant angina is a type of angina that affects people when resting, resulting in chest pain caused by a sudden tightening of the coronary arteries, which restricts blood flow to the heart. A study has shown that people with this type of angina have poorer outcomes (risk of acute coronary syndrome, symptomatic arrhythmia, or cardiac death) when treated with anti-platelet drugs if they smoke.13 Poorer treatment outcomes have also been reported for people who continue to smoke after a diagnosis of heart failure,14 compared with people who quit.
There are many potential mechanisms by which smoking could be affecting the outcomes and side effects of treatments for cardiovascular disease. Smoking causes considerable damage to the heart and to blood vessels, including increasing ‘bad fats’ (LDLs) and decreasing ‘good fats’ (HDLs), making artery walls sticky and causing fatty deposits to build up (atherosclerosis). Smoking increases problems such as inflammation, oxidative stress, the risk of blood clots, blood pressure and heart rate, and decreasing oxygen load due to higher levels of carbon monoxide (see Section 3.1).15,16 The buildup of a variety of stress and damage to the cardiovascular system puts people who smoke at higher risk of numerous cardiovascular diseases and of dying from those diseases. Medications for cardiovascular diseases may be affected by the dysregulation of metabolic enzymes seen in people who smoke, which can increase the breakdown of some drugs in the body and lessen their effects (see Section 3.15.2). People who smoke may be less compliant with medications or prevention programs in cardiac rehabilitation; this puts them at additional risk of poorer outcomes compared to non-smokers, potentially compounding the negative effects of continued smoking.17,18
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References
1. Athyros VG, Tziomalos K, Katsiki N, Gossios TD, Giouleme O, et al. The impact of smoking on cardiovascular outcomes and comorbidities in statin-treated patients with coronary artery disease: a post hoc analysis of the GREACE study. Current Vascular Pharmacology, 2013; 11(5):779-84. Available from: https://www.ncbi.nlm.nih.gov/pubmed/23140546
2. U. S. Preventive Services Task Force, Mangione CM, Barry MJ, Nicholson WK, Cabana M, et al. Statin use for the primary prevention of cardiovascular disease in adults: US Preventive Services Task Force recommendation statement. JAMA, 2022; 328(8):746-53. Available from: https://www.ncbi.nlm.nih.gov/pubmed/35997723
3. Frey P, Waters DD, DeMicco DA, Breazna A, Samuels L, et al. Impact of smoking on cardiovascular events in patients with coronary disease receiving contemporary medical therapy (from the Treating to New Targets [TNT] and the Incremental Decrease in End Points Through Aggressive Lipid Lowering [IDEAL] trials). American Journal of Cardiology, 2011; 107(2):145-50. Available from: https://www.ncbi.nlm.nih.gov/pubmed/21129718
4. Ursoniu S, Mikhailidis DP, Serban MC, Penson P, Toth PP, et al. The effect of statins on cardiovascular outcomes by smoking status: A systematic review and meta-analysis of randomized controlled trials. Pharmacological Research, 2017; 122:105-17. Available from: https://www.ncbi.nlm.nih.gov/pubmed/28602797
5. Ma WQ, Wang Y, Sun XJ, Han XQ, Zhu Y, et al. Impact of smoking on all-cause mortality and cardiovascular events in patients after coronary revascularization with a percutaneous coronary intervention or coronary artery bypass graft: a systematic review and meta-analysis. Coronary Artery Disease, 2019; 30(5):367-76. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30629001
6. Ki YJ, Han K, Kim HS, and Han JK. Smoking and cardiovascular outcomes after percutaneous coronary intervention: a Korean study. European Heart Journal, 2023; 44(42):4461-72. Available from: https://www.ncbi.nlm.nih.gov/pubmed/37757448
7. Garcia-Moll X. Where there is smoke there is risk: is there an irreversible threshold? European Heart Journal, 2023; 44(42):4473-5. Available from: https://www.ncbi.nlm.nih.gov/pubmed/37850511
8. Sharma SP, Dahal K, Rijal J, and Fonarow GC. Meta-analysis comparing outcomes of smokers versus nonsmokers with acute coronary syndrome underwent percutaneous coronary intervention. American Journal of Cardiology, 2018; 122(6):973-80. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30057236
9. Wang L, Pei D, Ouyang YQ, and Nie X. Meta-analysis of risk and protective factors for gastrointestinal bleeding after percutaneous coronary intervention. International Journal of Nursing Practice, 2019; 25(1):e12707. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30456863
10. D'Ascenzo F, Bollati M, Clementi F, Castagno D, Lagerqvist B, et al. Incidence and predictors of coronary stent thrombosis: evidence from an international collaborative meta-analysis including 30 studies, 221,066 patients, and 4276 thromboses. International Journal of Cardiology, 2013; 167(2):575-84. Available from: https://www.ncbi.nlm.nih.gov/pubmed/22360945
11. Wu C, Zheng Y, Zhang T, Liu M, Xian L, et al. Incidence and influencing factors of in-stent restenosis after percutaneous coronary intervention in patients with coronary artery disease: A systematic review and meta-analysis. Catheterization and Cardiovascular Interventions, 2025; 106(3):1682-99. Available from: https://www.ncbi.nlm.nih.gov/pubmed/40598759
12. Zhang X, Peng X, Li L, Yu H, and Yu B. Persistent cigarette smoking attenuates plaque stabilization in response to lipid-lowering therapy: A serial optical coherence tomography study. Frontiers in Cardiovascular Medicine, 2021; 8:616568. Available from: https://www.ncbi.nlm.nih.gov/pubmed/33859999
13. Cho SS, Jo SH, Kim HJ, Lee MH, Seo WW, et al. Smoking may be more harmful to vasospastic angina patients who take antiplatelet agents due to the interaction: Results of Korean prospective multi-center cohort. PLoS ONE, 2021; 16(4):e0248386. Available from: https://www.ncbi.nlm.nih.gov/pubmed/33798225
14. Conard MW, Haddock CK, Poston WS, Spertus JA, and Cardiovascular Outcomes Research C. The impact of smoking status on the health status of heart failure patients. Congestive Heart Failure, 2009; 15(2):82-6. Available from: https://www.ncbi.nlm.nih.gov/pubmed/19379454
15. Messner B and Bernhard D. Smoking and cardiovascular disease: mechanisms of endothelial dysfunction and early atherogenesis. Arteriosclerosis, Thrombosis, and Vascular Biology, 2014; 34(3):509-15. Available from: https://www.ncbi.nlm.nih.gov/pubmed/24554606
16. US Department of Health and Human Services. How tobacco smoke causes disease: the biology and behavioral basis for smoking-attributable disease. Atlanta, Georgia: Centers for Disease Control and Prevention, 2010. Available from: https://www.ncbi.nlm.nih.gov/books/NBK53017/.
17. Gaalema DE, Al Hemyari B, Morrow MM, Yant B, Zhang Y, et al. The effects of smoking status on patients in cardiac rehabilitation. Journal of Cardiopulmonary Rehabilitation and Prevention, 2025; 45(5):358-63. Available from: https://www.ncbi.nlm.nih.gov/pubmed/40622857
18. Doganer YC, Aydogan U, Kaplan U, Gormel S, Rohrer JE, et al. Statin adherence in patients with high cardiovascular risk: a cross-sectional study. Postgraduate Medicine, 2023; 135(4):361-9. Available from: https://www.ncbi.nlm.nih.gov/pubmed/36345979