---
title: Smoking and the heart
description: How smoking and other people's tobacco smoke harm the heart and blood vessels, why quitting helps at any age, what help with quitting clinical guidelines describe, what the sources say about e-cigarettes, and when to call an ambulance.
type: disease
aliases:
  - smoking
  - tobacco smoking
  - tobacco
  - tobacco use
  - smoking and heart disease
  - second-hand smoke
  - passive smoking
  - smoking cessation
  - quitting smoking
  - nicotine dependence
  - tobacco dependence
  - e-cigarettes
  - vaping
  - heated tobacco
sources:
  - tier: guideline
    org: esc
    title: 2021 Рекомендации ESC по профилактике сердечно-сосудистых заболеваний в клинической практике
    year: 2022
    doi: 10.15829/1560-4071-2022-5155
    url: https://doi.org/10.15829/1560-4071-2022-5155
  - tier: guideline
    org: minzdrav-rf
    title: Психические и поведенческие расстройства, вызванные употреблением табака (никотина). Синдром зависимости от табака, синдром отмены табака у взрослых
    year: 2024
    url: https://cr.minzdrav.gov.ru/view-cr/601_2
  - tier: guideline
    org: nice
    title: 'Tobacco: preventing uptake, promoting quitting and treating dependence (NG209)'
    year: 2025
    url: https://www.nice.org.uk/guidance/ng209
  - tier: guideline
    org: who
    title: Tobacco and nicotine (WHO fact sheet)
    year: 2026
    url: https://www.who.int/news-room/fact-sheets/detail/tobacco
  - tier: guideline
    org: who
    title: 'Tobacco: Health benefits of smoking cessation (WHO questions and answers)'
    year: 2020
    url: https://www.who.int/news-room/questions-and-answers/item/tobacco-health-benefits-of-smoking-cessation
  - tier: guideline
    org: who
    title: 'E-cigarettes: how risky are they? (WHO questions and answers)'
    year: 2024
    url: https://www.who.int/news-room/questions-and-answers/item/e-cigarettes-how-risky-are-they
  - tier: reference
    org: msd-manuals
    title: Smoking and Other Tobacco Use (MSD Manual Professional Version)
    year: 2025
    url: https://www.msdmanuals.com/professional/special-subjects/tobacco-use/smoking-and-other-tobacco-use
  - tier: reference
    org: msd-manuals
    title: Smoking Cessation (MSD Manual Professional Version)
    year: 2025
    url: https://www.msdmanuals.com/professional/special-subjects/tobacco-use/smoking-cessation
sources_checked: 2026-10-14
review: null
---

Smoking is a strong and independent risk factor for diseases of the heart and blood vessels.<Cite n={1} /> Tobacco harms nearly every organ in the body and causes, among other things, heart disease and stroke.<Cite n={[4, 7]} /> All forms of tobacco are harmful, and there is no safe level of exposure.<Cite n={4} />

This article is about what smoking does to the heart and blood vessels and how quitting helps.

<Diagram name="smoking-and-heart">
  <p slot="normal">
    The diagram shows a coronary artery, an artery of the heart, cut lengthwise. Its inner lining
    is smooth and whole, there is no plaque or clot, and blood flows freely. This is the lining
    that smoking damages.<Cite n={7} />
  </p>
  <p slot="disease">
    In people who smoke, the inner lining of the arteries is damaged and the blood becomes more
    prone to clotting.<Cite n={7} /> Cigarette smoke can cause atherosclerosis (plaques in the
    artery wall) and thrombosis, and smoking narrows the arteries, so blood gets through the
    narrowed passage only in a thin stream.<Cite n={2} />
  </p>
</Diagram>

## Why it happens

<Patient>

The harm of smoking comes mainly from breathing in smoke, while nicotine is mainly what causes the habit and the dependence.<Cite n={2} /> Most smoking-related health problems are caused by other substances in tobacco smoke, not by nicotine.<Cite n={3} /> Tobacco smoke contains thousands of chemicals, carbon monoxide among them.<Cite n={2} /> Nicotine itself is not harmless either: it slightly raises the heart rate and blood pressure and increases the risk of heart and blood vessel disease.<Cite n={[4, 7]} />

Smoking damages the inner lining of the arteries, raises blood pressure and heart rate for a while, makes the blood more prone to clotting and worsens the blood fats.<Cite n={7} /> Coronary heart disease is one of the main causes of tobacco-related deaths.<Cite n={7} /> Smoking also raises the risk of other blood vessel diseases, such as stroke and [aortic aneurysm](../abdominal-aortic-aneurysm/).<Cite n={7} />

Other people's smoke is dangerous too. There is no safe level of second-hand smoke: it causes serious heart and blood vessel diseases, including coronary heart disease.<Cite n={4} /> Cigarettes are not the only risk: some kinds of smokeless tobacco are also linked to heart and blood vessel disease.<Cite n={[1, 3, 7]} />

</Patient>

<Student>

Russian Ministry of Health guideline: tobacco smoke contains about 7,000 chemicals.<Cite n={2} /> ESC 2021: smoking causes 50% of all avoidable deaths in smokers, half of them due to ASCVD; a lifelong smoker has a 50% probability of dying from smoking and loses on average 10 years of life.<Cite n={1} /> Cardiovascular risk in smokers under 50 years is five times higher than in non-smokers; long-term smoking is more hazardous for women than for men.<Cite n={1} /> MSD: the risk of MI is doubled when smoking 1 pack a day, and the risk of cardiovascular mortality is increased by more than 50% over a 35-year period.<Cite n={7} />

According to the Russian Ministry of Health guideline, inflammatory processes and changes in the immune system are crucial in the pathogenesis of smoking-related diseases, atherosclerosis among them; cigarette smoke can also cause insulin resistance and the metabolic syndrome.<Cite n={2} />

Passive smoking is associated with an increased risk of CVD.<Cite n={1} /> According to MSD, in spouses of people who smoke, the risk of coronary artery disease is increased on average by approximately 20–30%.<Cite n={7} /> WHO estimates that second-hand smoke kills more than 1.6 million people prematurely every year.<Cite n={4} /> In Russia, according to 2023 Rosstat data cited by the Russian Ministry of Health guideline, 21.1% of the population used tobacco: 34.6% of men and 10.1% of women (not counting electronic nicotine delivery systems).<Cite n={2} />

</Student>

<HeartModel
  highlight={[
    'right-coronary-artery',
    'left-main-coronary-artery',
    'left-anterior-descending-artery',
    'circumflex-artery',
  ]}
/>

## Symptoms

<Patient>

The complaints of a person who smokes are usually the symptoms of the lung and heart diseases that smoking has caused.<Cite n={7} /> A chronic cough and shortness of breath on exertion are common; the person tolerates exercise less well, moves less, and their fitness drops even further.<Cite n={7} /> The signs of heart disease are described in the articles on [coronary heart disease](../coronary-heart-disease/) and [myocardial infarction](../myocardial-infarction/).

Smoking is a form of dependence.<Cite n={[2, 7]} /> When a person tries to quit, withdrawal symptoms appear: a strong craving to smoke, anxiety, irritability, trouble concentrating, poor sleep and increased appetite.<Cite n={[2, 8]} /> These feelings are why many people find it hard to stay off cigarettes even when they know the risks.<Cite n={8} /> Withdrawal is temporary.<Cite n={2} />

</Patient>

<Student>

According to the Russian Ministry of Health guideline, tobacco withdrawal also includes malaise and weakness, dysphoric mood, increased cough and aphthous stomatitis, and lasts from 7 days to several weeks, rarely months.<Cite n={2} />

According to MSD, withdrawal symptoms are worst in the first 3 days, when most people trying to quit relapse, and usually subside within 2–4 weeks, but craving may continue for months or even years.<Cite n={8} />

</Student>

## How it is diagnosed

<Patient>

Doctors are advised to ask every patient about smoking at every visit, whatever the reason for the visit.<Cite n={[7, 8]} /> The doctor asks at what age the person started, how much and for how long they smoke, which products they use and whether they have tried to quit.<Cite n={2} /> The strength of the dependence is assessed with one questionnaire, and readiness to quit with another.<Cite n={2} /> Carbon monoxide in the breath can be measured: it shows how heavily the person smokes, helps motivate quitting and later confirms that smoking has really stopped.<Cite n={2} />

Smoking is one of the main risk factors for heart and blood vessel disease, so in a person who smokes the doctor assesses the overall cardiovascular risk, taking into account other factors as well: blood pressure, cholesterol and diabetes.<Cite n={1} /> More about them in the articles on [hypertension](../hypertension/), [dyslipidaemia](../dyslipidemia/) and [diabetes and the heart](../diabetes-and-heart/).

</Patient>

<Student>

Russian Ministry of Health guideline: clinical diagnosis (complaints, history and the Fagerström test) is the main tool; tobacco dependence syndrome is diagnosed by ICD-10 when 3 or more of 6 features are present over 12 months, among them withdrawal, increased tolerance and continued use despite clear evidence of harm.<Cite n={2} />

Readiness to quit is assessed with the Prochaska questionnaire and smoking intensity with the smoking index (SI = cigarettes per day × years of smoking / 20); patients with an SI above 5 find it harder to quit on their own.<Cite n={2} /> The Russian Ministry of Health guideline classes exhaled CO of 6 to 10 ppm as light smoking, 11 to 20 ppm as moderate and more than 21 ppm as heavy.<Cite n={2} /> According to MSD, how soon a person smokes after waking also shows how severe the dependence is: smoking within 30 minutes is a sign of addiction.<Cite n={7} />

ESC 2021: systematic global CV risk assessment is recommended in individuals with any major vascular risk factor, smoking included (class I, level C).<Cite n={1} />

</Student>

## How it is treated

<Patient>

Quitting smoking is potentially the most effective of all preventive measures: it substantially reduces the rate of heart attacks, including repeat ones, and of deaths.<Cite n={1} /> It is worthwhile at any age.<Cite n={1} /> People with heart and blood vessel disease need to stop, especially during the acute phase of the illness.<Cite n={2} />

According to WHO, the benefit begins in the first minutes and hours after the last cigarette and grows over the years: heart rate and blood pressure drop, the carbon monoxide level in the blood returns to normal, and the risk of coronary heart disease gradually falls to that of a non-smoker.<Cite n={5} /> WHO also reports that people who quit after a heart attack markedly reduce their chances of having another one.<Cite n={5} /> The risk falls gradually: even in people who smoked heavily it decreases over several years but stays raised for some time.<Cite n={1} />

Stopping in one go is the best approach.<Cite n={3} /> Simply smoking fewer cigarettes may not improve health: people usually inhale more deeply to get their usual amount of nicotine.<Cite n={8} /> Weight often goes up after quitting, but this does not reduce the benefit for the heart and blood vessels, so quitting is still worthwhile.<Cite n={1} />

You do not have to quit alone. A doctor can give brief advice and offer help; behavioural support, motivational interviewing and cognitive behavioural therapy are used.<Cite n={[1, 2, 3]} /> Counselling together with medicines prescribed by a doctor can markedly increase the chance of quitting.<Cite n={4} /> Medicines reduce the discomfort of quitting while the person rebuilds their life without tobacco.<Cite n={8} /> Which medicines suit you is best discussed with a doctor, especially if you have heart disease. The Russian Ministry of Health guideline advises against methods without proven effectiveness for treating dependence, such as acupuncture, hypnosis, herbal remedies and homeopathy.<Cite n={2} />

**E-cigarettes and heated tobacco.** The sources differ here, so the position of each is given:

- WHO: e-cigarettes are harmful to health and are not safe.<Cite n={4} /> Their long-term effects are not yet fully known, but they generate toxic substances, some of which increase the risk of heart and lung disorders; the safest approach is to use neither tobacco nor e-cigarettes.<Cite n={6} />
- The Russian Ministry of Health guideline does not recommend e-cigarettes or smokeless tobacco products as a way to treat tobacco dependence, because there is no scientifically sound evidence of their effect on health.<Cite n={2} />
- ESC: e-cigarettes are probably less harmful than tobacco, but their long-term effects on the heart, blood vessels and lungs need further research; using both kinds of cigarettes at the same time should be avoided.<Cite n={1} />
- NICE (UK) includes nicotine-containing e-cigarettes among the options for adults to stop smoking and states that there is not enough evidence to know whether they have long-term harms, that they are likely to be substantially less harmful than smoking, and that any smoking is harmful, so people using e-cigarettes should stop smoking tobacco completely.<Cite n={3} />
- Heated tobacco products contain tobacco, so ESC does not recommend their use; WHO states that they are tobacco products and do not help people stop smoking.<Cite n={[1, 4]} />

</Patient>

<Student>

WHO: within 20 minutes of quitting, heart rate and blood pressure drop; at 12 hours, the blood carbon monoxide level drops to normal; at 1 year, the risk of CHD is about half that of a smoker; at 15 years, it is that of a non-smoker; people who quit after a heart attack reduce their chances of another heart attack by 50%.<Cite n={5} />

ESC 2021: cessation of all smoking is recommended, as smoking is a strong and independent risk factor for CVD (class I, level A); smoking cessation is recommended regardless of weight gain, as weight gain does not lessen the ASCVD benefits of cessation (class I, level B).<Cite n={1} /> According to ESC, even in people smoking more than 20 cigarettes a day, stopping reduces CV risk within 5 years, although the risk stays raised beyond 5 years.<Cite n={1} />

ESC very brief advice (Table 9) has three elements: ASK (establish and record smoking status), ADVISE (on the best way to stop) and ACT (offer help).<Cite n={1} /> NICE: offer behavioural support to people who smoke regardless of which option they choose to help them stop.<Cite n={3} />

WHO: counselling and medication can more than double a tobacco user's chance of successful quitting.<Cite n={4} /> According to MSD, combining counselling and medications is more effective than either alone.<Cite n={8} /> ESC: drug support for cessation should be considered in all smokers who are willing; three of the four cessation medicines it lists do not increase the risk of serious cardiovascular adverse events during or after treatment.<Cite n={1} /> Russian Ministry of Health guideline: patients at any cardiovascular risk should receive instructions on quitting, and therapy is chosen after weighing risks and benefits.<Cite n={2} />

E-cigarettes: ESC notes that they are addictive, so their use should be subject to the same marketing controls as standard cigarettes.<Cite n={1} /> According to MSD, the health benefits of e-cigarettes in the context of dual use are unproven.<Cite n={8} /> WHO: e-cigarette use increases conventional cigarette uptake, particularly among non-smoking youth, by nearly 3 times; dual use is at least as dangerous as, and likely more dangerous than, smoking conventional cigarettes or using e-cigarettes alone.<Cite n={6} />

</Student>

## When to call an ambulance

Smoking itself does not need emergency care; the danger lies in the diseases it leads to: heart attack and stroke.<Cite n={[4, 7]} /> For chest pain or pressure, severe shortness of breath, fainting or signs of a stroke, call your local emergency number (112 in the EU, 911 in the US and Canada, 999 in the UK) at once: this is the site's general safety rule. The signs of a heart attack are described in the article on [myocardial infarction](../myocardial-infarction/), and the signs of a stroke in the article on [carotid artery stenosis](../carotid-artery-stenosis/).