Tobacco and electronic cigarette use with hypertension and the mediating effect of dyslipidemia - the NHANES study

Abstract

Electronic cigarette adoption has transformed nicotine delivery patterns globally, with 15% prevalence among youth aged 13-15 years. The cardiovascular implications of combined electronic cigarette and combustible tobacco use remain incompletely characterized. We examined the associations of combined smoking and/or vaping vs. no nicotine exposure with elevated blood pressure (BP) and hypertension prevalence using nationally representative United States data from 2021 to 2023. Data from the US National Health and Nutrition Examination Survey (NHANES) 2021-2023 cycle, which included 6,262 individuals aged ≥12 years old with complete smoking/vaping status: any smoking and/or vaping (n = 1,190) vs. no smoking or vaping (n = 5,072), were used. Elevated BP was classified as ≥120/70 mmHg and hypertension as ≥140/90 mmHg, and a history of smoking and/or vaping was collected with a questionnaire. Multivariable logistic regression and mediation path analysis were conducted. Among 6,262 participants (mean age 42.2 years [SD 21], 63.3% female), smokers/vapers had significantly higher prevalence of elevated BP compared with nonsmokers/nonvapers (54.4% vs. 39.2%, P < 0.001) and hypertension (15.4% vs. 11.8%, P < 0.001). In fully adjusted models, smoking/vaping was associated with increased odds of elevated BP [adjusted odds ratio (aOR): 1.34, 95% CI: 1.12-1.60, P = 0.001] and hypertension (aOR: 1.46, 95% CI: 1.06-1.99, P < 0.001). Smoking/vaping was associated with a 1.05 mmHg higher diastolic BP (P < 0.001) but had no association with systolic BP. Mediation analysis revealed that higher total cholesterol partly mediated (6.7% mediation effect) the relationship between smoking/vaping and diastolic BP. Combined smoking and/or vaping exposure was associated with higher odds of elevated BP and hypertension compared to no nicotine use. The selective diastolic BP elevation suggests an increased peripheral vascular resistance as the primary mechanism; however, longitudinal studies examining these direct vascular mechanisms are warranted.NEW & NOTEWORTHY In this cross-sectional analysis of 6,262 multiracial US participants with diverse age groups, tobacco smoking and vaping were significantly associated with elevated blood pressure and hypertension. Smoking and vaping were predominantly associated with diastolic blood pressure, an association that was partly mediated by higher cholesterol levels.