Cigarette smoking, e-cigarette use, and hypertension: a population-based cross-sectional study

Journal of Human Hypertension ARTICLE www.nature.com/jhh OPEN Cigarette smoking, e-cigarette use, and hypertension: a population-based cross-sectional study ✉ Yusuff Adebayo Adebisi 1,2 , Massimo Volpe 8,9 Bader Ali Almustafa and Riccardo Polosa2,10 3,4 , Jacob George5, Ahmed K. Shukri6, Najim Z. Alshahrani 6 , Davide Capodanno7, 1234567890();,: © The Author(s) 2026 Cigarette smoking is an established cardiovascular risk factor, but the association between electronic cigarette (e-cigarette) use and hypertension remains unclear. We examined this association in a nationally representative adult population in Scotland using pooled cross-sectional data from 22,187 adults aged ≥16 years in the Scottish Health Survey (2017–2022). Participants were classified into five mutually exclusive groups: never users (n = 11,760), former smokers (n = 6,201), current cigarette smoking only (n = 2,747), current e-cigarette use only (n = 907), and current dual use (n = 572). Hypertension was defined as self-reported doctor-diagnosed high blood pressure, excluding pregnancy-related hypertension. Multivariable logistic regression estimated adjusted odds ratios (ORs) and 95% confidence intervals (CIs). Secondary analyses disaggregated current e-cigarette use only by smoking history, and propensity score matching was performed as a sensitivity analysis. Overall hypertension prevalence was 26.5%, ranging from 19.0% among current exclusive e-cigarette users to 33.5% among former smokers. Compared with never users, current e-cigarette use only was associated with lower odds of hypertension (OR 0.77, 95% CI 0.63–0.93), whereas former smokers had higher odds (OR 1.10, 95% CI 1.02–1.20). No significant associations were observed for current cigarette smoking only (OR 0.94, 95% CI 0.84–1.06) or current dual use (OR 0.95, 95% CI 0.75–1.20). The inverse association for exclusive e-cigarette use was confined to former smokers who had switched to vaping (OR 0.77, 95% CI 0.63–0.94). In propensity score-matched analyses, the inverse association for current exclusive e-cigarette use was attenuated and no longer statistically significant, suggesting that this finding may partly reflect healthy switcher bias and residual confounding rather than a protective effect. Journal of Human Hypertension; https://doi.org/10.1038/s41371-026-01171-4 INTRODUCTION Hypertension is the leading modifiable risk factor for cardiovascular morbidity and mortality worldwide, contributing to approximately 10.4 million deaths annually [1, 2]. In Scotland, an estimated one in three adults has been diagnosed with high blood pressure, imposing a substantial burden on the National Health Service and representing a major public health priority [3]. Identifying modifiable behavioural determinants of hypertension prevalence therefore remains an important objective for population health research. Cigarette smoking is an established risk factor for cardiovascular disease, though its relationship with measured blood pressure has long been characterised as paradoxical [4–6]. While acute nicotine exposure elevates blood pressure through multiple mechanisms including sympathetic activation and catecholamine release [7, 8], numerous cross-sectional epidemiological studies have reported that current smokers have similar or even lower blood pressure levels compared with non-smokers [4, 9–12]. This paradox has been attributed to several mechanisms, including the lower body weight of smokers, selection bias, survival effects, more intensive clinical management of cardiovascular risk factors in smokers, and the vasodilatory properties of chronic carbon monoxide exposure [12]. Despite these complexities, the overall cardiovascular harm of cigarette smoking is beyond dispute. Electronic cigarettes (e-cigarettes) have emerged as a rapidly growing alternative nicotine delivery system [13, 14]. In Great Britain, an estimated 5.4 million adults aged 16 years and over currently used an e-cigarette daily or occasionally in 2024, overtaking the number of current cigarette smokers for the first time [15]. E-cigarettes are frequently used as a smoking cessation aid, and the UK regulatory and public health environment has been broadly supportive of their harm-reduction potential as related to combustible cigarettes [16]. Nevertheless, the long-term cardiovascular safety of e-cigarettes remains unclear and currently represents an area of active investigation. The relationship between e-cigarette use and hypertension is not well established. Experimental studies have demonstrated that acute e-cigarette use raises blood pressure and heart rate 1 College of Social Sciences, University of Glasgow, 40 Bute Gardens, Glasgow G12 8RT Scotland, United Kingdom. 2Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy. 3Hypertension & Cardiovascular Prevention Unit, IRCCS San Raffaele Roma, Rome, Italy. 4Department of Clinical and Molecular Medicine, Università di Roma Sapienza, Rome, Italy. 5University of Dundee Medical School, Dundee, Scotland, UK. 6Department of Family and Community Medicine, Faculty of Medicine, University of Jeddah, Jeddah, Saudi Arabia. 7Division of Cardiology, AOU Policlinico G. Rodolico-San Marco, University of Catania, Catania, Italy. 8Secretary General, World Hypertension League, Riyadh, Saudi Arabia. 9Head, Scientific Committee, Saudi Hypertension Management Society, Riyadh, Saudi Arabia. 10Center of Excellence for the Acceleration of HArm Reduction (CoEHAR), University of Catania, Catania, Italy. ✉email: Received: 16 March 2026 Revised: 22 May 2026 Accepted: 29 May 2026 Y.A. Adebisi et al. 2 through nicotine-mediated sympathetic activation [17, 18]. However, the epidemiological evidence from population-based studies is mixed. Some cross-sectional analyses using US survey data have reported increased odds of hypertension among exclusive e-cigarette users [19–21], while others have found no significant association [22]. Importantly, studies examining smokers who switched to e-cigarettes have reported improvements in blood pressure control over follow-up periods of 6 to 12 months [23, 24], suggesting that the net cardiovascular effect may depend critically on whether e-cigarette use replaces or supplements combustible cigarette smoking [25]. A further limitation of the existing literature is that most population-based studies have classified cigarette smoking and e-cigarette use crudely, often treating e-cigarette use as a binary variable without distinguishing between exclusive e-cigarette users, dual users, and former smokers who no longer use any nicotine product. This classification approach can obscure important heterogeneity. For instance, a current exclusive e-cigarette user who is a former smoker has a different exposure history and potentially different cardiovascular risk profile compared with a never-smoker who currently vapes. The present study aimed to investigate the association between current cigar (...truncated)