QJM Advance Access originally published online on May 10, 2006
QJM 2006 99(6):407-415; doi:10.1093/qjmed/hcl047
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Smoking status, obesity and hypertension in a general population sample: a cross-sectional study
From the Institute of Epidemiology and Social Medicine, University of Greifswald, Greifswald, Germany
Address correspondence to Professor Dr U. John, Director of the Institute of Epidemiology and Social Medicine, University of Greifswald, Walther-Rathenau-Str. 48, D-17487 Greifswald, Germany. email: ujohn{at}uni-greifswald.de
Received 20 January 2006 and in revised form 20 March 2006
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Background: In some studies, hypertension is more common in never and former smokers than in current smokers.
Aim: To examine the associations between hypertension and smoking status, when divided into subgroups by overweight and obesity.
Design: Cross-sectional study.
Methods: We used data from a national health survey with a probability sample of the national population of Germany aged 18 to 79 (n = 6903 with complete data). Smoking status data were collected via questionnaire. Obesity and overweight were assessed by body mass index, hypertension by blood pressure measurement and by participants’ statements about antihypertensive treatment. Analyses were adjusted for gender, age, history of coronary artery disease, serum cholesterol levels, alcohol drinking, exercise, and education.
Results: Obese former smokers who were abstinent for 3 or more years had an adjusted odds ratio (OR) 3.6 (95% confidence interval, CI 2.3–5.7) for mild hypertension (
140 mmHg systolic or 90 mmHg diastolic blood pressure) and an adjusted OR 6.5 (95%CI 3.6–11.8) for moderate or severe hypertension (160 mmHg systolic or 100 mmHg diastolic). Normal weight never or former smokers did not differ from normal weight current smokers smoking 15 cigarettes/day with regard to likelihood of hypertension (normal weight never smokers, OR 1.1, 95%CI 0.8–1.5; normal weight former smokers, abstinent 3 or more years, OR 0.8, 95%CI 0.5–1.3).
Discussion: In this nationally representative sample, never or former smoking was unrelated to hypertension among normal weight individuals.
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Introduction |
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Higher blood pressure among former or never smokers than among current smokers has been reported from studies using non-clinical samples.1–5 This has been called a paradox, as tobacco smoking increases blood pressure acutely,5 and blood pressure decreases in smokers who do not smoke for a week.5,6 On the other hand, higher systolic blood pressure has also been found among current smokers than among former or never smokers.7 A general population study revealed higher systolic blood pressure among male current smokers than among former or never smokers aged 45 years or older, after adjustment for body mass index (BMI) and alcohol intake: there was interaction between BMI and smoking status with respect to systolic blood pressure.8 In another study of volunteers aged 20–69 years, the higher odds for former smokers than for never smokers disappeared when BMI was included in the logistic regression model.9
In a sample of male workers in Israel aged 20–39 years, the proportion of hypertensive individuals (140 or 90 mmHg) was lowest among those who smoked 20 cigarettes per day (cpd) and highest among never and former smokers, even after controlling for BMI and age. This association was not found among male workers aged 40–69 years.1 Higher incidence rates of hypertension were found among male workers in Japan and Korea who stopped smoking or who never smoked than among male workers who continued to smoke.3,4 Another study revealed that there were no differences in the proportions of hypertension between smokers and non-smokers.7
One reason for the smoking-hypertension paradox might be the increase of body weight after smoking cessation.5 Weight gain after smoking cessation has been well documented,10–12 although its determinants are still poorly understood. BMI increase over the years is lower among smokers than among non-smokers,13 the probability of weight gain is highest two years after smoking cessation,11 and it seems to be positively related to cigarette consumption rates.12,14 However, the contribution of smoking cessation to the BMI increase with age was practically negligible with respect to public health efforts.12
It has been reported that BMI could not fully explain the difference in blood pressure,5 because the relation between blood pressure and smoking 20 cpd remained after BMI adjustment.1 One effect on blood pressure might come from the relation between smoking and BMI. Overweight or obese former or never smokers could be more prone to hypertension than normal weight current smokers, whereas this might not be true for normal weight former or never smokers compared to normal weight current smokers. In addition, differentiation of smoking status, by number of years since smoking cessation among former smokers, and cigarettes smoked per day among current smokers, was rarely considered.
Overall, the existing studies are limited in several ways, in particular by not sufficiently considering the association between smoking and obesity or overweight, and not sufficiently considering years of abstinence among former smokers, and cpd among current smokers.1–7 They also recruited selected study populations, such as male workers1,3,4,7 or normotensive individuals2,4,6, or in small age ranges.3,4 The goal of this study was to estimate the risk of hypertension from smoking status (including number of years of abstinence) in obese, overweight and normal weight former and never smokers compared to normal weight current smokers in the female and male general population aged 18–79 years. We analysed subgroups by smoking status including cpd, and by overweight and obesity. We hypothesized that smoking status including being abstinent for 3 and for <3 years among former smokers and the median cpd among current smokers is unrelated to hypertension among the normal weight general population aged 18–79.
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Sample
We used a national sample of the German civilian, non-institutionalized population aged 18–79 years.15 A random sample (n = 13 222) stratified by the 16 German Federal States was drawn from the registration files in which every resident's address, age and gender is included by law. When attempting to contact the people in the sample, 1621 (12.3%) had died, had moved, were not known at the registered address, or did not speak German. Of the remaining 11 601, 7124 (61.4%) participated in the study.16 A health examination was conducted in an examination centre (i.e. rooms rented for the purpose of the study) at 120 sample points.17 Data were collected between October 1997 and March 1999.16 Among the participants, 6913 had complete information on smoking status and hypertension, including antihypertensive treatment, and 6903 had complete information on smoking status, BMI and hypertension, including antihypertensive treatment. The study was conducted by the Robert Koch Institute of the German Federal Ministry of Health and monitored by a review board of independent scientists. It was approved by the responsible data security official. The subjects gave informed consent.
Assessments
Data on smoking were collected by a questionnaire to be filled in by the participant in the examination centre. The participant was assisted if unable to fill in the questionnaire. Individuals were asked whether they had formerly smoked or whether they currently smoked. Former smokers were those who had stopped smoking and were abstinent at the time of the health examination. Former smokers were asked whether they had quit <1 year prior to the health examination, or at what age they had stopped smoking if 1 year prior to the health examination. Individuals who said that they currently smoked at the day of the health examination were defined as current smokers. Never smokers were respondents who affirmed ‘Have not smoked yet (or very rarely tried to smoke)’.
Body height was measured by a fixed stadia rod with the person wearing no shoes. Body weight was measured by a scale with the person wearing no shoes and light clothing. BMI was calculated as body weight (kg) divided by body height (m) squared. We used BMI <25 kg/m2 for normal weight, BMI 25 and <30 kg/m2 for overweight and, due to small cell frequencies, merged all individuals with BMI 30 kg/m2 into obesity.18
Blood pressure was assessed with a standard sphygmomanometer (ERKA, Kallmeyer GmbH) in the sitting position. One of the two differently sized cuffs was applied to the participant's upper right arm according to its circumference. Three measurements were taken with a 3-min resting period between the fastening or complete deflation and the inflating of the cuff. Systolic blood pressure and diastolic blood pressure were determined with the first and fifth Karotkoff sounds. Blood pressure measurement was done by physicians who had participated in a special training for the purpose of the study. Correct blood pressure measurement was monitored by site visits of a data safety and monitoring committee. The mean of the second and third measurement was used in the data analysis. Hypertension was defined according to the guidelines of the World Health Organization together with the International Society of Hypertension.19 We categorized subjects as normotensive when systolic blood pressure was <140 mmHg systolic, when diastolic blood pressure was <90 mmHg, and when they did not answer ‘Yes’ when asked whether they had taken antihypertensive medication at least once a week during the last 12 months prior to the health examination. Those with a systolic blood pressure 140 and <160 mmHg or a diastolic blood pressure 90 and <100 mmHg who said no to the antihypertensive medication question were classified as mild hypertensives. Those with a systolic blood pressure 160 mmHg or diastolic blood pressure 100 mmHg who said no to the antihypertensive medication question were classified as moderate or severe hypertensives. Those who said yes to the antihypertensive medication question were assumed to be taking antihypertensive drugs.
Data on alcohol drinking, exercise, school education, and prior histories of heart disease or heart failure were assessed by questionnaire. The respondents answered for myocardial infarction, other coronary artery disease, and heart failure whether they ever had the single disease condition (yes/no/do not know). We merged ‘no’ and ‘do not know’ into one category. Alcohol drinking was assessed by questions about quantity and frequency of alcohol consumption. We used four categories of grams pure alcohol per day: <25, 25 and <50, 50 and <100, 100 g/day. In a meta-analysis, these categories were related to hypertension in both men and women.20 Exercise was assessed from the question ‘How often do you exercise?’ (never, 
2 h/week, >2 h/week). School education was assessed by the number of years at school based on the three-level German school system (9, 10–11, 12–13 years). Non-fasting blood samples were taken. Serum total cholesterol was precipitated and measured photometrically (Merck).
Statistical analysis
We calculated likelihood ratio 
2 tests and used the effect size measure Cohen's w21 to analyse bivariate associations between hypertension and smoking. Following Cohen,21 we interpreted values 0.10 to <0.30 as indicating a small, and 0.30 or higher, a medium effect size. For testing differences between means, analysis of variance was used, and 
2 for the effect size.22 We assumed values >0.06 as a large effect size (analogous to Cohen's d).21 We applied multinomial logistic regression analysis with mild, moderate or severe hypertension, and with antihypertensive treatment, each compared to normotension as the dependent variable. Former smokers were classified into those abstinent for 3 years and those abstinent for <3 years prior to the health examination, for reasons of comparability with a previous study.3
In the multivariate analysis, we first analysed the association of smoking status (including 3 or more years of abstinence vs. less than 3 years of abstinence among former smokers and 15 vs. <15 cpd among current smokers), obesity, and overweight with hypertension. Analyses were adjusted for gender, age, alcohol drinking, exercise, school education, serum cholesterol levels, prior history of myocardial infarction, other coronary artery disease, and heart failure. Age and serum cholesterol entered the model as continuous and the other confounders as categorical variables. We controlled for prior cardiac diseases for their potential influence on current blood pressure, and because smokers who were aware of such diseases might well have been more likely to quit smoking. We further controlled for variables that had been used in former studies such as alcohol consumption, exercise, school education.1–5,7 Then we analysed subgroups of smoking status and obesity, overweight and normal weight. A p value <0.05 was considered significant. All analyses used SPSS v. 14.0.
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Smoking status showed relationships with BMI, myocardial infarction, other coronary artery disease, alcohol drinking, and exercise (Table 1). Among overweight individuals, 26.4% were former smokers, vs. 14.6% among those of normal weight. Among those who reported drinking
50 g alcohol per day, the proportion of never smokers was 31.7% or lower, vs. 47.1% among individuals who reported drinking <25 g alcohol per day.
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Under bivariate analysis, 60.4% of former smokers who had been abstinent for
3 years at examination were hypertensive, vs. 34.4% of current smokers consuming 15 cpd. In relation to hypertension, there was an effect size of w = 0.23 for smoking status, but w = 0.39 for obesity/overweight/normal body weight (Table 2).
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Multivariate data analysis using multinomial logistic regression revealed higher odds ratios for moderate or severe hypertension and for treated hypertension among never smokers and among former smokers who had abstained for
3 years at examination, vs. current smokers consuming 15 cpd (Table 3). However, among those of normal weight, former or never smokers did not differ from current smokers consuming 15 cpd with respect to likelihood of hypertension (Table 4). This was true of both sexes (data not shown). In contrast, obese former smokers abstinent for 3 years had an OR 3.6 (95%CI 2.3–5.7) for mild hypertension and an adjusted OR 6.5 (95%CI 3.6–11.8) for moderate or severe hypertension, when compared to normal weight current smokers consuming 15 cpd. These results remained stable when not adjusting for myocardial infarction, other coronary artery disease, and heart failure.
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Normal weight former or never smokers were not more likely to be moderately or severely vs. mildly hypertensive (normal weight former smokers abstinent
3 years: OR 1.5, 95%CI 0.8–3.0) or to be taking antihypertensive medication vs. mildly hypertensive (normal weight former smokers abstinent 3 years: OR 1.4, 95%CI 0.6–3.0). Normal weight former or never smokers were also not more likely to be taking antihypertensive medication than were moderately or severely hypertensive individuals (normal weight former smokers abstinent 3 years: OR 1.0, 95%CI 0.4–2.5) after adjustment for myocardial infarction, other coronary artery disease, and heart failure, alcohol risk drinking, exercise, school education, gender, age, and serum cholesterol. Compared to current smokers, never smokers had an OR of 1.3 (95%CI 1.1–1.5) for overweight and of 1.5 (95%CI 1.3–1.8) for obesity, and former smokers had an OR of 1.7 (95%CI 1.4–2.0) for overweight and of 1.9 (95%CI 1.5–2.3) for obesity after adjustment for gender, age, school education, alcohol consumption and exercise. |
Discussion |
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Our data suggest that the smoking-hypertension paradox may be explained by obesity and overweight. Normal weight never or former smokers were not more likely to have hypertension than normal weight current smokers consuming
15 cpd. There does not even seem to be a trend. This finding is independent of the status of a never or former smoker, of whether the former smokers abstained for more or less than 3 years, and of smoking more or less than 15 cpd. In the subgroup analysis (Table 4), of the 12 odds ratios for hypertension for normal weight individuals vs. normal weight current smokers consuming 15 cpd, none was significant. When not considering subgroups by BMI and smoking status, there are higher odds for moderate or severe and for treated hypertension in never or former smokers vs. current smokers consuming 15 cpd. Only when the BMI subgroups are considered does it become apparent that obesity and overweight, but not former or never smoking, adds to the risk of hypertension.
When only normal weight subjects were considered, never or former smokers were not more likely than current smokers (15 cpd) to be moderately or severely hypertensive or taking antihypertensive medication vs. mild hypertension. The suggestion that smoking cessation does not add to the risk of hypertension is further supported by the finding that smoking <15 cpd did not increase the risk of hypertension among our current smokers. Former and never smokers had higher odds for overweight and obesity compared to current smokers, even after myocardial infarction, other coronary artery disease, and heart failure had been removed from the statistical model. Hence, the relations may not be explained by confounding from cardiac diseases. Although the data are cross-sectional only, this supports our view that overweight and obesity, but not quitting smoking itself, might be a factor in the development of hypertension. Smoking status (including period of abstinence among former smokers and consumption among current smokers) appears to be unrelated to hypertension among the normal weight general population aged 18 to 79 years.
These results are in accordance with previous findings: firstly, evidence of acute blood pressure increase from tobacco smoking5 and that blood pressure decreases 1 week after smoking cessation.6 That evidence suggests that long-term blood pressure among former smokers should be as high as among current smokers, or even lower, considering age. Secondly, our findings (Table 3) are in accordance with evidence from non-clinical samples. Studies using non-clinical samples have reported higher blood pressure or higher proportions of hypertensive individuals among former or never smokers,1–5,7 but did not report the interaction of smoking status with obesity, overweight and normal body weight in detail. In addition, two of these studies were limited to working men in middle adult age in Japan and Korea.3,4
Our findings contrast with evidence of higher blood pressure among current than among former or never smokers,7,8 including data from a national health survey in the UK. A limitation of these studies is that only men were included. One study was restricted to male factory employees, finding small but significant differences in systolic blood pressure between current and former or never smokers.7 The findings of the survey were also limited to systolic blood pressure, and to men aged 45 years.8 Blood pressure may be higher in current smokers than in former or never smokers among subgroups of the general population who have smoked for many years and thus may have accumulated odds for hypertension. A limitation of our sample is that subgroups were too small to allow for such an analysis of men or women in single age groups.
Hypertension is highly prevalent in Germany.23 Blood pressure 140/90 mmHg or current use of antihypertensive medication was found in 55.3% of residents aged 35–64 years in Germany, whereas a study in North America found about half that proportion (27.8% for the US, 27.4% for Canada).23 The proportion of 35–64-year-old individuals with a blood pressure <160/90 mmHg among individuals with hypertension medication in Germany is 24.8%: in the same range as other European countries, but lower than in the US (65.5%).24 In 1997, the proportion of tobacco-attributable death cases among all death cases in Germany was 17%,25 similar to the US, where tobacco-attributable mortality was 19% of all death cases in 1995.26 Mean BMI in Germany was 26.4–27.4 among 35–64-year-old men and women of six European countries, the US and Canada.23
A strength of our study is that its sample is representative of the general population aged 18–79 of one Western nation. On the other hand, there are limitations. First, this is a cross-sectional study; the data do not allow final conclusions about causal relations. Second, the odds for treated hypertension among normal weight never smokers barely missed statistical significance. Such an association might well have been statistically significant in a larger subpopulation. Third, sample selection bias may have resulted in less healthy individuals being over-represented among those who did not take part in the study. However, we do not expect that such a bias would contradict our findings. Fourth, only BMI was used to estimate obesity or overweight, although waist-hip ratio or other parameters of body fat might have been more useful. Likewise, the number of confounding health behaviour-related variables was limited to alcohol consumption and exercise. There may be additional health-related behaviours, such as low-salt diet, that might explain our findings. Fifth, antihypertensive medication and heart disease were only assessed by the statements of the respondents with no verification. Sixth, there was no validation of self-reported level of smoking. However, evidence shows that the proportion of smokers who deny or minimize smoking in survey studies may be negligible, because they do not significantly change the results with respect to smoking status.27
Conclusions
In this nationally representative health examination survey, never or former smoking was not associated with hypertension among the normal weight population. Smoking cessation may not add to hypertension if the person who quits does not gain weight. The data suggest that smokers who quit should not be afraid of hypertension following smoking cessation. Smoking is clearly not an adequate behaviour to keep blood pressure low among individuals who are normal weight, regardless of their status as former or never smokers. Future studies should examine interactions between smoking status and obesity, overweight and normal weight with respect to hypertension. Blood pressure, but also multiple change of health-related behaviour, particularly diet and exercise, should be analysed in the context of smoking cessation. Public health efforts to encourage smoking cessation should be supported, but the need to control body weight in the prevention of hypertension should also be promoted.
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This work was financially supported by grant IX311a 406.68.43.05 [EC] from the Social Ministry of the State of Mecklenburg-West Pomerania in Germany, grant 01 EB 0420 from the German Ministry of Education and Research, and by the Krupp-von-Bohlen-and-Halbach foundation. The data were provided by the Robert Koch Institute of the German Federal Ministry of Health.
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