Tobacco and Electronic Cigarette Use with Hypertension and the Mediating Effect of Dyslipidemia - The NHANES Study

Background: 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 versus no nicotine exposure with elevated blood pressure (BP) and hypertension prevalence using nationally representative United States data from 2021-2023. Methods: 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) versus no smoking or vaping (n=5,072) were used. Elevated BP was classified as ≥120/70mmHg and hypertension as ≥140/90mmHg, and history of smoking and/or vaping were collected with questionnaire. Multivariable logistic regression and mediation path analysis were conducted. Results: Among 6,262 participants (mean age 42.2 years [SD 21], 63.3% female), smokers/vapers had significantly higher prevalence of elevated BP compared to non-smokers/non-vapers (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 (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. Conclusions: 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.