Japanese Study Links Heated Tobacco Use With Higher Hypertension Risk

A study of 30,979 Japanese adults found that current heated tobacco users had a higher risk of developing hypertension than never-smokers in the main analysis. But the association was not statistically significant in several sensitivity analyses, and the findings do not show that heated tobacco use caused hypertension.

Published in Hypertension Research, the study examined tobacco-use status and new cases of hypertension among adults who did not have the condition at the start of the study. Heated tobacco products warm processed tobacco to produce nicotine-containing aerosols. They are different from e-cigarettes and vapes.

How the study was conducted

Researchers used a Japanese database to identify 30,979 people who completed a detailed smoking questionnaire between 2021 and 2025 and had no hypertension at baseline. Participants were grouped as never-smokers, current heated tobacco users, current cigarette smokers, current users of both products, or former smokers.

Over an average follow-up of about 2.8 years, the researchers recorded new hypertension, defined as elevated blood pressure measurements or the start of antihypertensive medication. They used a statistical method to reduce differences between the five groups at the start of the study.

What the researchers found

Hypertension occurred in 5% of never-smokers, 8% of current heated tobacco users, 9% of current cigarette smokers, 8% of dual users and 9% of former smokers.

In the primary adjusted analysis, current heated tobacco users had a significantly higher risk of developing hypertension than never-smokers. Higher risks were also observed among current cigarette smokers, dual users and former smokers.

However, the heated tobacco association did not remain statistically significant in several sensitivity analyses. It remained significant after an additional adjustment for baseline differences, but not after adjustment for follow-up duration, in the complete-case analysis, or when hypertension was defined as requiring both a new diagnosis and antihypertensive medication.

The researchers found no statistically significant evidence that the associations varied by age, sex, body mass index, kidney filtration efficiency, history of cardiovascular disease or stroke, or use of a health-support application.

Limits to what the findings can show

The study found an association, not proof that heated tobacco use caused hypertension. Smoking status was recorded only at baseline, so researchers could not track changes in tobacco use during follow-up. The database also lacked information on exposure frequency, intensity and duration, or when participants may have switched from cigarettes to heated tobacco products.

Previous cigarette use among current heated tobacco users was unknown, so some may have had earlier exposure to conventional cigarettes. The study therefore cannot attribute the observed risk to heated tobacco exposure alone. It also cannot establish whether hypertension risk among current heated tobacco users is lower, higher or similar to that among current cigarette smokers.

Blood pressure was measured during periodic health check-ups, which may have led to some misclassification. The cohort had a mean age of 46.8 years, so the findings may not apply in the same way to older adults or populations with different demographic or socioeconomic characteristics.

The researchers noted that other studies have suggested possible links between heated tobacco use and changes in blood pressure or blood vessels. They also said tobacco use can occur alongside lifestyle factors associated with cardiovascular risk. The current study, however, does not establish the contribution of these factors to its results.

Further research with more detailed information on past and cumulative tobacco exposure is needed to clarify the long-term cardiovascular risks of heated tobacco use and whether similar associations are seen in other Asian populations.