The relationship between smoking and the cardiovascular health of athletes and exercisers: a systematic review on risks, performance and prevention

Abstract

Introduction: Smoking is a leading preventable cause of cardiovascular disease worldwide. Its deleterious effects, including endothelial dysfunction, increased arterial stiffness, and hypertension, are well established in the general population. However, the assumption that physical fitness may neutralize these risks in athletes remains unproven. Objectives: This review aimed to evaluate the cardiovascular effects of active and passive smoking among athletes and physically active individuals. Specific goals included examining pathophysiological impacts, assessing performance deficits, identifying smoking prevalence, and reviewing preventive strategies. Methodology: A systematic review was conducted in accordance with PRISMA guidelines. Databases included PubMed, SciELO, Web of Science, Scopus, SPORTDiscus, and LILACS. Inclusion criteria comprised studies involving athletes or regular exercisers (>3x/week), published between 2000 and 2025, addressing smoking's cardiovascular impact. Data extraction included study design, population, exposure type, and cardiovascular outcomes. Methodological quality was assessed using NOS, AMSTAR 2, and JADAD tools. Results: Fifty-two studies were analyzed. Smoking was consistently associated with endothelial dysfunction (73%), increased blood pressure (52%), and reduced heart rate variability. Arterial stiffness and carotid thickening were observed in 22 studies, even among young athletes. Performance deficits included reduced VO₂ max (29 studies) and decreased time to exhaustion. The prevalence of active smoking ranged from 8% to 27%, with a higher risk of arrhythmias, hypertension, and myocardial infarction among smokers. Passive smoking also impaired cardiovascular function, increasing inflammatory markers and reducing VO₂ max by up to 10%. Discussion: Despite high physical conditioning, smoking athletes exhibited significant cardiovascular compromise. VO₂ max reduction correlated with elevated carboxyhemoglobin and impaired oxygen delivery. Structural cardiac changes, such as ventricular hypertrophy and arrhythmias, occurred in active smokers. Preventive interventions were limited, with only 15 studies addressing smoking cessation, mainly via motivational counseling and pharmacotherapy. Programs involving coaches and health teams were more successful in reducing relapse. Passive exposure was especially concerning in poorly ventilated training environments. Conclusion: Smoking negatively affects cardiovascular health and performance in athletes, refuting the notion that exercise mitigates tobacco-related risks. Both active and passive smoking contribute to cardiovascular dysfunction. Evidence supports urgent implementation of targeted educational strategies, smoke-free policies, and cessation programs in sports settings. Final Considerations: Integrating tobacco control into sports medicine is essential to safeguard the cardiovascular health of athletes. Multidisciplinary interventions, environmental policies, and continuous health education are key to effective prevention.