Despite declines in smoking prevalence in many Western countries, tobacco use continues to grow in global importance as a leading preventable cause of cardiovascular disease. Tobacco smoke is both prothrombotic and atherogenic, increasing the risks of acute myocardial infarction, sudden cardiac death, stroke, aortic aneurysm and peripheral vascular disease. Even very low doses of exposure increase the risk of acute myocardial infarction. However, smoking cessation and second-hand smoke avoidance swiftly reduce this risk. While promising new agents are emerging, proven cost-effective and safe cessation interventions already exist, such as brief physician advice, counseling and nicotine replacement therapy. These should be routinely offered, where available, to all smokers. This is especially important for those at risk of, or with established and even acute, cardiovascular disease. Clinicians must play a more active role than ever before in supporting complete cessation in patients who smoke and in advocating for stronger tobacco control measures.