Although the link between cigarette smoking and its cardiovascular effects is well established, the mechanisms through which smoking raises blood pressure remain to be clarified. Possible mechanisms include nicotine-induced peripheral and central sympathetic nervous system stimulation, persisting levels of nicotine in blood because of incomplete metabolism, release of vasopressin, and chemoreceptor stimulation. Effects of nicotine on hemostasis, arterial rigidity, and vessel wall damage, together with detrimental effects on lipid metabolism, may contribute to an overall increased cardiovascular risk in smokers. Nonselective beta blockers are not as effective in smokers as they are in nonsmokers. Smoking cessation is a very important intervention in reducing cardiovascular risk in hypertensive patients. Physicians should counsel patients about smoking cessation at every visit. Use of the various smoking deterrents can help some patients quit.