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The aim of the study was to assess the impact of current smoking on 24-hour blood pressure (BP) and inflammatory and hemostatic activity and thereby the incidence of cardiovascular disease (CVD) in Japanese hypertensive patients. A total of 810 hypertensive patients (mean age 72 years; 38% men) were prospectively followed-up (2799 person-years). During the follow-up, 66 cases of CVD occurred (stroke, 55; myocardial infarction, 7; both, 4). At baseline, the current smokers (n=166) had higher levels of high-sensitivity C-reactive protein (hs-CRP) (0.21 mg/dL vs 0.14 mg/dL) and plasminogen activator inhibitor-1 (PAI-1) (46.1 ng/mL vs 37.8 ng/mL; both P=.001), but not of 24-hour BP, compared with nonsmokers. Using a Cox regression analysis, current smoking was independently associated with an increased risk of CVD (hazard ratio [HR], 2.6; P<.01), and the risk was substantially higher in women (HR, 6.1; P<.001) than in men (HR, 1.4; P=.41). The CVD risk of current smokers was magnified when it was accompanied with high hs-CRP (highest quartile range, ≥0.40 mg/L) or PAI-1 levels (≥58.9 ng/mL) compared with that in smokers with low hs-CRP or PAI-1 levels (both P<.05). Among hypertensive patients, current smokers had increased risk of CVD events, and the increase was more prominent when accompanied by circulatory inflammatory and hemostatic abnormalities. J Clin Hypertens (Greenwich). 2012;00:00–00. ©2012 Wiley Periodicals, Inc.