PURPOSE: Although over the past 2 decades great strides have been made in increasing the awareness, detection, and treatment of hypertension (HTN), actual control of blood pressure is far from optimal. We hypothesized that current cigarette smoking, by acting as a marker for poor health related behavioral patterns, would be significantly associated with uncontrolled blood pressure (BP). PATIENTS AND METHODS: Over a 3-month period in 1994, all patients who presented to a public hospital medical walk-in clinic were screened, and had their BP measured if they had been prescribed BP medication within 1 year and were aware of their diagnosis of HTN. Patients were defined as controlled hypertensives if both systolic BP and diastolic BP were ≤ 140/90 mm Hg. Severe uncontrolled hypertensives were those with either systolic BP ≤ 180 mm Hg or diastolic BP was ≤ 110 mm Hg. RESULTS: Of the 221 patients meeting all inclusion criteria (1 refusal), 86 had uncontrolled HTN (mean BP = 192/106 mm Hg), 130 were controlled (mean BP = 130/80 mm Hg), and 5 were not African American. Severe uncontrolled hypertensives, when compared with controlled hypertensives, were significantly more likely to be current (versus former) smokers (odds ratio [OR] = 4.17; 95% confidence interval [CI]: 1.8 to 9.5), and be less compliant with medications (OR = 2.33; 95% CI: 1.3 to 4.1). Age, gender, alcohol use, marital status, education, and comorbidity were not associated with HTN control. In an adjusted logistic regression model, both current and never-smokers when compared with former smokers were significantly more likely to have uncontrolled HTN in compliant patients (OR = 14.4; 95% CI: 3.3 to 63.3 and OR = 5.7; 95% CI: 1.5 to 21.7, respectively). In noncompliant patients, smoking status was not associated with uncontrolled HTN. CONCLUSION: In disadvantaged African-American patients who report good medication compliance, former smoking status is strongly associated with HTN control. Physicians may need to be especially vigilant of BP control in patients who smoke.