Environmental tobacco smoke (ETS) exposure and alcohol (EtOH) consumption often occur together, yet their combined effects on cardiovascular disease development are currently unclear. A shared feature between ETS and EtOH exposure is that both increase oxidative stress and dysfunction within mitochondria. The hypothesis of this study was that simultaneous EtOH and ETS exposure will significantly increase atherogenesis and mitochondrial damage compared to the individual effects of either factor (ETS or EtOH). To test this hypothesis, apoE(-/-) mice were exposed to EtOH and/or ETS singly or in combination for 4 weeks and compared to filtered air, nonalcohol controls. Atherosclerotic lesion formation (oil red O staining of whole aortas), mitochondrial DNA (mtDNA) damage, and oxidant stress were assessed in vascular tissues. Combined exposure to ETS and EtOH had the greatest impact on atherogenesis, mtDNA damage, and oxidant stress compared to filtered air controls, alcohol, or ETS-exposed animals alone. Because moderate EtOH consumption is commonly thought to be cardioprotective, these studies suggest that the potential influence of common cardiovascular disease risk factors, such as tobacco smoke exposure or hypercholesterolemia, on the cardiovascular effects of alcohol should be considered.