Objectives: Previous studies suggest that smokers have a misperception of their 10-year cardiovascular risk. We aimed to compare 10-year cardiovascular risk self-perception and calculated risk among smokers willing to quit and assess the determinants of a possible misperception. Design: Cross-sectional secondary analysis of baseline data from a randomized controlled trial of smoking cessation. Participants: 514 participants, mean age 51.1 years, 46% women, 98% Caucasian. Eligible participants were regular smokers, aged between 40 and 70 years, with a consumption of at least 10 cigarettes per day for at least a year. None of them had experienced CVD before. Exclusion criteria comprised history of myocardial infarction, coronary heart disease (CHD), stroke, heart failure, peripheral vascular disease, carotid atherosclerosis or cardiac arrhythmia. Participants with renal or liver failure, psychiatric disorders, substance and alcohol abuse and with smoking cessation therapies were excluded. Interventions: Participants were asked to estimate their 10-year cardiovascular risk using a 3-item scale corresponding to high, moderate and low risk categories. We compared their risk perception with the Framingham and Procam score. We used multi-variable adjusted logistic regression models to determine characteristics of participants who underestimate their risk vs. those who correctly or overestimate it. Results: Between 38-42% of smokers correctly perceived their 10-year cardiovascular risk, 39-50% overestimated their 10-year cardiovascular risk while 12-19% underestimated it compared to their calculated 10-year cardiovascular risk depending on the score used. Underestimation of 10-year cardiovascular risk was associated with male gender (OR 8.16; CI 3.83-17.36), older age (OR 1.06; CI 1.02-1.09), and the presence of hyperlipidemia (OR 2.71; CI 1.47-5.01) and diabetes mellitus (OR 13.93; CI 3.83-50.66). Conclusions: Among smokers, misperception of their 10-year cardiovascular risk is common, with one fifth underestimating it. These findings may help physicians target patients with such characteristics to help them change their health behavior and adherence to risk-reduction therapy.